ORAL HEALTH POLICIES: PACIFIERS

Policy on Pacifiers
Adopted How to Cite: American Academy of Pediatric Dentistry. Policy on
2022 pacifiers. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:86-9.

Purpose Risks of pacifier use

The American Academy of Pediatric Dentistry (AAPD) Practitioners can provide counseling and anticipatory guidance
encourages health care providers to follow evidence-based regarding pacifier selection and safe usage to parents of infants
literature to educate parents about the safe practices, benefits, and children who utilize a pacifier. Pacifiers of single piece
and risks of pacifier use by infants and children in order to construction are less likely to break apart and become a
promote healthy growth andevelopment. choking hazard.8 For safety, AAP recommends a pacifier shield
be firm, have ventholes, and measure at least 1.5 inches across
Methods (i.e., large enough not to pass completely into the mouth).8
This policy, developed by the Council on Clinical Affairs, is Additionally, the U.S. Consumer Product Safety Commission
based on review of current dental and medical literature, in- prohibits straps, cords, or attachments that could pose a
®
cluding a search of the PubMed /MEDLINE database using
the terms: pacifier AND emotional development, safety,
danger to infants or children.9 Regular inspection of the pacifier
by caregivers is recommended to evaluate for any structural
benefits, malocclusion, crossbite, open bite, fields: all; limits: wear that poses a safety risk.8
within the last 10 years, English. Five hundred forty-nine Pacifier use is a risk factor for otitis media in infants and
articles met these criteria. Papers for review were chosen from children.10-14 The AAP suggests the incidence of acute otitis
this list and from references within selected articles. media may be reduced by decreasing or eliminating use of a
pacifier in the second six months of life.15 Evidence linking
Background pacifier use to issues with speech development or speech delay
Sucking behaviors in infants can be a natural reflex to satisfy is limited.16,17 Recent research suggested that while prolonged
a physiological (i.e., nutritive) or psychological (i.e., non- day-to-day pacifier use lasting several hours may have sig-
nutritive) need. The nonnutritive drive may be satisfied by nificance with atypical speech errors, a strong speech-related
sucking a finger or thumb or an available object such as a justification against pacifier use is not evident.18 The U.S.
pacifier. Pacifier use is common among infants in the United Food and Drug Administration recommends that infants and
States (U.S.).1 Cultural background may play a role in pacifier young children not be given pacifiers containing or dipped
introduction.2 Considerations when counseling parents on in honey.19 Honey contains spores of a particular bacterium,
introducing pacifiers include safety and potential risks and Clostridium botulinum, that produces a neurotoxin capable
benefits of pacifier use. Although the American Academy of of causing respiratory difficulty, paralysis, and even death.19
Pediatrics (AAP) has recommended delaying pacifier use in Recent cases of infant botulism in Texas were attributed to
breastfed infants until breastfeeding is established to prevent commercially-available honey-filled pacifiers.19
breastfeeding disruption,3 a recent Cochrane systematic review Pacifiers can serve as a reservoir for microbes, and their use
found pacifier use, whether started from birth or after lactation, is linked to oral yeast infections.14,20 Sterilization/disinfection,
did not affect the prevalence or duration of breastfeeding in either by boiling in water for 15 minutes or preferably spray-
healthy, term infants up to four months of age4. ing an anti-microbial agent (e.g., 0.12 percent chlorhexidine),
The controlled action of sucking promotes feelings of can minimize and eliminate microbes such as Staphylococcus,
security5 and allows infants to self-soothe5,6 and to initiate the Candida albicans, and Streptococcus mutans.16,21,22
process of self-regulation6. Pacifiers may continue to provide Children using a pacifier 36 months or longer had a
comfort in the toddler years. Cessation may be carried out significantly higher incidence of anterior open bite compared
either through self-implementation or caregiver mediation.7 A to those not using a pacifier.12,23-32 Pacifier usage beyond one
recent review found evidence that psychological interventions year also leads to a significantly higher incidence of anterior
such as positive and negative reinforcement effectively im- open bite,15 although an anterior open bite will improve after
prove nonnutritive sucking habits in children.7 Positive reward
for pacifier cessation (e.g., recognition or incentive for each
day of non-use) is preferable to negative reinforcement (e.g., ABBREVIATIONS
criticism, restraint) which can inadvertently cause power AAP: American Academy of Pediatrics. AAPD: American Academy
struggles and extend the duration of nonnutritive sucking of Pediatric Dentistry. SIDS: Sudden infant death syndrome. U.S.:
habits.6 United States.

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 ORAL HEALTH POLICIES: PACIFIERS

elimination of the pacifier before age three.31-33 In addition, for the Study and Prevention of Perinatal and Infant Death50
increased pacifier use leads to posterior crossbite,12,26-31,34,35
including crossbite with midline deviation.36-39 A prospective
®
and the Safe to Sleep campaign of the United States Depart-
ment of Health and Human Services51.
study examining pacifier use beyond age four concluded the Pacifier use may be beneficial when mothers cannot
transverse occlusal relationship should be evaluated before breast feed due to medication or severe illness, if infants need
three years of age.33 To limit the development of a posterior early oral stimulation to develop or maintain the sucking re-
crossbite, discontinuing or limiting pacifier use when canines flex, or in neonatal intensive care environments when infants
emerge38 (approximately 18 months of age)36 has been recom- need calming, pain relief, or decreased stress.52 The benefits of
mended.33 Malocclusion was affected by duration more than pacifier use also include adjunctive pain relief in newborns
frequency,35,39 and the percentage of open bite was significant- and infants undergoing common, minor procedures in the
ly greater as the duration of nonnutritive sucking continued emergency department and reducing the likelihood of a
beyond three years of age34. Increased overjet and a Class II digit-sucking habit.1,12,16,53-55 Children who started using an
malocclusion are more strongly associated with a finger habit orthodontic pacifier before four months old had a lower risk of
versus a pacifier habit.33,39 developing a finger/thumb sucking habit compared to children
A systematic review noted orthodontic pacifiers induce who began after four months.56 Because forced early cessation
less open bite compared to conventional pacifiers.29 While of pacifier usage has been associated with prolonged finger
one study30 showed conventional pacifiers use exhibited higher sucking, allowing the habit to continue beyond 14 months of
odds of posterior crossbite and anterior open bite compared age may help prevent a persistent finger habit.57
to orthodontic pacifiers, another28 found pacifier usage had
a significantly higher incidence of posterior crossbite versus Policy statement
non-habit children although the difference between pacifier The AAPD supports parents in the decision to introduce a
types with regards to posterior crossbite was not significant. pacifier based on their infant’s needs and parental preference.
A prospective study introduced a pacifier with a thin-neck to During the first few months of life, pacifiers may be beneficial
children (average age 20 months) who had a diagnosed anterior in helping premature infants develop the sucking reflex, offer-
open bite and already used a conventional pacifier; the study ing comfort and soothing, providing an analgesic effect during
group was compared to not only the original pacifier group minor invasive procedures, decreasing the incidence of SIDS,
but also to children not using any pacifier for at least three and preventing a persistent finger-sucking habit. However, a
months.40 A significant difference (P< 0.001) regarding overbite prolonged pacifier habit after 12 months of age can increase
and overjet changes between pacifier groups was reported the risk of acute otitis media. Pacifier use beyond 18 months
(i.e., the thin-neck pacifier resulted in less increase in the can influence the developing orofacial complex, leading to
overbite and open bite compared to the conventional pacifier); anterior open bite, posterior crossbite, and Class II malocclu-
however, no improvement in either pacifier group compared sion. Understanding the safety, benefits, and risks is critical to
to cessation of pacifier use was found.40 Two reviews compar- counseling parents on the use of pacifiers.
ing orthodontic versus conventional pacifiers stated evidence The AAPD encourages additional research regarding the
was insufficient to support a preference for orthodontic paci- biometrics for pacifier selection to minimize disturbances of
fiers preventing malocclusions.41,42 the developing orofacial complex.
The pacifier design (orthodontic, conventional, or physio-
logic) and shield design (conventional or flare) have implica- References
tions for the use and function of different brand pacifiers. 1. Sexton S, Natale R. Risks and benefits of pacifiers. Am
Pacifiers interact with the palate differently based on their fit Fam Physician 2009;79(8):681-5.
(i.e., design and size) regardless of whether they are labeled 2. Feştilă D, Ghergie M, Muntean A, Matiz D, Şerb Nescu
conventional or orthodontic.43 Pacifier sizing has been brought A. Suckling and non-nutritive sucking habit: What
into focus for the role it plays in providing palatal support should we know? Clujul Med 2014;87(1):11-4.
to prevent loss of transverse palatal dimensions and causing 3. American Academy of Pediatrics Section on Breastfeeding,
palatal collapse.30,31,43-45 Palatal collapse contributes to the early Eidelman AI, Schanler RJ, et al. Breastfeeding and the
development of posterior crossbites.29,45,46 The use of biometrics use of human milk. Pediatrics 2012;129(3):e827–e841.
to aid pacifier selection has shown promise in recent research.47,48 4. Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of
restricted pacifier use in breastfeeding term infants for
Benefits of pacifiers use increasing duration of breastfeeding. Cochrane Database
Based on good-quality patient-oriented evidence, the AAP Syst Rev 2016;(8):CD007202.
recommends offering a pacifier when an infant is placed to 5. Staufert Gutierrez D, Carugno P. Thumb Sucking.
sleep due to its protective effect on the incidence of sudden [Updated 2021 May 19]. In: StatPearls [Internet]. Trea-
infant death syndrome (SIDS), but a pacifier should not be sure Island (FL): StatPearls Publishing; January 2021.
forced on resistant infants.49 This recommendation is sup- Available at: “https://www.ncbi.nlm.nih.gov/books/NBK
ported by other organizations such as the International Society 556112/”. Accessed February 26, 2022.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 87

ORAL HEALTH POLICIES: PACIFIERS

6. Augustyn M, Frank DA, Zuckerman BS. Infancy and 19. U.S. Food and Drug Administration. Honey pacifiers
toddler years. In: Carey WB, Crocker AC, Elais ER, suspected in Texas infant botulism cases. FDA reminds
Feldman HM, Coleman WL eds. Developmental- parents not to feed honey to children younger than 1 year.
Behavioral Pediatrics. 4th ed. Philadelphia, Pa.: Saunders; November 16, 2018. Available at: “https://www.fda.gov/
2009:24-38. food/alerts-advisories-safety-information/honey-pacifiers-
7. Borrie, FR, Bearn, DR, Innes NP, Iheozor-Ejiofor Z. suspected-texas-infant-botulism-cases#:~:text=The%20
Interventions for the cessation of non-nutritive sucking FDA%20is%20recommending%20parents,it%20and%
habits in children. Cochrane Database Syst Rev 2015; 20discard%20it%20immediately”. Accessed February 5,
2015(3):CD008694. 2022.
8. American Academy of Pediatrics. Pacifier Safety. Caring 20. Comina E, Marion K, Renaud FN, Dore J, Bergeron E,
for your Baby and Young Child: Birth to Age 5. Updated Freney J. Pacifiers: A microbial reservoir. Nurs Health Sci
November 19, 2018. Available at: “https://www.healthy- 2006;8(4):216-23.
children.org/English/safety-prevention/at-home/Pages/ 21. Lopes DF, Fernandes RT, Medeiros YL, Apolonio ACM.
Pacifier-Safety.aspx”. Accessed February 26, 2022. Disinfection of pacifier focusing on Candida albicans.
9. U.S. Consumer Product Safety Commission. Pacifiers Clin Pediatr (Phila) 2019;58(14):1540-3.
Business Guidance. Available at: “https://www.cpsc.gov/ 22. Nelson-Filho P, Louvain MC, Macari S, et al. Microbial
Business--Manufacturing/Business-Education/Business- contamination and disinfection methods of pacifiers.
Guidance/Pacifiers-Business-Guidance”. Accessed February J Appl Oral Sci 2015;23(5):523-8.
26, 2022. 23. Larsson E. Artificial sucking habits: Etiology, prevalence
10. Stone KN, Fleming P, Golding J. Socio-demographic and effect on occlusion. Int J Orofacial Myology 1994;
associations with digit and pacifier sucking at 15 months 20(1):10-21.
of age and possible associations with infant infection. 24. Germa A, Clement C, Weissenbach M, et al. Early risk
The ALSPAC Study Team. Avon Longitudinal Study of factors for posterior crossbite and anterior open bite in
Pregnancy and Childhood. Early Hum Dev 2000;60(2): the primary dentition. Angle Orthod 2016;86(5):832-8.
137-48. 25. Bueno SB, Bittar TO, Vazquez FL, et al. Association of
11. Warren JJ, Levy SM, Kirchner HL, et al. Pacifier use and breastfeeding, pacifier use, breathing pattern and maloc-
the occurrence of otitis media in the first year of life. clusion in preschoolers. Dental Press J Orthod 2013;18
Pediatr Dent 2001;23(2):103. (1):30.e1-6
12. Gederi A, Coomarawamy K, Turner JP. Pacifiers: A review 26. Ling HTB, Sum FHK, Zhang L et al. The association
of risks vs benefits. Dent Update 2013;40(2):92-101. between nutritive, non-nutritive sucking habits and pri-
13. Salah M, Abdel-Aziz M, Al-Farok A, Jebrini A. Recur- mary dental occlusion. BMC Oral Health 2018;18(1):
rent acute otitis media in infants: Analysis of risk factors. 145.
Int J Pediatr Otorhinolaryngol 2013;77(10):1665-9. 27. Adair SM, Milano M, Lorenzo I, et al. Effects of current
14. Nowak AJ, Warren JJ. Oral habits and orofacial develop- and former pacifier use on the dentition of 24- to 59-
ment in children. In: Griffen A, Torchia MM, eds. UpTo- month-old children Pediatr Dent 1995;17(7):437-44.
Date. Available at: “https://www.uptodate.com/contents/ 28. Zardetto CGC, Rodriguez CRMD, Stefani FM. Effects
oral-habits-and-orofacial-development-in-children?search of different pacifiers on the primary dentition and oral
=pacifier&sorce=search_result&selectedTitle=1~41&usage myofunctional structures of preschool children. Pediatr
_type=default&display_rank=1”. Accessed February 26, Dent 2002;24(6):552-60.
2022. 29. Schmid KM, Kugler R, Nalabothu P, et al. The effect of
15. Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical pacifier sucking on orofacial structures: A systematic
practice guideline: The diagnosis and management of literature review. Prog Orthod 2018;19(1):8.
acute otitis media. Pediatrics 2013;131(3):e964-e999. 30. Lima AADSJ, Alves CMC, Ribeiro CCC, et al. Effects
Errata: Pediatrics 2014;133(2):346-7. of conventional and orthodontic pacifiers on the dental
16. Nelson AM. A comprehensive review of evidence and occlusion of children aged 24-36 months old. Int J
current recommendations related to pacifier usage. J Paediatr Dent 2017;27(2):108-19.
Pediatr Nurs 2012;27(6):690-9. 31. Warren JJ, Bishara SE. Duration of nutritive and non-
17. Burr S, Harding S, Wren Y, Deave T. The relationship nutritive sucking behaviors and their effects on the dental
between feeding and non-nutritive sucking behaviours arches in the primary dentition. Am J Orthod Dento-
and speech sound development: A systematic review. facial Orthop 2002;121(4):347-56.
Folia Phoniatr Logop 2021;73(2):75-88. 32. Duncan K, McNamara C, Ireland AJ. Sucking habits in
18. Strutt C, Khattab G, Willoughy J. Does the duration and childhood and effects on the primary dentition: Findings
frequency of dummy (pacifier) use affect the develop- of the Avon Longitudinal Study of Pregnancy and
ment of speech? Int J Lang Commun Disord 2021;56 Childhood. Int J Paediatr Dent 2008;18(3):178-88.
(3):512-27.

88 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ORAL HEALTH POLICIES: PACIFIERS

33. Bishara SE, Watten JJ, Broffitt B, et al. Changes in the 47. Lee CL, Costello M, Tesini DA. Computational simulation
prevalence of nonnutritive sucking patterns in the first 8 of pacifier deformation and interaction with the palate.
years of life. Am J Orthod Dentofacial Orthop 2006;130 Clin Exp Dent Res 2021;7(5):884-7. Available at: “https:
(1):31-6. //onlinelibrary.wiley.com/doi/10.1002/cre2.428”. Accessed
34. Montaldo L, Montaldo P, Pasquale P, et al. Effects of June 26, 2022. Corrigendum: Clin Exp Dent Res 2022;
feeding on non-nutritive sucking habits and implications 8(2):610.
on occlusion in mixed dentition. Int J Paediatr Dent 48. Tesini DA, Hu LC, Usui BH, Lee CL. Functional com-
2011;21(1):68-73. parison of pacifiers using finite element analysis. BMC
35. Lima Vasquez F, Castro Meneghim M. Association of Oral Health 2022;22:49. Available at: “https://bmcoral
breastfeeding, pacifier use, breathing pattern and maloc- health.biomedcentral.com/articles/10.1186/s12903-022
clusions in preschoolers. Dental Press J Orthod 2013;18 -02087-4”. Accessed June 26, 2022.
(1):1-6. 49. American Academy of Pediatrics Task Force on Sudden
36. Melink S, Vagner MV, Hocevar-Boltezar I. Posterior Infant Death Syndrome. SIDS and other sleep-related
crossbite in the deciduous dentition period, its relation infant deaths: Updated 2016 recommendations for a safe
with sucking habits, irregular orofacial functions, and infant sleeping environment. Pediatrics 2016;138(5):
otolaryngological findings. Am J Orthod Dentofacial e20162938.
Orthop 2010;138(1):32-40. 50. International Society for the Study and Prevention of
37. Lopes Freire GM, Suarez de Deza JEE, Rodrigues IC, et Perinatal and Infant Death. How to keep your baby
al. Non-nutritive sucking habits and their effects on the healthy and reduce the risk of sudden infant death
occlusion in the deciduous dentition in children. Eur J (SIDS). July 5, 2020. Available at: “https://www.ispid.org/
Paediatr Dent 2016;17(4):301-6. infantdeath/id-prevention”. Accessed February 5, 2022.
38. Larsson E. Sucking, chewing, and feeding habits and the 51. U.S. Department of Health and Human Services Safe
development of crossbite: A longitudinal study of girls
from birth to 3 years of age Angle Orthod 2001;71(2):
®
to Sleep campaign. Safe Sleep for Your Baby. Reduce
the Risk of Sudden Infant Death Syndrome (SIDS) and
116-9. Other Sleep-Related Causes of Infant Death. NIH Pub
39. Cenci VS, Marciel SM, Jarrus ME, et al. Pacifier-sucking No 17-HD-7040, June 2017. Available at: “https://
habit duration and frequency on occlusal and myofunc- www.nichd.nih.gov/sites/default/files/publications/pubs
tional alterations in preschool children. Braz Oral Res /Documents/NICHD_Safe_to_Sleep_brochure.pdf ”.
2015;29(1):1-7. Accessed February 5, 2022.
40. Wagner Y, Heinrich-Weltzien R. Effect of a thin-neck 52. Lubbe W, Ten Ham-Baloyi W. When is the use of
pacifier on primary dentition: A randomized controlled pacifiers justifiable in the baby-friendly hospital initiative
trial. Orthod Craniofac Res 2016;19(3):127-36. context? A clinician’s guide. BMC Pregnancy Childbirth
41. Corrêa CC, Sallas Bueno MR, Pereira Lauris JB, et al. 2017;17(1):130.
Interference of conventional and orthodontic nipples in 53. Campos RG. Rocking and pacifiers: Two comforting
system stomatognatic: Systematic review 2016. Codas interventions for heelstick pain. Res Nurs Health 1994;
2016;28(2):182-9. 17(5):321-31.
42. Medeiros R, Ximenes M, Massgnam C, et al. Malocclusion 54. Marter A, Agruss JC. Pacifiers: An update on use and
prevention through the usage of an orthodontic pacifier misuse. J Spec Pediatr Nurs 2007;12(4):278-85.
compared to a conventional pacifier: A systematic review. 55. Vu-Ngoc H, Uyen NCM, Thinh OP, et al. Analgesic effect
Eur Arch Paediatr Dent 2018;19(5):287-95. of non-nutritive sucking in term neonates: A randomized
43. Tesini DA. Design, sizing and ergonomics of infant controlled trial. Pediatr Neontol 2020;61(1):106-13.
pacifiers: A biometric basis for pacifier fit. Pediatr Nurs 56. Caruso, S. Nora A, Darvizeh A, et al. Poor oral habits
2022;48(1):36-41. and malocclusion after usage of orthodontic pacifiers:
44. Lindner A, Hellsing E. Cheek and lip pressure against An observational study on 3-5 year-old children. BMC
the maxillary dental arch during dummy sucking. Eur J Pediatr 2019;19(1):294.
Ortho 1991;13(5):362-6. 57. Fukumoto E, Fukumoto S, Kawasaki K, et al. Cessation
45. Levrini L, Merlo P, Paracchini L. Different geometric age of breastfeeding and pacifier use is associated with
patterns of pacifiers compared on the basis of finite persistent finger-sucking. Pediatr Dent 2013;35(7):506-9.
element analysis. Eur J Paediatr Dent 2007;8(4):173-8.
46. Doğramacı EJ, Rossi-Fedele G. Establishing the associ-
ation between nonnutritive sucking behavior and maloc-
clusions: A systematic review and meta-analysis. J Am
Dent Assoc 2016;147(12):926-34.

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