Pacifiers and Sleep: Blessing or curse?

Have you ever tried to get a straight answer when it comes to the pacifier? The sleep books dance around it, online information is so conflicting, so what does the scientific literature really say about pacifier use?

The Science

There are benefits and drawbacks to pacifier use, making it difficult to decide whether to use a pacifier. Pacifier (or dummy) use is considered "non-nutritive sucking" by researchers, along with thumb and finger sucking (see our blog on thumb sucking here). Sucking is natural and soothing and can help a baby or toddler transition to sleep without other sleep associations like rocking or feeding to sleep. However, pacifier use can also become a powerful sleep association, leading some babies to wake up every 1-2 hours all night long needing to have it replaced. In addition, some studies suggest that pacifier use interferes with breastfeeding during the first few months of a babies life. On the other hand, pacifier use may help reduce the risk of SIDS. As a result, the American Academy of Pediatrics (AAP) suggests that parents consider using the pacifier when placing a baby down for sleep at all naps and night sleep during the first year after breastfeeding has been established. Here’s the full link for your reference.

Of course, we recommend following the AAP guidelines on paci use, yet we know those recommendations aren’t always what families do. Some babies won’t take a pacifier and that's ok. Some babies love their pacifiers too much and their sleep-deprived parents aren’t able to take naps due to work demands or multiple children. Those parents may make the choice to stop using the pacifier before the age of one after weighing the risks of their own sleep deprivation while driving or performing their job tasks vs their baby’s individual risk factors for SIDS (of which the pacifier is just one small part)!

If your baby requires multiple pacifier replacements all night long, then talk with your pediatrician to determine whether stopping the pacifier makes sense. Below are our tips and tricks for pacifier use at different stages of a baby's development.

For babies under 4 1/2 months:

It's ok to offer the pacifier if your baby will take it, but don't try to force your baby to take it. Although a baby will often sleep well with a pacifier during the first few weeks and months, pacifiers can become strong sleep associations by the time a baby is 3-4 months old (see our blog on the four month regression). If you are worried that your baby depends on the pacifier for sleep, then it's ok to give your baby some practice going to sleep without it. For example, you might rock or pat your baby to sleep without the pacifier a few nights a week. If the pacifier becomes a problem (i.e., you replace it over and over), you might consider very interactive sleep training after four months at bedtime only to help your baby learn to sleep and self-soothe without the pacifier. We recommend starting only at bedtime because four-month-olds are still very young and long bouts of frustration can lead to extreme sleep loss. For more information on newborns and sleep see our blogs on the dream feeding, swaddling and common age by stage schedules. Safety note: never tie, clip, or attach the paci to your baby in the crib.

For babies between 4 ½ -7 months:

These are the hardest months because a baby can develop a strong dependence on a pacifier to fall asleep, but can't replace it independently. This means that you may find yourself replacing the pacifier as often as every nighttime sleep cycle (60-90 minutes), especially during the second half of the night.

Some parents stop the pacifier completely at this point because it’s just too tiring to keep replacing it so many times a night. You may choose to do sleep training in the first half of the night and/or rock , hold, or soothe your baby in another way as s/he gets used to the change (our online sleep training class discusses how to deal with the pacifier). Learning to sleep without the pacifier is not easy, so expect several difficult nights.

Other parents opt to try a split night paci option (kind of like the split night swaddle) as a step on the path towards independent sleep. With a split night you would stop using the pacifier at bedtime and throughout the first half of the night, pairing any non-feeding wakings with a sleep training method that feels like a good fit for you and your baby. At this age your baby will have deeper sleep in the first part of the night making it easier for your baby to learn this new skill. As you cross into the second half of your night, when sleep may still be maturing, sleep pressure is low, and lighter sleep dominates, you may find yourself using the paci and/or a feeding or two as a way to just survive the rest of the night until your baby gets just a little older and is ready for full night sleep training. You can end up with one LONG stretch of paci – free sleep, followed by the last irregular stretch of the night. It’s not perfect, but it’s a step in the direction of independence from the pacifier.

During this time, you may continue to use the pacifier during the day for naps! It’s actually important to keep your baby well rested during the day while you are working on nighttime changes so go ahead and keep using the paci during the day if it’s helpful for the daytime naps. It is behaviorally inconsistent, but your baby would likely lose a lot of sleep during the day while learning to sleep without the pacifier. Such additional sleep loss can be too much for babies this age and can make night waking worse.

Finally, some parents will want to keep the paci. You'll teach your baby to find the pacifier by guiding your baby's hand to it during wake ups (see below for more detail). In this case, you'll still have many pacifier replacements throughout the night until your baby is old enough to replace it independently.

For babies over 7 months:

Most babies can start to learn to find their pacifiers on their own around this age. Practice, practice, practice the skill during the day and be sure your baby has access to plenty of pacifiers in the night. Creating a paci corner with a stash of them in the same spot may be helpful as your baby learns to reach up and grab another if one falls out of the crib. Allow your baby to be in charge of the paci now. Hold one up in your hand and say, “get your paci” with some verbal coaching. Or, when bedtime routine is over, place your baby into his/her crib and coach/cue your baby by saying, “find your paci” and then rub his tummy or cheek for a moment or two as some last steps in your bedtime routine. In other words – around the 7 month mark is the time for you to step back and let your baby be in charge of his paci as much as s/he can! If you find yourself needing to start some sleep training and you’d like to keep the pacifier, be sure you let your baby be in charge of finding it for soothing as your go through your responses! For more information on this, our online sleep training class also covers how to sleep train while teaching your baby to find the pacifier. Safety note: Never tie or clip the pacifier to your child or anything in the crib.

If you decide to stop the paci at this point, it’s generally best to stop it for the full night. Your baby is old enough now for full night sleep training if needed and consistency is always best. You may continue to keep the paci for naps while you work on nights to preserve daytime sleep but when nights are on track, you’ll probably want to work on naps shortly thereafter. In some cases, babies keep their pacifiers at daycare or with a nanny although they never use one for their parents.

Please do not allow your baby to fall asleep at bedtime WITH the pacifier and then later deny it to him/her when s/he’s having trouble going back to sleep. Removing the pacifier after your baby has fallen asleep is also largely useless since the sucking-to-sleep association has already occurred at bedtime and will then likely need to be repeated in the night.

Age One +

As you approach age one you’ll find yourself at another paci-crossroads. You’ve made it as far as the AAP recommends and now you have a decision to make. Keep it for the long haul, or stop it altogether. If the pacifier is not on your radar at all as a soothing tool for your toddler, now’s the time to stop it completely.

If you are open to extended pacifier use, you might be surprised to hear us say that if you’ve kept the pacifier as long as one year AND your child loves it and you do too, plan to keep it until your child is at least three. That’s right, at least age three!

After the first year, chances are your baby has become very bonded with the paci as a soothing tool and it’s embedded in the quality of sleep. If you stop the pacifier at, say 18 months or 27 months, your child may have trouble figuring out what to do for soothing and may pick up something more maladaptive like body rubbing, rocking or banging AND, most importantly if you pull the pacifier at age 2, you may pull the nap with it!

Some important ground rules for extended pacifier use during ages 1-3+:

1. Coping and Speech: The paci is for sleep and lives in the crib. There may be a few other exceptions like on a long car trip, or at a religious service but for the most part, the paci is for sleep only. This will help you avoid using it as a coping tool for your toddler when s/he gets upset. Help your child learn other age-appropriate coping strategies instead. Keeping paci use limited to sleep times will also prevent the paci from impacting speech. Toddlers who walk around with their pacifiers for hours a day are at increased risk for speech problems and delays.

2. Oral care: Be sure you are doing mouth/gum care AFTER milk and BEFORE inserting a pacifier. At this age, pacifier or not– you need to brush or clean your baby’s mouth and gums AFTER any milk and before bed.

3. Ear Infections: Some studies indicate paci use may contribute to ear infections. If your child suffers from chronic ear infections, talk to his/her pediatrician about his/her risk factors.

4. Child-led Use: At bedtime and in the night let your child be in charge of the paci. Your job is simply to make sure s/he has access to them if s/he needs them. Keep a little stash in the same corner of the crib each night or have a small, child friendly bowl of them on a dresser or floor next to a toddler bed.

6. Extended Crib Time: Paci lovers tend to hang out in their cribs more than other babies – don’t abuse this. Just because your child will happily lie in his/her crib if it means s/he can suck on his/her pacifier, doesn’t mean you should let him/her. Meet your child’s developmentally appropriate sleep needs.

7. Dental issues: There is some evidence that extended pacifier use can cause a crossbite or increased dental arch, although it is unclear whether these concerns develop when pacifier use is limited to sleep. As a result, we recommend that you inform your pediatrician that your child is using a pacifier after age one. Your pediatrician may refer you to a pediatric dentist for further evaluation.

Stopping the pacifier with older toddlers: If your child is still in a crib (which we recommend until age 3, see our blog on that here), stop the pacifier FIRST in the crib and establish good sleep there, and then move your child to a bed. Stop the paci around times of relative developmental calm (ie: not while toilet training, not the week new sibling arrives or at the start of the school year). Specific strategies to move away from the pacifier include:

1. Start offering a replacement lovey – something you hope will take the place of the pacifier. You might take your child to a store together and pick out something soft, small and appropriate for sleep (our blog on choosing a lovey is here). At first, this lovey can be used frequently during the day (such as in a carseat, stroller, or while reading a book to promote bonding while the pacifier is not in use) as well as night. Later, it’s often helpful if loveys, like pacifiers, are used for times of sleep.

2. Set a date to stop the paci and inform your child: You should let your child know when the pacifiers will go away. Try to avoid making your child anxious. Stay calm and keep the tone light. You can also do modeling with a toy or stuffed animal during pretend play time (e.g., do a few "naps" giving the paci to a stuffed animal and a few without, where you offer redirecting comforts). Please don’t make this transition about a new baby, going to school, or time to “be a big kid.”

3. When the big night arrives – just do it! Start at bedtime FIRST because that is when the sleep drive is strongest. There’s really no 50/50 with the pacifier – your child either has them or s/he doesn’t.

Here are some popular paci strategies for 3 year olds:

The Dentist: At your child's 3 year old dental check up, call ahead and ask the dentist to talk to your child briefly and gently about keeping healthy teeth and the big teeth that will be growing in. The dentist (and you!) can talk about how one of the ways to keep teeth healthy is to stop using the pacifier. Later, you can pack them up, and drop them off at the dentist – all of them!

Paci Donation: Take this opportunity to start an age appropriate conversation about babies who might be less fortunate than yours and who might not have any pacifiers of their own. Package up the pacifiers and "give" them to another child or donation center.

Paci Fairy: Just like it sounds – the pacifier fairy comes in the night, gathers up all of the pacifiers and leaves a small gift in their place.

Paci as Currency: Allow your child to “buy” a special toy or experience s/he’s been hoping for with the pacifiers.

When deciding what will be the best fit for your child as s/he transitions into life without the pacifier, please don’t trick your child and please don’t cut the nipple (sabatoge the paci) as this could become a choking hazard.

Remember, life without the pacifier will be hard for your child. The adjustment period could be three days or three weeks. It depends on how old your child is and how strong their habit was! Be prepared to be very supportive and assure your preschooler you know this will be hard and you’ll help him/her through it. Plan a sleep training method of your choice that feels like a good fit for you and your child – probably one leaning on the more interactive side as a starting point for toddlers.

As always, if you need help, more step-by-step guidance, or have questions – we're happy to work with you in a one-on-one consultation.

References

Strutt, C., Khattab, G. and Willoughby, J., 2021. Does the duration and frequency of dummy (pacifier) use affect the development of speech?. International Journal of Language & Communication Disorders, 56(3), pp.512-527.

Schmid, K.M., Kugler, R., Nalabothu, P., Bosch, C. and Verna, C., 2018. The effect of pacifier sucking on orofacial structures: a systematic literature review. Progress in orthodontics, 19, pp.1-11.

Butler, R., Moore, M. and Mindell, J.A., 2016. Pacifier use, finger sucking, and infant sleep. Behavioral sleep medicine, 14(6), pp.615-623.