AAP Recommendations on Pacifier Use in Children

Benefits & When to Use

• The AAP recommends offering a pacifier at the onset of sleep (naps and nighttime) due to its well-documented protective effect against sudden infant death syndrome (SIDS).
• A pacifier should not be forced on a resistant infant.
• If it falls out after the infant falls asleep, it does not need to be reinserted.

• The AAP recommends delaying pacifier introduction in breastfed infants until breastfeeding is well established, typically around 1 month of age.
• However, a Cochrane systematic review found that pacifier use - whether from birth or after lactation is established - did not significantly harm breastfeeding duration or exclusivity.

• The AAP recommends pacifier use (especially with sucrose solution) in infants up to 6 months of age for analgesia during minor invasive procedures (e.g., venipuncture, lumbar puncture).

• The AAP supports pacifier use in preterm infants for non-nutritive sucking, which helps develop the sucking reflex, may shorten hospital stay, and facilitates earlier transition to oral feeding.

Risks & When to Stop

• The AAP/AAFP joint guidelines recommend reducing or stopping pacifier use in the second 6 months of life (6-12 months) to reduce the risk of acute otitis media (ear infections).
• Some guidelines suggest avoiding pacifier use after 10 months entirely.

• The AAP recommends weaning by age 1, partly due to the increased risk of ear infections with continued use.
• The AAPD (aligned with AAP messaging) recommends discontinuing all non-nutritive sucking habits by 36 months at the latest to prevent dental malocclusion.

• Prolonged pacifier use is associated with:
  • Anterior open bite
  • Posterior crossbite
  • Dental malocclusion
• These risks increase significantly beyond age 2-3. Evidence is insufficient to prefer orthodontic pacifiers over conventional ones in preventing malocclusion.

Safety Guidelines

• The shield must be firm, have ventilation holes, and measure at least 1.5 inches (3.8 cm) across - wide enough that it cannot fully enter the mouth.
• No straps, cords, or attachments (prohibited by the U.S. Consumer Product Safety Commission).
• Single-piece construction is preferred to reduce choking hazard.
• Caregivers should regularly inspect pacifiers for structural wear or damage.
• Pacifiers should never be coated in honey (botulism risk) or sugar.

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