Should I give my baby a dummy?
Should I give my baby a Dummy?
When I chose to write this blog about dummies/pacifiers I was surprised to almost disappear down a research rabbit hole! This article considers the pros and cons of dummy use according to the available evidence, and I found there is a LOT of research to consider. Dummies or pacifiers have been used in various forms to settle infants for centuries. The dummies currently available are similar to those that have been available for decades.
Non-Nutritive Sucking
Suckling without fluid transfer is called non-nutritive sucking (NNS). Non-nutritive sucking is considered a normal part of fetal and neonatal development. As early as 13–16 weeks gestation the fetus has started sucking and swallowing movements.
These fetal movements are considered to be important precursors for the life- sustaining requirements of breathing and swallowing. Non-nutritive sucking is intimately related with the rooting reflex, which is the movement of the infant’s head and tongue towards an object touching its cheek. The object is usually the mother’s breast, but may also be a finger (parent’s or baby’s own) or a pacifier.
Non-nutritive sucking in infants is nearly universal and is considered normal. A variety of non-nutritive sucking habits exist, but thumb, digit and pacifier sucking are most common. Pacifiers/dummies encourage NNS - the immature front-back action of suckling.1
Some newborn babies demonstrate their own version of NNS by sucking their tongues or lips in utero. This habit established before birth can sometimes interfere with a baby’s ability to latch and effectively suckle at the breast, temporarily. “Suck training” on a parents’ finger can coaxe the babies tongue position forward, and when rewarded with small amounts of colostrum/breastmilk the baby discovers a more appropriate way of sucking which is more rewarding.
Using Dummy’s Whilst Breastfeeding
Concerns have been raised about the use of dummies and teats during breast feeding. Historically, the WHO Baby Friendly Health Initiative (BFHI) have strongly advised against the use of pacifiers and teats because it interferes with breastfeeding and significantly decreases duration of lactation. (BFHI Step 9). This advice was modified in 2018 in response to evidence-based research, to read: “Counsel mothers on the use and risks of feeding bottles, teats and pacifiers”.
The impact of pacifier use on breastfeeding has been the subject of numerous studies. The objective of one large study conducted in Argentina was to evaluate whether the recommendation to offer a pacifier once lactation was well established reduced the prevalence or duration of lactation. The population included 1023 mothers who were highly motivated to breastfeed whose newborns regained birth weight by 15 days. Mothers were randomly assigned to one of two groups: offering a pacifier, and not offering pacifier. The offering group received a package containing six silicone pacifiers, supplied by MAM Babyartikel Gesmbh and not sold in Argentina. The study demonstrated that when mothers are determined to breastfeed for more than three months and they are successfully breastfeeding at two weeks the advice to use or not to use a pacifier does not affect breastfeeding. Results from four other randomised controlled trials also revealed no difference in breastfeeding outcomes in different types of pacifier interventions 2.
There is little evidence that dummy use adversely influences breast feeding development in pre-term babies. The literature indicates benefits of using non- nutritive sucking with infants who are premature. Non-nutritive sucking benefits pre- term babies in terms of successful transition to oral feeding and quicker discharge home. Note - this does not necessarily refer to breastfeeding, and may in fact refer to oral feeding via bottle and teat 3.
Providing NNS using a pacifier has shown to reduce babies’ distress during painful medical procedures. Likewise, a landmark study “Pacifiers and Sudden Infant Death Syndrome” carried out in 1993 first showed the connection between SIDS and pacifiers, specifically, the reduced risk of SIDS if a pacifier had been used. This was supported by eleven further case-control studies which compare a treatment or intervention group with a group which have not received the treatment. These studies showed the risk of SIDS was reduced by approximately 50% if a pacifier was used. Additional meta-analyses (which analyse the results of multiple studies) also reached the same conclusion. Interestingly, the use of a pacifier at the onset of sleep appeared protective, even if the pacifier falls out of the mouth after the infant falls asleep.
How are pacifiers protective in the sleep environment?
One recent study suggests that pacifiers lower the auditory arousal threshold, and they may provide a mechanical barrier to rolling over into the prone position. Sucking on a pacifier keeps the tongue forward maintaining upper airway patency. An infant who is soothed by a pacifier may not move as often during sleep, thus limiting the chance of becoming covered by blankets. It has also been suggested that pacifier use could lead to slight carbon dioxide retention and increase the respiratory drive4.
The Role of Dummies in Infant Feeding
So, the humble dummy might not be the demonic tool some clinicians warn parents must avoid. Common sense should have a place here, amongst the auspicious research. Like any tool, it is how it is used which determines its effectiveness, or otherwise. Dummies CAN be misused, for example, as a means of making baby wait longer between feeds aka “stretching feed times”. This is never appropriate. Regardless of whether baby is breastfed or bottle fed, babies should be fed when they indicate they are hungry.
Dummy use may suppress hunger cues, or parents may miss noticing baby’s cues which can lead to less frequent feedings, insufficient weight gains and reduced lactation in breastfeeding mothers. Breastfeeds may be cut short if the mother does not permit a period of non-nutritive suckling towards the end of a feed phase, and gives baby a dummy instead. This can result in baby failing to cue for further phases of the feed which could compliment the initial breastfeed phase by providing an opportunity to transfer some of the higher-fat, slower flowing milk which completes the breastfeed.
Missing or misunderstanding hunger cues can happen more easily in the first few weeks of baby’s life. These early days of apparently endless feeds and nappy changes are crucial for baby’s wellbeing, as well as stimulating the initiation and establishment of a mother’s breast milk supply. For this reason avoiding dummy use in the first few weeks is usually recommended by health professionals.
Which dummy shape is best?
Pacifier use has been implicated as potentially contributing to increased risk of ear infections, particularly in older infants. However, other studies have not found evidence to attribute direct causality, with socio-demographic characteristics influencing results 5. Which leads to the next question: Which dummy shape is the best? The quest to answer this led me even deeper down the research rabbit hole. A venture to internet shopping revealed a dazzling range of dummy choices. To keep it simple, there are 4 basic shapes on offer – orthodontic, cylindrical, butterfly and cherry shapes.
This is where the research got heavy. Really, heavy. The pro-orthodontic shape recommendations are underpinned by elaborate modelling experiments which calculate the forces exerted by various shaped dummies inside a simulated infant oral cavity. This research was conducted by orthodontic clinicians investigating the role of the pacifier as a potential cause of dental malocclusions. Their findings indicate the orthodontic shape is less likely to compromise development of the midpalatine suture, and maintains support of the transversal diameters of the premaxilla, reducing the risk of open bite.6 That’s my simplified translation!
However, nowhere in this extensive body of complicated dental research did I see any reference to pacifier/dummy use and breastfeeding efficacy or support - no human babies were used (or harmed ) during this research. Additionally, when I viewed the full text version I noted “Competing interests” are recorded, relating to several US patents (Smilo and Tomy). Keeping this information in context, the effects of pacifier use on infants’ intra-oral development is significantly determined by the duration of its use. Most commonly parents are advised to eliminate use of dummies/pacifiers by 2 years of age to avoid potential detrimental effects on the child’s primary dentition (baby teeth).
Breastfeeding is associated with optimal oral and craniofacial development in infants7 The round “cherry” shaped dummy is most commonly recommended by breastfeeding clinicians, as it most closely resembles the (ideal) shape of a human nipple. The rounded shape encourages “cupping” of the sides of the tongue, which is consistent with the tongue action during suckling at the breast. During swallowing, the tongue naturally moves towards the back of the throat, and a rounded “cherry” shape enables a similar action during non-nutritive sucking. Conversely, some “orthodontic” shaped dummies can encourage a humping of the tongue and reverse tongue movement towards the front of the mouth. This tongue action is incompatible with breastfeeding.
The cylindrical shaped dummy is commonly used in neonatal settings, often introduced to counteract pain responses during medical interventions. The small diameter of the bulb tends to suit small and premature baby’s mouths. I have not been able to find any research which demonstrates the rationale for the flat peg-shaped bulb of the Butterfly dummy. Dr Browns butterfly pacifier is marketed as being developed by a pediatric dentist to help prevent dental issues. The contoured shape of the shield curves away from baby’s nose and cheeks.
Regardless of the scientific research and artificial modelling, the method of feeding or the parents’ pre-baby plans - ultimately the baby decides. Many babies flat out reject all types of dummies. Trial and error may result in the baby declaring which dummy is acceptable, following multiple dummy purchases.
In Closing
Here’s what I have to say about using dummies in my book “NewBaby101 – A Midwife’s Guide for New Parents” Dummies or pacifiers and bottle feeding with a teat are not recommended for breastfeeding babies because they alter the way baby uses his tongue, which can confound baby’s tongue action when breastfeeding. If you choose to have a dummy on hand, choose one with a round bulb end (cherry style). The “orthodontic” or flat/wedge shaped dummies encourage a sucking action which may encourage the back of the tongue “hump” which can be detrimental to baby’s suckling action at the breast.
Towards the end of a breastfeed baby may reduce nutritive suckling and revert to non-nutritive sucking as she drifts off the sleep. This normal transition is a legitimate part of the breastfeed, enabling the milk which is still moving from her throat to her stomach to be ingested gradually, and the comfort provided by the non-nutritive sucking enhances relaxation and the transition to sleep8.
Here are some practical tips from The Raising Children’s Network 9 for everyday dummy use: If you’re breastfeeding, offer the dummy only when you can be sure your baby isn’t hungry – for example, after or between feeds. This helps to ensure that dummy-sucking doesn’t interfere with breastfeeding.
• Check the dummy regularly to see whether it’s worn or degraded. Replace the dummy if it’s broken or worn. Babies can choke on any loose bits.
• Keep spare dummies handy. Your baby is sure to drop the dummy somewhere without you noticing, then get upset when they want it again.
• Don’t dip the dummy in sweet drinks or sweet food like honey. This can cause tooth decay.
• Don’t tie the dummy around your baby’s hand, neck or cot. This is
a strangulation risk if the dummy chain or tie is long enough to catch around your baby’s neck.
Babies under 6 months should use dummies that have been sterilised. There are several ways to sterilise bottle-feeding equipment, which you can also use to sterilise dummies. From about 6 months, your child will be more resistant to infections. This means you need only to wash the dummy with soap and water, rather than sterilising it. Just make sure to squeeze out any fluid that gets inside. Choose a dummy that complies with Australian Standard AS 2432:2015
References:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462418/
2. https://researchoutreach.org/articles/pacifiers-interfere-breastfeeding-success/
3. An evaluation of the benefits of non-nutritive sucking for premature infants as described in the literature. C Hardy Arch Dis Child. 2009 Aug;94(8):636-40. doi: 10.1136/adc.2008.144204.
4. https://researchoutreach.org/articles/pacifiers-interfere-breastfeeding-success/
5. Socio-demographic associations with digit and pacifier sucking at 15 months of age and possible associations with infant infection. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood - PubMed (nih.gov)
6. Tesini, D.A., Hu, L.C., Usui, B.H. et al. Functional comparison of pacifiers using finite element analysis. BMC Oral Health 22, 49 (2022). https://doi.org/10.1186/s12903-
022-02087-4
7. Sanches MT. Clinical management of oral disorders in breastfeeding. J Pediatr (Rio J) 2004;80(Suppl 5):S155–S162. [PubMed] [Google Scholar]
