Pacifiers are one of the hotly contested topics in baby care. Should every baby get one? Is using a pacifier protective against Sudden Infant Death Syndrome (SIDS)? Do pacifiers mess with breastfeeding? Does sucking on a nuk lead to more ear infections or crooked teeth? Are hand-rolled pacifiers from Cuba superior?
Since it’s been awhile since I was a binky connoisseur myself, I’ll stick to addressing the pacifiers-and-breastfeeding issue. And, as usual, giving you the information to make your own decisions is my jam.
With the advent of caring about breastfeeding initiation and exclusive breastfeeding rates within hospitals, courtesy of Joint Commission National Quality Measures, as well as the implementation of the Baby-Friendly Hospital Initiative’s 10 Steps to Successful Breastfeeding and recommendations from the American Academy of Pediatrics (AAP) to hold off on introducing pacifiers until breastfeeding is established, we see a bit less of this in hospitals:
While it is common to hear that pacifiers will interfere with breastfeeding, the evidence is less conclusive.
What research tells us about breastfeeding and pacifier use
When it comes to randomized controlled trials (RCTs—i.e., the “gold standard” of research studies), we don’t consistently see a significant difference in breastfeeding duration between babies who receive pacifiers and those who do not. That said, there are not many RCTs that look specifically at pacifier use in normal, healthy, full-term breastfeeding infants. A study of this population looked at supplemental feeding (with bottles or cups) as well as pacifier use and concluded that both supplementation and pacifier use can negatively impact breastfeeding.
On the other hand, observational and other qualitative studies consistently see a relationship between pacifier use and breastfeeding duration. Due to the nature of these studies, we can’t draw the conclusion that more pacifiers = less breastfeeding. One study sums it up as:
Pacifier use is highly correlated with early weaning, even after controlling for possible confounders. Until it is determined if pacifier use is causally related to weaning or is a marker for other undetermined causes, pacifier use probably should not be recommended for breast-fed infants.
The results imply that pacifier use may be a marker of breastfeeding difficulties or decreased maternal motivation to breastfeed, as opposed to being the causal agent in early weaning.
One systematic review concludes:
The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity. The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean.
Some hospitals have experimented with keeping pacifiers secured on their mother-baby units in order to make it more difficult for staff to give them to parents. One hospital examined exclusive breastfeeding rates before and after restricting access to pacifiers. This AAP writeup of the research explains that, “The pacifiers were locked up and nurses had to enter a code and a patient’s name in order to access them for special circumstances (e.g., to help soothe infants undergoing painful procedures).” The data show that in this hospital, restricting pacifiers decreased exclusive breastfeeding, and supplementation of breastfed babies with formula increased from 18 to 28 percent. One key piece of information the AAP article excludes is that formula access was not restricted during this time period. Go figure—if you lock up pacifiers but not formula, you’ll end up using formula more often in your attempts to soothe babies.
In theory, judicious use of pacifiers with attention paid to how and when they are used could be used as a tool to increase exclusive breastfeeding, but without good support for breastfeeding, pacifier use in the early days of a full-term baby’s life may decrease breastfeeding duration.
The lactation consultant perspective
Pacifiers have been around in various forms for thousands of years; the enjoyment of non-nutritive sucking is not an invention of the modern infant. One thing is true of all pacifiers, though: They’re not boobs (or any other form of food).
What lactation professionals are concerned about when saying, “Give no pacifiers or artificial nipples to breastfeeding infants,” is mostly feeding frequency and, to a lesser extent, what is referred to as “nipple preference” or “nipple confusion.”
While newborns can be sleepy and unpredictable in terms of feeding skill and frequency within the first 24 hours after birth, the general rule of thumb for new babies is that they should be going no longer than 3 hours between feedings. This applies regardless of feeding method. Longer stretches of sleep can lead to poor feeding, and infrequent breast stimulation can also lead to delayed onset of lactation and lowered milk supply. Using pacifiers can interrupt feeding frequency by encouraging longer stretches of sleep and helping parents to hold off on feedings. Especially during the wakeful and fussy second day of life where babies eat very frequently and want to be held constantly, pacifiers are pulled out as a tool to help calm a baby exhibiting normal baby behaviors.
In the early days, a breastfed baby’s sucking is best done at the breast. In the days before milk increases in volume and there is a transition from colostrum to mature milk, a baby’s sucking helps to trigger that milk increase and helps to establish a full milk supply. Attention needs to be paid to signs that a baby’s latch is effective. In the earliest days, the things to watch for are whether or not breastfeeding hurts, the number of wet and dirty diapers, and the percentage of weight loss (keeping in mind any interventions that happened during birth that may inflate birth weight).
Breastfeeding takes practice. The more opportunities a baby has to use his mouth correctly, the more this skill is reinforced, and the faster good breastfeeding happens. Depending upon what kind of pacifier you use and how it is used, less-than-ideal sucking skills may be reinforced. Pacifiers and bottle nipples are not much like breasts, so the shape of the pacifier (or bottle) may shape a baby’s mouth in ways that does not translate well to the breast. (Some research touches on this.)
It has been suggested that there is a dose-response effect between pacifier use and breastfeeding duration. That means the more you use a pacifier, the more likely it may interfere with breastfeeding.
For what it’s worth, all of this applies to giving a baby a finger to suck on as well. It’s not the pacifier or artificial nipple itself that is the issue, but how it is used.
What it all comes down to
My advice on pacifiers is pretty practical:
- Your baby may not want or need one.
- Waiting to introduce one until you’re confident breastfeeding is going well is prudent.
- Breastfed babies should be offered a breast to meet their suck needs, but if you need a break or assistance soothing your little one when it’s not practical to breastfeed (like on car rides), go for it.
- If you find yourself wanting to offer a pacifier because breastfeeding hurts, is too difficult, or is too overwhelming, that’s a sign you may need help from a lactation expert.
- Regardless of whether your baby is breast- or bottle-fed, watch carefully for feeding cues and do not use the pacifier to hold off on feedings. This can be detrimental to your baby as well as your milk supply.
And one big advantage to opting out of pacifiers: You never have to worry about losing the things.
