What are the advantages and disadvantages of using soothers (pacifiers) in newborns and infants?

Pacifier Use in Newborns and Infants

Pacifiers should be offered to infants at nap time and bedtime to reduce the risk of sudden infant death syndrome (SIDS), with introduction delayed until breastfeeding is well established in breastfed infants (typically 3-4 weeks of age). 1

Major Advantages

SIDS Risk Reduction (Primary Benefit)

• Pacifier use during sleep provides significant protection against SIDS, with a 61% risk reduction when used during last sleep (multivariate OR 0.39,95% CI: 0.31-0.50). 2
• The protective effect persists even if the pacifier falls out of the infant's mouth after sleep onset, so it does not need to be reinserted. 1
• Based on US SIDS rates, one SIDS death could be prevented for every 2,733 infants who use a pacifier when placed for sleep. 2
• The mechanism of protection remains unclear, but the consistency of evidence across multiple studies is remarkable. 1, 3

Pain Relief and Procedural Comfort

• Pacifiers provide analgesic effects during minor painful procedures such as heel sticks, venipuncture, IV insertion, and immunizations in neonates and infants younger than 6 months. 1
• When combined with 25% sucrose solution (2 mL administered into cheeks), pacifiers enhance pain reduction during procedures. 1
• Nonnutritive sucking alone contributes to calming infants and decreasing pain-elicited distress. 1

Soothing and Calming

• Pacifiers satisfy the infant's natural sucking instinct and provide comfort, which is the most commonly reported reason for use by caregivers (80%). 4, 5

Major Disadvantages

Breastfeeding Interference

• For breastfed infants, pacifier introduction must be delayed until breastfeeding is firmly established, typically by 3-4 weeks of age, to avoid potential negative effects on breastfeeding duration and success. 1
• Studies show conflicting evidence about whether pacifiers reduce breastfeeding duration, but the precautionary delay is recommended. 6, 3
• Infants who are not being directly breastfed can begin pacifier use immediately as desired. 1

Dental Malocclusion

• Adverse dental effects can become evident after 2 years of age, but primarily manifest after 4 years of prolonged use. 6
• Dental deformities are a recognized risk of continued pacifier use beyond early childhood. 5

Otitis Media (Ear Infections)

• Recurrent acute otitis media is associated with prolonged pacifier use. 5, 6
• The American Academy of Family Physicians recommends weaning children from pacifiers in the second six months of life (6-12 months) to prevent otitis media. 6

Other Risks

• Risk of strangulation if pacifiers are hung around the infant's neck or attached to clothing during sleep. 1
• Potential for accidents if objects like stuffed toys are attached to pacifiers, creating suffocation or choking hazards. 1
• Development of latex allergy, tooth decay, oral ulcers, and sleep disorders with prolonged use. 5

Implementation Guidelines

Safe Introduction

• Offer the pacifier when placing the infant for all sleep episodes, including daytime naps and nighttime sleep. 1, 2
• Never force the pacifier if the infant refuses it; try again when the infant is older. 1
• For breastfed infants, wait 3-4 weeks until breastfeeding is well established before introducing a pacifier. 1
• For formula-fed infants, begin pacifier use as soon as desired. 1

Safety Precautions

• Never hang pacifiers around the infant's neck due to strangulation risk. 1
• Do not use pacifiers that attach to infant clothing with sleeping infants. 1
• Avoid attaching any objects (stuffed toys, other items) that may present suffocation or choking risks. 1

Weaning Timeline

• Pacifier use is recommended up to 1 year of age, which includes the peak ages for SIDS risk and the period when the infant's sucking need is highest. 2
• Consider weaning in the second six months of life (6-12 months) to prevent otitis media. 6
• Weaning methods include gradual decrease (27.8% of caregivers found effective) or abrupt removal (24.8% found effective). 4

Common Pitfalls to Avoid

• Do not introduce pacifiers too early in breastfed infants (before 3-4 weeks), as this may interfere with breastfeeding establishment. 1
• Do not continue pacifier use beyond 1 year of age to minimize dental and otitis media risks. 6, 2
• Do not reinsert the pacifier once the infant falls asleep, as the protective effect against SIDS persists even after it falls out. 1
• Ensure parents understand that the SIDS protection benefit is strongest when the pacifier is offered at sleep onset, not just occasional use. 2