Oral habits (part 1) thumb sucking

thumb sucking pacifier habit

1. Oral Habits By - Sudeep Madhusudan Chaudhari MDS 2 nd Year Dept of Paedodontics & Preventive Dentistry

2. Contents Introduction Definitions Classification Prevalence of habit Thumb sucking Pacifier habit Tongue thrusting Mouth breathing Bruxism Lip habit Frenum thrusting Cheek biting Nail biting Postural habit Masochistic habit Conclusion References

3. Introduction Repetitive behaviours are common during childhood. Most of them are benign and self-limiting. These responses are very essential for survival of an infant and to explore the world around him/her. Oral habits may be a part of normal development, a symptom of deep rooted psychological basis or may be the result of abnormal facial growth.

4. Digit sucking, mouth breathing, tongue thrusting, lip and nail biting, bruxism, etc may be considered as some of the common oral habits seen in children. These habits bring about harmful unbalanced pressures to bear upon the immature, highly malleable alveolar ridges, the potential changes in positions of teeth and occlusion. One of the most valuable services that can be rendered as part of the interceptive orthodontic procedures is elimination of the abnormal habits before they can cause any damage to the developing dentition.

5. Definition It is a tendency towards an act which has become a repeated performance relatively consistent, fixed and easy to perform by an individual. -Boucher OC (1963) Habit can be defined as a fixed or constant practice established by frequent repetition. -Dorland(1957)

6. The frequent or constant practice or acquired tendency, which has been fixed by frequent repetition. - Butterswort (1961) An act, which is socially unacceptable. -Finn(1987) Oral habits are learned patterns of muscular contractions which are complex in nature. -Moyers(1982)

7. Classifications Obsessed (deep rooted) Intentional / meaningful eg . digit sucking, nail biting, lip biting Masochistic / self inflicting eg . gingival stripping Non obsessed (easily learned and dropped) Unintentional / empty eg . chin propping, abnormal pillowing Functional eg . mouth breathing, tongue thrusting, bruxism

8. According to James (1923) - Useful habits Include all those habits of normal function such as correct tongue position, proper respiration and deglutition. Harmful habits All those that exerts perverted stress against the dental archs and teeth eg. thumb sucking, mouth breathing, tongue thrusting

9. According to Finn (1987) - Compulsive habits Acquired as a fixation in the child to the extent that he retreats to the practice whenever his security is threatened Noncompulsive habits Children appears to undergo continuing behaviour modification, which permit them to release certain undesirable habit patterns and form new ones which are socially accepted.

10. According to Morris and Bohanna (1969) -

11. Prevalence of habit Kharbanda et al (2003): 5-13 years old children, tongue thrusting is most common (18.1%) followed by mouth breathing (6.6%). Thumb sucking (0.7%) and lip biting (0.04%) are relatively less common. Shetty , Munishi (1998): digit sucking (3.1%), pencil biting (9.8%) and tongue thrust (3.02%) highly prevalent among 3-6 years. Mouth breathing (4.6%) and bruxism (3.1%) - significant in 7- 12 years, lip/cheek biting (6%) and nail biting (12.7%) - more common in 13-16 years. Digit sucking, tongue thrust, mouth breathing and bruxism - more prevalent among boys. Lip/cheek biting, nail biting and pencil biting - more prevalent among girls. Khan I, Mandava P, Singaraju GS. Deleterious oral habits: a review. Annals and Essences of Dentistry. 2015;7(1) .

12. 1.Thumb and Digit Sucking Is defined as placement of the thumb or one or more fingers in varying depths into the mouth. – Gellin (1978) Repeated and forceful sucking of thumb with associated strong buccal and lip contractions. – Moyer

13. Classification of thumb sucking a) Psycological -The habit may have a deep-rooted emotional factor involved. -May be associated with neglect and loneliness. b) Habitual -The habit does not have a psycological bearing, however the child performs the act. Normal thumb sucking The thumb sucking habit is considered normal during the first 2 years of age. Such a habit is usually seen to disappear as the child matures. The habit at this age does not generate any malocclusion. Abnormal thumb sucking It is considered abnormal when thumb sucking habit persist beyond the preschool period. If the habit is not controlled or treated during this age it may cause deleterious effect to the dento facial structure.

14. According to Crook (1958) Alpha group – the thumb pushes the palate in a vertical direction and displays little buccal wall contractions Beta group – Strong buccal wall contractions are seen and a negative pressure is created resulting in posterior cross bite Gamma group – alternate negative and positive pressure is created.

15. According to Subtelny (1973) Type A : Almost 50% of the children place the whole digit inside the mouth with the pad of the thumb pressing over the palate, while at the same time maxillary and mandibular contact is present.

16. Type B (24%): The thumb is placed into the oral cavity without touching the vault of the palate. While at the same time maxillary and mandibular anterior contact is maintained.

17. Type C (18%): The thumb is placed into the mouth just beyond the first joint and contacts the hard palate and only the maxillary incisors, but there is no contact with the mandibular incisors.

18. Type D (6%): The thumb is not fully inserted into the mouth. The lower incisor makes contact at the approximate level of the thumbnail.

19. According to Johnson and Larson (1993)

20. Theories & concepts of thumb sucking Classical Freudian Theory (Sigman Freud, 1919) :- The psycoanalytic theory has proposed that a child goes through various distinct phases of psycological development. In oral phase, it is believed that the mouth is the erogenous zone. During this phase the child takes everything in his mouth. It is believed that any kind of the deprivation of this activity will probably cause an emotionally insecure indivudial.

21. Oral drive theory (Sears and Wise, 1982) :- The strength of the oral drive is in part a function of how long a child continues to feed by sucking. It is not the frustration of weaning that produces thumb sucking but in fact it is the prolonged nursing that causes it.

22. Rooting reflex (Benjamin, 1962) :- The rooting reflex is movement of the infant’s head and tongue towards an object touching its cheek. He suggested that thumb sucking arises from the rooting and placing reflexes common to all mammalian infants during the first 3 months of life.

23. Sucking reflex (Ergel, 1962) :- The process of sucking is a reflex occuring in the oral stage of development and is seen at 29 weeks of intrauterine life and may disappear during normal growth between the ages of 1 to 3 1 / 2 years. It is the first coordinated muscular activity of infants. Babies who are restricted from sucking due to disease or other factors become restless and irritable. This deprivation may motivate the infant to suck the thumb and finger for additional gratification.

24. Learning theory (Davidson, 1967) :- According to this theory, habit stems from an adaptive response and assumes no underlying psychological cause and is acquired as a result of learning.

25. Etiological factors associated with thumb sucking High Mother is in better position to feed the baby & in short time baby’s hunger is satisfied. Low Mother unable to provide sufficient breast milk, hence in the process the infant suckles intensively for a long time thereby exhausting the sucking urges. Socioeconomic status :- This theory explains the increased incidence of thumb sucking in industrialized areas when compared to rural area.

26. Working mother :- Thumb sucking habit is commonly observed to be present in children with working parents because such children are brought up in the hands of caretaker and develop feelings of insecurity Number of siblings :- More the number increases the attention meted out by the parents to the child gets divided. The child who feels neglected by the parents may attempt to compensate his feelings of insecurity by means of thumb sucking.

27. Phases of development Phase I: (Normal and Sub-clinically significant) Many children suck their thumbs or fingers for short periods during infancy or early childhood with the habit considered normal during the first 2 years of life. If present at such an early age, parents should be advised to periodically observe the nature & intensity of the habit.

28. If the child demonstrates gradually diminishing activity, it is probable the habit will cease without intervention. The average age at which digit sucking stopped was 3.8 years. The effect digit sucking on the occlusion are not probably permanent if the habit is discontinued by age of 3 to 4 years.

29. Phase II: (Clinically Significant Sucking): The second phase extends between 3-6 years of age. Continued, purposeful digit sucking during this time deserves more serious attention because the possibility indicates a clinically significant anxiety and it is the time to solve dental problems related to digit sucking.

30. Phase III: (Intractable Sucking) : Any thumb sucking persisting beyond the fourth or fifth year of life should alert the dentist to the underlying psychological aspects of the habit. A thumb sucking habit seen during this phase may require psychological therapy and an integrated approach by the dentist.

31. The trident factors affecting thumb sucking (Graber & Swin, 1985) Intensity : implies how vigorously the habit is pursued. The digit may rest passively in the mouth or may be sucked with enthusiasm. Duration : indicates the number of years the habit is continued. Frequency : indicates how often during the day the habit is practiced.

32. Apart from these conditioning factors, the type of malocclusion produced also depends on a number of variables as suggested by Nanda(1989) : Position of digit in the mouth Associated orofacial muscle contractions Mandibular position during sucking. Facial skeletal pattern

33. Changes associated with thumb sucking - When the formula frequency + intensity + duration = negative dental and oral changes is applied to the concept of thumb sucking and if there is a great deal of thumb sucking daily and/or nightly, with a very strong sucking action and this pattern continues for an extended length of time, changes to the dentition and disruption of dental equilibrium (i.e. causing instability of tooth position) and interference with the normal rest position of the mandible (the freeway space) will occur. The change in the rest posture of the mandible triggers continued eruption of posterior maxillary teeth while the anterior teeth are inhibited from erupting or the incisors may become flared facially due to the continual presence of a thumb or finger.

34. Diagnosis of thumb sucking - History Emotional status Extra oral examination The digits Lips Facial form Other feature Intra oral examination Tongue Dento -alveolar structures Gingiva

35. A)History : Once the positive history of habit is determined the question regarding the frequency, intensity and duration of the habit is determined. The remedies that have been tried at the home, the feeding patterns, parental care of the child is also ascertained.

36. B)Emotional status : It is essential to determine if the habit is meaningful or empty. This requires an insight into the emotional security and familial well being of the child.

37. C)Extraoral examination : Digits: that are involved in the habit will appear reddened, exceptionally clear, chapped and a short fingernail i.e. a clean dishpan thumb. Fibrous roughened callus may be present on the superior aspect finger.

38. Lips: The position of the lips at rest or during swallowing should be observed. A short, hypotonic upper lip frequently characterizes chronic thumb suckers. Lower lip is hyperactive and this leads to further proclination of upper anterior teeth.

39. Facial form analysis: Check for mandibular retrusion, maxillary protrusion, high mandibular plane angle and profile. Facial profile is either straight or convex.

40. When swallowing, the patient is observed for presence of a facial grimace or an excessive mentalis muscle contraction, a normal placement of the tongue against the teeth and palate and whether the pattern of speech of the child is essentially normal.

41. Other features include associated symptoms that should be watched for during the initial examination are habitual mouth breathers and tongue thrust swallow, particularly in children with anterior open bite. Active thumb suckers also have a higher incidence of middle ear infection and frequently have enlarged tonsils accompanied by mouth breathing.

42. D)Intraoral examination : Tongue : Position at rest , during swallowing. Gingiva : Evidence of mouth breathing Etching of gumline Staining on maxillary labial surface

43. Dento alveolar structure :- Flared , proclined maxillary anteriors with diastema Retroclined mandibular anteriors Deformed right or left sided maxillary arch

44. Effects on maxilla Increased maxillary arch length Increased clinical crown length of incisors Counterclockwise rotation of occlusal plane Atypical root resorption Trauma to incisors Decreased palatal arch width

45. Increased SNA angle

46. Effect on mandible - Retroclination / proclination of mandibular incisors Retroclination due to direct apical & lingual force from digit Proclination due to indirect force from tongue beneath digit

47. Decreased clinical crown length of mandibular anteriors Increased mandibular inter-molar distance

48. Retrusion of mandible

49. Effect on inter-arch relationship - Anterior open bite Decreased overbite

50. Increased overjet Unilateral / bilateral class II malocclusion

51. Posterior cross bite

52. Sucking habits and facial hyperdivergency as risk factors for anterior open bite in the mixed dentition Paola Cozza , Tiziano Baccetti , Lorenzo Franchi , Manuela Mucedero and Antonella Polimenie American Journal Of Orthodontics And Dentofacial Orthopedics . 2005;128:517-9 The aim of this study was to evaluate sucking habits and hyperdivergency as risk factors for anterior open bite in mixed-dentition subjects. Pretreatment cephalometric records of 1710 mixed-dentition subjects were assessed for sucking habits, dental open bite, and facial hyperdivergency . Multiple logistic regression showed that both prolonged sucking habits and hyperdivergent vertical relationships significantly increased the probability of an anterior dentoalveolar open bite, with a prevalence rate of 36.3%. Conclusions: Prolonged sucking habits and hyperdivergent facial characteristics are significant risk factors for anterior open bite in the mixed dentition. Cozza P, Baccetti T, Franchi L, Mucedero M, Polimeni A. Sucking habits and facial hyperdivergency as risk factors for anterior open bite in the mixed dentition. American journal of orthodontics and dentofacial orthopedics . 2005 Oct 1;128(4):517-9.

53. Sequelae of thumb sucking Anterior openbite – interference with occlusal movement of the incisors. This openbite can lead to tongue thrusting problems and speech difficulties. Proclination and spacing of the maxillary anterior teeth if thumb is held upward against the palate. Prominences of this labially posed incisor make them particularly vulnerable to accidental fractures. Mandibular postural retraction may develop if the weight of the hand or arm continuously forces the mandible to assume a retruded position in order to practice the habit. Pressure in the lingual direction causes lingual tipping of mandibular incisors.

54. When maxillary incisors have been tipped labially and an openbite has developed it becomes necessary for the tongue to thrust forward during swallowing in order to effect an anterior oral seal - “compensatory tongue thrusting”. During thumb sucking, buccal wall contractions produce, a negative pressure within the month, with resultant narrowing of the maxillary arch – bilateral posterior cross bite may be produced. With these changes in the force system in and around the maxillary complex it is often impossible for the nasal floor to drop vertically to its expected position during growth.Therefore thumb suckers have a narrow nasal floor and high palatal vault.

55. Upper lip becomes hypotonic and lower lip becomes hyperactive. These abnormal muscle contractions during sucking and swallowing stabilize deformation. Compensatory tongue thrust, retained infantile swallowing pattern, abnormal perioral muscle function will assist the thumb sucking in producing the malocclusion.

56. Effect on speech due to thumb sucking - The facial muscles utilized in chewing, swallowing, and speech constitute an important part of the foundation upon which speech is constructed. When the thumb anchors the tongue down and forward and serves to reinforce an incorrect rest posture of the tongue, an inaccurate and inappropriate spring-off point for speech sound production occurs. Some sounds may be produced incorrectly. When the tongue is resting low and forward, the production of a frontal /t/d/n/l/, or interdental /s/ lisp may occur.

57. Management of thumb sucking :- According to Forrestor (1981), three main areas should be assessed in constructing a treatment plan. 1. Emotional significance of the habit 2. The age of the patient 3. The status of the child’s occlusion.

58. 1. Emotional significance of the habit Before initiating corrective procedures, it is important to determine whether the thumb- sucking is a meaningful or an “empty” habit. One should treat the meaningful habit with the psychological approach and the empty habit with the dental approach. Consultation with a psychiatrist is considered if the sucking habit is a symptom of an abnormal behavior problem.

59. 2. The age of the patient Treatment of an infant (birth to 2 years) Thumb sucking during infancy is of no concern to the dentist or the parent if no physical effect is produced on the teeth. When sucking is abnormally vigorous enough to displace the teeth, the problem is of concern and also could act as a symptom of: 1. Insufficient feeding 2. Inadequate love 3. Bored, unhappy or over the fatigued child.

60. No attempt should be made to cure the habit in a malnourished or sick infant who may obtain significant emotional gratification from it. Frequently, the only treatment necessary may be a little more cuddling and playing with the child and simple instruction to the mother in the technique of feeding the infant.

61. Treatment in a preschool child (2 1⁄2 - 3 years) - At these years, child begins to assert his/her independence from the mother and inevitably tensions and frustrations may occur causing an occasional short-lived sucking episode. In the preschool child, thumb sucking which is practiced only before going to bed may be disregarded being a benign activity, and correction may prove harmful. However, if it is frequently indulged during the waking hours, the child is over fatigued bored or unhappy, then suitable factors in the environment should be corrected. A child should have ample play facilities and an adequate amount of self-expression.

62. Treatment in 3-7 years old - This age group child may be more of a concern depending on the type of habit and whether the child is pulling the maxilla anteriorly or just sucking his digit with buccal constriction. The child with good molar intercuspation and little anterior pull, i.e., the passive sucking child should be counseled, and the dentist should work along with the parent with contingent behavior modifications.

63. Treatment in children older than 7 years - These children are mainly characterized by anterior open bite that will usually not close by itself due to functional patterns that have been established. These children will all require some form of active orthodontic treatment.

64. Techniques for habit cessation Habit awareness - Habit reversal therapy is commonly used in repetitive, body focused behavior disorders that cause significant functional impairment. It involves training the individual to recognize the behaviors preceding digit sucking, together with situations where it occurs. It also aids in teaching the individual about alternative responses to the habit behavior.

65. Covert sensitization - Covert sensitization is a procedure in which a cognitive-induced aversive response is paired with the habit. An imaginary picture of the activity to be eliminated is evoked and then accompanied by a mental image of an aversive response like nausea.

66. Contingency contracting - Punishment using the time out from positive reinforcement A contract of reward or punishment is made contingent on habit cessation or the lack of habit cessation, reward, respectively. Contingent reading has also been used to treat night-time thumb sucking.

67. Sensory attenuation procedure - Many procedures are designed to interrupt the sensory feedback experienced with NNS. These procedures are divided into - Psychological therapy Reminder therapy Mechanotherapy

68. Psychological therapy - Screen the patient for underlying psychological disturbance that sustain thumb sucking habit. Once the psychological dependence is suspected child referred for counseling. Thumb sucking children between the age of 4 to 8 year need only reassurance, positive reinforcements and friendly reminders. Various aids are employed to bring the habit under the notice of child such as study model, mirrors etc.

69. Dunlop hypothesis:- He belives that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he can learn to stop performing the act. The child should be ask to sit in front of the mirror and asked to suck his thumb, observing himself as a indulges in the habit. This will make him realize how awkward he looks and want to stop sucking his thumb.

70. Patient should presented with positive mental and visual images of dentofacial ideals expected from habit cessation. During treatment adequate emotional support & concern should be provided to child by parents. When habit is discontinued the child can be reward with a favorite new toys.

71. (b) Reminder therapy - Reminder therapy is appropriate for those who desire to stop the habit but need some assistance. The purpose of these reminders should be thoroughly explained to the child. These are reminders for child to make the habit unpleasant and difficult to practice. Finn (1972): Habit reminders can be basically divided into two extra oral reminders and intraoral reminders.

72. Extra oral reminders Chemical and Mechanical therapy involves the use of bitter and unpleasant tasting preparations which are painted on the nails to serve as a deterrent to placing the fingers or thumb in the mouth. These preparations are effective only if the habit is new and are less effective in countering a long-standing habit. Simple devices for controlling thumb are the application of adhesive tape to the thumb or finger and bending the elbow.

73. Intra oral appliance - Palatal bar :- The palatal bar is one of the principal habit reminders. It consists of a 0.030 inch round lingual arch wire attached to the upper first molar bands with an anterior platform, which clears the palate by about 1/8 inch. This keeps the thumb or finger from exerting pressure on the soft tissue of the palate. The seal is broken, there is no suction, and the pleasure of thumb-sucking
is destroyed. An occlusal rest on the occlusal surface of the upper first premolars prevents the palatal bar from settling into the soft tissue. The bar must be so designed that it will not prevent the teeth from closing normally.

74. Palatal arch - Bands are placed on either the maxillary second deciduous molars or the first permanent molars. The palatal arch is made from 0.040-inch stainless steel wire and is similar in design to the palatal crib, except that it does not have a vertical fence like portion.

75. Palatal crib - Habit retraining appliance, which utilizes a blunt wire “reminder” which may prevent the child from indulging in the habit. The crib consists of a wire embedded in removable acrylic appliance similar to a Hawley retainer, or it may be a “fence” added to an upper palatal arch and used as fixed appliance.

76. Hay-rake - Mack (1951) introduced a dental appliance for children over 3 1⁄2 years of age who are persistent thumb suckers. A rake may be a fixed or removable appliance, just as the crib. As implied by the term, this appliance more nearly punishes than reminds the child. It is constructed as is the crib, but has blunt tines or spurs projecting from the crossbars or acrylic retainer into the palatal vault. The tine discourages not only thumb sucking but also tongue thrusting and improper swallowing habits as well.

77. Blue grass - Appliance consists of a roller made of Teflon which is constructed over a 0.045 stainless steel wire which is soldered to bands placed on either the maxillary first molars or on the primary second molars. The roller is placed in the most superior aspect of the palate and must not be in contact with the palatal tissue so that patients can roll them with their tongues. This device works through a counter-conditioning response to the original conditioned stimulus for thumb sucking. This appliance is placed for 3-6 months and in early or mixed dentition period it is indicated.

78. Baker modified blue grass appliance with 4 mm acrylic beads, multiple rollers and thus expanding its use from primary to permanent dentition. The advantage of the new design is that it encourages maximum neuromuscular stimulation by using two or more beads, according to the principles of Castillo-Morales. One to four beads are placed on the cross­ palatal wire, depending on the amount of space available. Haskell and Mink recommended to leave the bluegrass in the mouth for 6 months after the habit has stopped. Earlier removal has resulted in the reappearance of the habit.

79. Quad helix - The quad helix is a fixed appliance used to expand the constricted maxillary arch. The helixes of the appliance serve as a reminder to the child not to place the finger in the mouth. May be modified to incorporate a roller simulating blue grass appliance. The disadvantages of intraoral appliances include a period of emotional upset until they get used to the appliance, speech being affected temporarily and difficulty in eating. With the use of fixed orthodontic habit breakers increased tendency for caries and decalcification of enamel surfaces, gingival inflammation may occur.

80. Current strategies - Increasing the arm length of the night suit. Thumb- home concept Currently the use of hand puppets is gaining popularity Thumb sucking book My special shirt

81. Increasing the arm length of the night suit :- This is usuful in children who sincerely want to dincontinue the habit and only perform during their sleep. The arm of their night suit are lengthened so thet they cannot reach the thumb during night.

82. Thumb- home concept :- This is the most recent concept. In this a small bag is given to the child to tie around his wrist during sleep and it id explained to the child that just as the child sleeps in his home, the thumb will also sleep in its house and so the child is restrained from thumb sucking during night.

83. Thumb sucking book :- “The Little Bear who Sucked His Thumb” is a book directed at children, for children. The book has been written and illustrated by Dr.Dragan Antolos, an experienced dentist with a special interest in thumb sucking habits in children. The book and chart are a non-invasive and effective strategy for stopping thumb sucking, and have received positive support from psychiatrists, speech pathologists and pedodontic societies. It is important to balance the psychological benefits of thumb sucking with the negative impact it has on developing, permanent teeth. “The Little Bear who Sucked His Thumb” is a book that the child will relate to the story and it will deliver a positive message without pressure.

84. My special shirt :- This helps in minimizing the damage of finger sucking by providing a number of tools to address the habit in a phased manner. This shirt keeps the child busy thereby avoiding the habit. By working as a team, the child will gain confidence, balance emotion and stop their depedence on need to suck.

85. 2. Pacifier habit Pacifiers have been used by mankind for more than thousands of years. They have been identified to help children in transitioning to sleep, to soothe infants, to provide comfort while teething. The effect of pacifier sucking as the same as non nutritive sucking or thumb sucking but some other associated risk are as follows -

86. Effict of pacifier use on breastfeeding - Newman hypothesized that the use of pacifier causes ‘nipple confusion’ in the infant and a faulty technique of breastfeeding which eventually leads to early weaning. This was also supported by Mitchell who found out that infants given pacifiers in hospitals are less likely to breastfeed mothers on discharge as compared to those who were not given pacifiers.

87. Pacifier and caries - Prolonged use of pacifiers in children and specially those used with sugar syrups or sweetened liquids have a positive relation with caries.

88. Effects of different pacifiers on the primary dentition and oral myofunctional structures of preschool children Zardetto et al. Pediatric Dentistry – 2002;24:6. The aim of this study was to evaluate the characteristics of the dental arches and some oral myofunctional structures in 36- to 60-month-old children who sucked a pacifier or did not have this habit. Methods: Sixty-one children were divided into 3 groups: (1) those who never sucked a pacifier, (2) those who exclusively sucked a physiological pacifier, and (3) those who exclusively sucked a conventional one. A clinical examination was performed on the children to observe the relationship between the arches and their width, as well as the following oral myofunctional structures: lips, tongue, cheeks, and hard palate. Conclusions: Children who sucked pacifiers, both conventional and physiological ones, showed higher prevalence of alterations in the relationship of the dental arches and oral myofunctional structures, when compared to those who never sucked a pacifier.

89. Pacifier recommendations- The pacifier should be used when placing the infant down for sleep and not be reinserted once the infant falls asleep. Pacifiers should not be coated in any sweet solution. Pacifiers should be cleaned often and replaced regularly. For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.

90. Pacifiers should never be used to replace or delay meals and should be offered when the caregiver is certain the child is not hungry. Pacifiers should have ventilation holes and a shield wider than the child’s mouth (at least 1 1⁄4 inches in diameter). Pacifiers should be one piece and made of a durable material, replaced when worn, and never tied by a string to the crib or around a child’s neck or hand.

91. Infants and children with chronic or recurrent otitis media should be restricted in their use of a pacifier. Pacifiers should not be routinely discouraged as the current evidence suggests a decreased risk of sudden infant death syndrome associated with their use.