SIDS and pacifiers

June 30, 2006
The connection between Sudden Infant Death Syndrome and pacifiers is explored in several studies, leading to precautionary measures that are still debated.

By Michelle Hurlbutt, RDH, BS

Baby season is here! More than four million babies are born in the United States each year, with the biggest birth months being July, August, and September. With the excitement of new life comes the worry of parenthood. A universal worry among most parents is Sudden Infant Death Syndrome (SIDS). We know the nightmare &mash; a young baby goes to sleep and does not wake up.

Sudden Infant Death Syndrome (SIDS) continues to represent the leading cause of death in infants between two weeks and 12 months of age.(1) SIDS is the unexplained death of an infant, under age 1, after all attempts to determine the cause of death, including an autopsy, have been investigated.(2) According to the Centers for Disease Control and Prevention, SIDS accounts for 7.7 percent, or 2,162 deaths per year.

There is some good news related to SIDS. Our national public education campaign promoting a supine sleeping position for the infant has significantly reduced SIDS in the United States. The "Back to Sleep" campaign, introduced in 1994, has resulted in a 50 percent reduction in the rate of SIDS.(3)

To learn more about this campaign, go to Evidence demonstrates that SIDS is a multifactorial disorder, influenced by many risk factors ranging from placing the infant in a prone sleep position, to infant overheating, to maternal smoking. Other factors associated with SIDS include infants born to mothers who are less than 20 years old at the time of their first pregnancy, babies born to mothers with late or no prenatal care, premature or low-birth-weight babies, and infants born to mothers with too short of an interval between pregnancies. Statistics also show that SIDS peaks between two and four months, more deaths among males (60 percent), as well as more deaths during the fall/winter months. Interestingly, recent studies reveal a possible association between pacifier use and SIDS.

A meta-analysis reviewed seven published case-control studies on SIDS.(4) Five articles provided data for both usual and last sleep pacifier use, and two provided data for last sleep pacifier use only. The analysis revealed a strong correlation between pacifier use during sleep and a lower risk of SIDS, as much as 61 percent. The authors of the meta-analysis discussed the literature that focused on arousal, mouth-breathing, and sleep position to explain this protective effect of the pacifier. The authors concluded that pacifier use should be encouraged and is, "likely to be beneficial on a population-wide basis: One SIDS death could be prevented for every 2,733 infants who use a pacifier when placed for sleep."

Since this analysis, two other studies supporting pacifier use have been published, one from Germany and one from California. The California study examined cases of SIDS from 11 counties that were reported to the California Department of Health Services and to the coroner's office in Los Angeles County.(5) This population-based case-control study looked at 185 infants who died from SIDS compared to 312 normal infants of similar age and socioeconomic and ethic backgrounds. Odds ratios were used to predict the relative risk of SIDS associated with pacifier use and concluded that a 92 percent reduction to risk was seen with the use of a pacifier. This association was present with both breast-fed and bottle-fed infants.

Explanations offered on the protective effects of the pacifier include:(6)

• May keep the tongue in a more forward position, reducing airway obstruction

• May increase upper airway muscle tone and reduce likelihood of airway collapse during sleep

• May reduce apneic periods by stimulating airway drive

• May ease the transition to oral breathing from nasal breathing if the nasal airway becomes occluded

• May prevent infant from turning to a prone position during sleep

• May keep infant's nose free of bedding to maintain adequate air supply

• May quiet a restless infant, thus reducing likelihood of infant placing his/her head under bedcovers

• May produce saliva, which in turn may stimulate swallowing, which may have some protective role

• May reduce the potential for gastroesophageal reflux

• May alter mother's behavior, causing her to check her infant more frequently for pacifier loss

The American Academy of Pediatrics supported this evidence and amended its guidelines on preventing SIDS in October 2005. The new guidelines reiterate the importance of the supine position for sleep and suggest that a pacifier be used during the first year of life according to the following procedures:

• The pacifier should be used when placing the infant down to sleep and not be reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it.

• Pacifiers should not be coated in any sweet solution.

• Pacifiers should be cleaned often and replaced regularly.

• For breastfed infants, delay pacifier introduction until one month of age to assure that breastfeeding is firmly established.

To see the AAP amended guidelines, go to

These new guidelines have set off a firestorm of criticism. Debate among researchers center on the use of the last sleep data as a source of evidence as well as the effect of pacifier use measured in terms of odds ratio. Breastfeeding organizations also have weighed in on these recommendations for pacifier use. The La Leche League International ( claims that pacifiers could lead to a reduction in milk supply due to reduced stimulation of the breasts and may affect breastfeeding duration. The Academy of Breastfeeding Medicine ( states that pacifier use has been associated with increased risk of ear infections, later dental problems, and reduced breastfeeding.

Dr. Fern Hauck, principal author of the meta-analysis supporting pacifier use, recently commented on this debate. In the May 2006 issue of Pediatrics, the official journal of the American Academy of Pediatrics, Dr. Hauck pointed out that the evidence supporting the protective effects of the pacifier have been available as early as 1979 and the reluctance to recommend pacifiers is comparable to the initial concerns associated with recommendations against prone sleeping. She stressed that health-care providers should inform parents about the AAP guidelines and share both sides of the controversy. Dr. Hauck stated, "It is especially important to tell mothers who are not breastfeeding, because they tend to have other characteristics that may place their infants at greater risk for SIDS." And goes on to conclude that, "As with every infant-care practice, parents are ultimately responsible. It is our responsibility to provide them with well-balanced, unbiased information to help them make these important decisions."(7)

Michelle Hurlbutt, RDH, BS, graduated from the University of Nebraska and has lived in Upland, California since 1985. She has been an active member of our professional association since her graduation and has held numerous positions, including President of the Nebraska Dental Hygienists' Association, President of the Tri County Dental Hygienists' Society, ADHA District XI Trustee, ADHA Delegate, CDHA Component Trustee and Associate Editor to the CDHA Journal. Her career has included clinical practice, education, public health, corporate sales, national lecturing, and consulting. Michelle works two days a week for William Domb, DMD, in Upland, CA. In addition, she works as a public health dental hygienist for San Bernardino county and is an adjunct dental hygiene faculty two days a week at Riverside Community College. She serves on the board of directors for the Dental Health Foundation and is an active member of the Oral Health Access Council, a state-wide coalition dedicated to increasing access to care for all Californians. Always up for a new challenge, Michelle begins her online MSDH program in September 2004 through the University of Missouri, Kansas City. She is married to her high school sweetheart, Lee and has two children, Kaitlin and Matthew.

1. Hauck FR, Herman SM, Donovan M, Iyasu S, Merrick Moore C, Donoghue E, Kirschner RH, Willinger M. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago infant mortality study. Pediatrics.111. 5 Part 2. (2003); 1207-14.
2. Krous HF, Beckwith JB, Byard RW, Rognum TO, Bajanowski T, Corey T, Cutz E, Hanzlick R, Keens TG, Mitchell EA. Sudden infant death syndrome and unclassified sudden infant deaths: a definitional and diagnostic approach. Pediatrics.114.1. (2004); 234-8.
3. SIDS: "Back to Sleep Campaign." Dec. 22, 2005. National Institutes of Health, National Institute of Child Health and Human Development. June 12, 2006.
4. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics.116.5. (2005); e716-23.
5. Li DK, Willinger M, Petitti DB, Odouli R, Liu L, Hoffman HJ. Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population based case-control study. BMJ.7.332. (2005); 18-22.
6. Adair SM. Pacifier use in children: a review of recent literature." Pediatric Dentistry. 25.5. (2003); 449-458.
7. Hauck FR. Pacifiers and sudden infant death syndrome: what should we recommend? Pediatrics. 117.5. (2006); 1811-1812.