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Pacifier Use: Promoting a New Recommendation on Reducing the Risk of SIDS

I. Summary

Epidemiological studies have shown that while Sudden Infant Death Syndrome (SIDS) cannot be prevented, modifications to an infant’s sleep environment can reduce an infant’s risk of SIDS. These modifications include back sleeping, elimination of soft bedding, sleeping in cribs and not inappropriate sleep surfaces and the elimination of tobacco exposure. Since 1993, epidemiological studies have shown that pacifiers are protective against SIDS. Researchers and the public health community have considered recommending the use of pacifiers to further reduce the risk of SIDS. However, until recently, they have been reluctant to do so due to valid concerns that arise with pacifier usage. Pacifier use has been associated with interference with breastfeeding, increased incidence of acute otitis media infections and development of dental problems. The National Sudden Unexpected Infant/Child Death & Pregnancy Loss Program Support Center (PSC), a program of First Candle, supports recommending the use of pacifiers as an additional measure to reduce the risk of SIDS for several reasons:
  1. The American Academy of Pediatrics’ (AAP) Task Force on Sudden Infant Death Syndrome recently published their revised risk reduction recommendations which now includes the use of a pacifier (1).
  2. The National Institute of Child Health and Human Development (NICHD) has adopted the AAP’s policy statement on reducing the risk of SIDS. NICHD is working to incorporate the new risk-reduction messages into all Back to Sleep campaign materials (2).
  3. Epidemiological research continues to indicate that pacifiers reduce the risk of SIDS (3).
  4. The U.S. SIDS rate is no longer declining and in the most recent data, the rate has slightly increased (4).
  5. The concerns related to the use of a pacifier (such as interference with breastfeeding, dental malocclusion, acute otitis media and pacifier safety) can be appropriately managed or addressed.

II. Background

The use of pacifiers has been documented since 1000 B.C. (5). Infants have a biological need to suck which includes non-nutritive sucking (NNS) on fingers, thumbs, fists, bottles and pacifiers (6). NNS is considered normal for infants and often starts in the womb. The prevalence of NNS in a society depends on ethnic and social-economic factors and child care practices. In western society, pacifier use is common (range 45 percent to 60 percent) along with finger/thumb sucking (range 15 percent to 30 percent) and during the last 30 years, pacifier rates have increased while finger sucking has decreased (6). In Sweden, pacifier use increased from 10 percent to 70 percent from 1950 to 1983, and thumb sucking decreased from 50 percent to 15 percent (7). Pacifier use peaks at 2 to 3 months of age, and it is often introduced within the first month of life (8,9,10). While parents generally decide before birth if they plan to use a pacifier, they often change their mind after an infant’s birth (8). Pacifiers are more likely to be given to male infants which has been linked to increased crying among male infants as a possible reason (9,11). Most children stop pacifier use on their own between 2 and 4 years of age (13).

A. Epidemiological Evidence

In 1993, Mitchell reported that pacifiers were protective against SIDS in a case-control study (13). Subsequently, additional studies supported this association. Fleming found pacifiers to be protective in a case-control study in England in 1996 (14). In a 1999 study, Fleming also found significantly fewer deaths from SIDS among pacifier users (15). In a Norwegian study, the estimated odds ratio of pacifier use ranged between 0.27 to 0.59 (1.5 to 4 times less risk) (16). In a study conducted in the Netherlands, pacifier use was found to be a preventive factor for SIDS independent of other risk factors such as prone sleeping and soft bedding (7). Also in the Netherlands, a case-control study showed that there was a preventive effect associated with pacifier use with an odds ratio of 0.05 (7). In a population-based case-control study in Chicago from 1993 to 1996, pacifier use was associated with decreased risk (unadjusted OR .03-(0.2 -0.5) (17). In 2005, Hauck published a meta-analysis of the published research evaluating the strength of evidence on the use of pacifiers as a protective measure against SIDS. From the meta-analysis, she concluded that there is a strong correlation between pacifier use and reduced risk of SIDS (3).

B. Theories

Although the physiologic mechanism to explain the protective nature of pacifiers against SIDS remains unclear, there are several major categories of theories. These include:
  1. Infant sleep position: A pacifier may discourage an infant from turning to the stomach position while sleeping. The use of pacifiers was found to decrease rollovers by the infants but to increase rotation around the crib (7). A German study found that there was no significant association between the use of a pacifier and the prone sleep position (18).
  2. Infant arousal during sleep: Research on infant arousal and pacifier use shows that pacifier users have lower auditory thresholds than non-pacifier users (19). Infants may also arouse more easily when pacifiers fall out during sleep.
  3. Airway and/or respiration effects: Pacifier use may make it easier to for infants to keep their airways free. Pacifier use also changes infant tongue position (21).
  4. Unknown variable: Pacifier use may also be a marker for some undiscovered variable such as the mother’s behavior or an infant characteristic (21).
Any theory must address the short duration a pacifier remains in a sleeping infant’s mouth. Video tapes of infants at night demonstrate that infants spend most time without a pacifier in their mouths during the night (20). Recommending pacifiers to reduce the risk of SIDS should not be delayed due to the lack of a known physiologic mechanism explaining the protective nature of pacifiers. Until the cause(s) of SIDS is known, all SIDS risk reduction recommendations, including back sleeping, remain hypotheses.

C. Concerns

Before a recommendation can be made to promote the use of pacifiers to reduce the risk of SIDS, it is important to review the associated risks of pacifier usage. Research indicates that pacifiers have been associated with reduced rates of breastfeeding and duration of breastfeeding, increased risk of acute otitis media and dental problems (21). Dental Issues | The sucking of pacifiers, fingers and thumbs has been shown to lead to dental problems such as overbites, open-bites and cross-bites (6). The impact of pacifier use and finger-sucking is associated with posterior lateral cross-bite which disappears from pacifiers users by age 9 (22). In Greece, a survey of 5-year-olds showed that only 3.4 percent of 5­year-olds were still using a pacifier while 80 percent of finger suckers were still sucking on their fingers (6). The authors conclude that pacifiers can have a preventive effect against finger sucking, which is more harmful to dentition than pacifiers (6,21). In their guidance to parents, the American Academy of Pediatric Dentists (AAPD) notes that all types of NNS sucking impact teeth in the same way, but pacifiers are an easier habit to break compared to finger or thumb sucking. According to the AAPD, NNS is not a problem for teeth unless it continues after the child’s permanent teeth have come in (12). Breastfeeding | During the 1990s, the World Health Organization/United Nations Children’s Fund Baby Friendly Hospital Initiative discouraged the use and offering of pacifiers to mothers because of the belief that pacifier use interfered with breastfeeding (23,24). The use of pacifiers and the impact on the start and duration of breastfeeding has been studied in England, Brazil, Sweden, New Zealand and the United States. These observational studies found that pacifier use reduces the duration of breastfeeding before infants are weaned and that pacifiers reduce the initiation of breastfeeding (9,25,26,27,28). The two major theories explaining why the use of a pacifier may impact breastfeeding include nipple confusion and reduced sucking time. Reduced sucking time on the breast results in a lowered milk supply which may encourage earlier weaning (8). As no physiological evidence exists that infants actually experience nipple confusion, it is most likely that the pacifier use results in decreased sucking time (23). Not all studies confirm the relationship between pacifier use and reduced breastfeeding rates and duration. L’Hoir found that pacifier use did not influence the duration of breastfeeding in the Netherlands (7). Other studies indicate that mothers who want to bottle feed and discontinue breastfeeding elect to use pacifiers (29,30). As most studies to date have been cohort studies, they can only indicate a relationship, not demonstrate causality. However, a Swiss randomized study found that pacifier use had no impact on prevalence or durations of breastfeeding at 6-months (24). Another randomized study investigating if pacifier use is causally related to early weaning found that the use of a pacifier by a mother was a marker of breastfeeding difficulties, not the cause (23). An additional group of pacifier users that has been studied is preterm infants. As pacifiers are used by hospital staff and parents to comfort distressed infants, concern exists that pacifier use may impede breastfeeding for preterm infants. Previous studies had shown that pacifier use by preterm infants resulted in shorter hospital stays and no negative effect on breastfeeding (31). A randomized controlled trial also found no impact on breastfeeding by preterm infants who used a pacifier (31). Acute Otitis Media | Research studies have shown that pacifier use is associated with acute otitis media (AOM) (22). Common symptoms of AOM include night restlessness, poor appetite, vomiting, earache and cough. AOM is closely related to viral respiratory infections. Incidence is highest in children less than 2 years of age and the peak incidence is between 6 and 12 months. The risk factors for AOM include child care attendance, older siblings, environmental tobacco smoke exposure, bottle feeding and pacifier use (32). Child care attendance and having older sibling are the main risk factors. Breastfeeding has been found to be protective against AOM and infants who breastfeed for at least four months have 50 percent fewer AOM occurrences (32). Supine sleep position has also been found to be protective against AOM. For a comprehensive review of proposed theories on why pacifiers may be associated with otitis media, see Adair’s literature review (21). As with breastfeeding, it is difficult to determine if pacifier use results in increased ear infections or if infants with ear infections are more likely to be given pacifiers to comfort them.

III. Recommendations

The PSC and First Candle support the adoption of the AAP’s recommendations on pacifier use as a SIDS risk reduction measure. According to Hauck, one SIDS death could be prevented for every 2,733 infants who use a pacifier when placed to sleep (3). The AAP recommendations are as follows:
  • Offer a pacifier at nap time and bedtime. Do not force an infant to use a pacifier. Do not reinsert a pacifier after the infant falls asleep.
  • Pacifiers should not be coated in any sweet solutions.
  • For breastfed babies, the pacifier should be delayed until 1 month of age to ensure that breastfeeding is firmly established.
Concerns by the public health community and parents about the use of pacifiers have been documented since the early 1900s (21). If we want parents and caregivers to adopt pacifiers as a SIDS risk reduction measure, it is important to not only address pacifier safety and cleanliness issues (i.e., do not attach cords to pacifiers and clean pacifiers appropriately) but also address parents’ and caregivers’ potential concerns about their use. In addition, we need to include additional educational messages that explicitly support breastfeeding, incorporate the AAPD’s infant dental care recommendations and address AOM concerns.


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