Frequently Asked Questions

Are pacifiers safe?
All pacifiers made or sold in Europe have to meet the requirements of a stringent European Standard. All pacifiers that conform to this standard are labelled with the “EN 1400” mark. This may vary in different countries depending on appropriate version. For example, in Austria the label will indicate “ÖN EN 1400”, in Germany, “DIN EN1400” and in the UK “BS EN1400”. Other than the National language, all these standards are exactly the same. Every aspect of the pacifier is described in EN 1400 – general requirements such as the number, position, and size of the ventilation holes, mechanical tests such as how strong the pacifier should be when pulled with a force or impacted with a heavy weight, and chemical tests to ensure all materials used to manufacture the pacifier are safe in use. There is no doubt that standards such as EN 1400 have contributed to an outstanding safety record for pacifiers. In the US, there is also a standard for pacifiers – this CPSC Standard is mandatory.

Which are the most important characteristics of a pacifier?
Many parents are confused about which style is right for their baby. The following suggests a number of factors which should be considered when selecting a pacifier:

1. Always purchase a pacifier which meets National and
    International Standards. In Europe this means looking
    for the “EN 1400” mark on the packaging.

2. Always choose an orthodontic pacifier. Preferably one which
    has a non-pneumatic teat with a symmetrical shape. A teat
    with a relatively thin, flexible “neck” is also ideal.

3. The shield should curve towards the child’s mouth.

4. The shield should have large ventilation holes. The larger
     the hole area the better.

5. Choose a pacifier brand which offers several sizes. This
    allows the growing child to move smoothly to the next size.

What steps should I take to ensure the safety of my baby when using a pacifier?
Many manufacturers will produce pacifiers in various sizes. Always ensure you buy the correct one for the age of your child. Always follow the manufacturer’s instructions, which may include:

1. Before first use place the pacifier in boiling water for 5
    minutes, allow to cool and squeeze out any trapped water
    from the pacifier. This is to ensure hygiene.

2. Clean before each use.

3.  Never dip the teat in sweet substances or medication.
     Your child may get tooth decay.

4. Inspect carefully before each use, especially when your
    child has teeth. Pull the pacifier in all directions. Throw
    away at the first signs of damage or weakness.

5. Do not leave a pacifier in direct sunlight or heat, or leave
    in disinfectant (“sterilising solution”) for longer than
    recommended, as this may weaken the teat.

6. Never attach ribbons or cords to a pacifier, they may
    strangle your child. If you want to prevent a pacifier from
    falling on the floor always use a pacifier holder.

7. For safety and hygiene reasons, replace the pacifier between
    one and two months of use.

8. In the unlikely event that the pacifier becomes lodged in the
    mouth, DO NOT PANIC; it cannot be swallowed and is
    designed to cope with such an event. Remove from the
    mouth with care, as gently as possible.

Please remember that the use of a pacifier should never be a substitute for parental attention.

When should my child give up the use of a pacifier?
Although non-nutritive sucking habits during infancy and early childhood are believed to be of little lasting consequence to the orofacial structures, such habits when they persist especially after the age of 3 years may cause dental problems. 

Do pacifiers reduce the risk of Sudden Infant Death Syndrome (SIDS)?
In 2005 the American Academy of Pediatrics (AAP) revised their recommendations for the reduction of the risk of SIDS. These included:

1. Back to sleep: Infants should be placed for sleep in a
    supine position (wholly on the back) for every sleep.

2. Use a firm sleep surface: Soft materials or objects such
    as pillows, quilts, comforters, or sheepskins should not be
    placed under a sleeping infant. A firm crib mattress, covered
    by a sheet, is the recommended sleeping surface.

3. Keep soft objects and loose bedding out of the crib.

4. Do not smoke during pregnancy. Also, avoiding an infant’s
    exposure to second-hand smoke is advisable for numerous
    reasons in addition to SIDS risk.

5. A separate but proximate sleeping environment is
    recommended: The AAP task force recommends that the
    infant’s crib or bassinet be placed in the parents’ bedroom,
    which, when placed close to their bed, will allow for more
    convenient breastfeeding and contact.

6. Consider offering a pacifier at nap time and bedtime:
    Although the mechanism is not known, the reduced risk
    of SIDS associated with pacifier use during sleep is
    compelling, and the evidence that pacifier use inhibits
    breastfeeding or causes later dental complications is not.
    Until evidence dictates otherwise, the task force recommends
    use of a pacifier throughout the first year of life according
    to the following procedures:
•   The pacifier should be used when placing the infant down
    for sleep and not be reinserted once the infant falls asleep.
    Do not force the pacifier if the baby refuses to accept it.
•   Pacifier should not be coated in any sweet solution.
•   Pacifier 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.

7. Avoid overheating: The infant should be lightly clothed for
    sleep, and the bedroom temperature should be kept
    comfortable for a lightly clothed adult.

It can be seen that the above recommendations include the use of a pacifier. This ground-breaking policy followed similar recommendations in the Netherlands and Germany and was quickly followed by a number of other countries, including Israel, the United Kingdom and Austria.

Can a pacifier help a premature or low birth weight baby?
One of the problems associated with premature and low weight babies is that these children often exhibit feeding problems due to a poor sucking (and swallowing) ability. As the ability of the weak premature infant to suckle on the breast is limited they often require to be fed for some weeks after birth using a nasogastric tube. With increasing maturity, sucking becomes more co-ordinated and a characteristic feeding posture develops. A great deal of research has been carried out on the benefits of pacifier sucking for premature and low weight babies. These may be divided into 4 categories:

•   Changes, improvement or modulation of behavioural
     states, particularly prior to or during feeding
•   Assistance in feeding
•   Reduction or relief of pain
•   Other physiological effects

 However, these are not distinct or isolated benefits, as one may influence the other.

Why is the replacement of thumb sucking important?

1. Pacifiers can be sterilized – thumbs cannot.

2. There is a great deal of both observational and research
    evidence that a pacifier sucker gives up the habit before a
    thumb sucker. Therefore many malocclusions will correct
    naturally after this earlier cessation of pacifier sucking.

3. Pacifier use as opposed to thumb sucking is significantly
    protective against the risk of Sudden Infant Death Syndrome.

Is there a connection between pacifier use and reduced Breastfeeding?
The first suggestion that pacifiers might be implicated in the trend toward lower breast-feeding incidence was in 1991 when the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) introduced the Baby Friendly Hospital Initiative (BFHI).

BFHI was a programme of ten steps designed to encourage health care providers to establish a hospital programme to promote and support breastfeeding (World Health Organization 1989). WHO/UNICEF rewards hospitals who subscribe to these ten steps. Step 9 of the programme states: “Give no artificial teats or pacifier (also called dummies or soothers) to breastfeeding infants.”

In 2011 Jaafar SH et alia published a comprehensive review. “Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding (Review) “, Cochrane Database of Systematic Reviews, Issue 3. They state that “Pacifier use in healthy term breastfeeding infants, started from birth or after lactation is established, did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age.“ The authors of the study even suggest a review of the recommendations against using pacifiers contained in the WHO guideline “Ten Steps to Successful Breastfeeding”. Despite this, there was no epidemiological evidence of an association between pacifier and breast feeding at that time and indeed the first paper reporting such an effect was published 2 years later (Victora et al 1993).

Do you have any advice for bottle feeding?
Quite naturally, closeness is developed through breastfeeding that is essential to both mother and child. This intensive physical contact should not be neglected when bottle feeding. Nestled in mum’s arms or snuggled in bed, babies enjoy skin contact and a feeling of security when drinking from a bottle. Along with this comes excellent interaction through eye contact. Regularly changing sides when bottle-feeding helps train and develop hand-eye coordination. Make yourself comfortable – choose a favourite chair you feel comfortable in which gives you plenty of back and neck support. Position your baby very close to you in the crook of your arm in a semi-upright position; your baby will swallow less air and feel a special closeness to you.

Offer the bottle to the baby by tilting it to make sure there are no air bubbles and put a few drops on your baby’s lips. This will get your baby to take the bottle and start sucking. Make sure the bottle remains tilted so the baby doesn’t take in any air bubbles. Follow your baby’s pace, and don’t push to have more than the baby seems to want just to finish the bottle.

When the bottle teat touches your baby’s mouth the sucking reflex begins. Babies love sucking: It calms them, aids in digestion and protects their airway against collapse. The hole in the bottle teat should be as small as possible to provide prolonged sucking opportunities at every meal; this will guarantee relaxed feedings. When the need to suck is not fulfilled, but the baby is no longer hungry, the bottle can be replaced by a finger or pacifier. 

What are the recommendations concerning Breastfeeding?
The WHO and virtually all health organizations recommend exclusive breastfeeding for the first 6 months after birth.

Are there any contraindications to Breastfeeding?
Although breastfeeding is optimal for infants, there are a few conditions under which breastfeeding may not be in the best interest of the infant. These include:

•   Breastfeeding is contraindicated for infants with classic
    galactosemia (galactose 1-phosphate uridyltransferase deficiency).
•   Mothers who have active untreated tuberculosis disease
    or are human T-cell lymphotropic virus type I– or II–positive.
•   Mothers who are receiving diagnostic or therapeutic
    radioactive isotopes or have had exposure to radioactive
    materials (for as long as there is radioactivity in the milk).
•   Mothers who are receiving antimetabolites or chemotherapeutic
    agents or a small number of other medications until they
    clear the milk.
•   Mothers affected by substance abuse issues.
•   Mothers who have herpes simplex lesions on a breast
    (infant may feed from other breast if clear of
•   In the United States and many other developed countries,
    mothers who are infected with human immunodeficiency
    virus (HIV) have been advised not to breastfeed their infants.

The situation regarding breastfeeding by HIV positive mothers in developing and Third World countries remains controversial. Although mother to infant transmission of the virus needs to be eradicated, health organizations currently consider that the perceived mortality risks associated with artificial feeding may outweigh the possible risks of acquiring HIV infection.

Can I use Nipple Shields during Breastfeeding?
Amongst some lactation experts the use of nipple shields remains a controversial subject. Nipple shields should generally be used under the supervision of a lactation consultant that can provide proper lactation guidance and instruct on how to use nipple shields. Nipple shields are frequently used (and sometimes misused) for:

•   Sore nipples (protection and/or prevention)
•   Flat nipples
•   Engorged breasts
•   Nipple confusion/nipple preference
•   Premature infants
•   Neurological challenges of the infant
•   Breast refusal

One very successful technique is for the mother to warm the nipple shield in water or by holding it in her hand for a few minutes. This allows for more pliability in the shield, which can then be turned partially inside out, placed directly over the mother’s nipple, and “peeled back” over the breast to create a tight fit. Moistening the inside of the shield with milk or water will help to maintain a seal once the shield is placed well onto the breast.

What can I do about sore nipples?
If you experience sore nipples always consult your lactation advisor, health visitor or doctor. The most frequent causes of sore nipples are incorrect positioning at the breast and suction trauma. During the first two to four days after birth, the mother’s nipples may feel tender at the beginning of a feeding as the baby’s early suckling stretches her nipple and areolar tissue far back into his mouth. If a baby is positioned properly at the breast, this temporary tenderness usually diminishes once the milk lets down, and disappears completely within a day or two.

Nipple soreness that increases or lasts beyond the first week should be interpreted as a warning that something is wrong. Once adjustments in positioning and latch-on have been made, a few days with little or no improvement suggest that the source of the pain lies elsewhere. Sucking problems, a retracted or improperly positioned tongue, strong clenching response, and improper breast pump use are possible causes of nipple soreness.

Engorgement has been known to cause nipple pain. Engorgement of the breasts may predispose a mother to nipple tenderness, fissures and abscesses, and may lead to breastfeeding cessation. Hand-expressing a little milk ahead of time can soften the nipple and areola enough to avoid these problems.

What volume of expressed milk can I expect when using a breast pump?

1. The amount is highly variable both between mothers and
    for an individual mother. Although individual pumps
    (and vacuums) produced different quantities of milk, these
    variations appeared less significant than other factors such
    as whether the mother was breast feeding her baby,
    emotional state of the mother, her experience etc.

2. Up to 60% of the available milk was expressed within
    2 minutes of the commencement of successful pumping,
    and between 70 and 100% after 5 minutes. If your own
    experience is widely outside these guidelines, consult your
    lactation advisor.

3. The volume expressed from the left and right breast may
    be significantly different.

4. It would therefore seem that the so-called “average” mother
    expresses a total of 100 to 150ml breast milk per session,
    when the volume from both breasts is added together.

What is the difference between latex and silicone? 

What is latex allergy?
Some proteins in latex products may sensitize susceptible individuals, or if the child is already sensitized by e.g. repeated exposure to latex gloves, they could cause an allergic reaction. These proteins are similar to those which cause allergic reactions to some fruits and vegetables.

Which products are critical?
Undoubtedly the most common cause is latex gloves. This is the reason for the high incidence amongst operating theatre staff. It has also been reported that balloons have caused allergic reactions. There are no reports that latex teats and pacifiers have caused an allergic sensitisation amongst healthy children. 

What precautions should I take to safeguard the health of my baby?
If your baby has experienced several operations in the first few months of life, or has an allergic reaction to some foods – especially fruit – do not use a latex product. Pacifier and bottle teats made from silicone rubber may be used as an alternative. In all other cases, there is no reason why you should not give your baby a latex pacifier or a bottle teat made from latex rubber. However, if you see any signs of reaction consult your physician.

When does Teething occur?
A few babies are born with 1 or 2 teeth and some take over 12 months to show any teeth. However, in the majority of cases first teeth start to make their presence felt at 3-4 months, and they appear at 6-7 months. The expression “teething” is often used to refer to the process of the primary teeth appearing, which takes place over a year or so on.

What are the symptoms of teething?
The onset of teething will often be heralded by drooling, extra fussiness and sleeplessness. The following symptoms are typical:

•   Irritability
•   Drooling
•   Mouthing objects
•   Sleep disturbances
•   Biting
•   Ear rubbing
•   Rash
•   Gum rubbing
•   Decreased appetite

However, first teeth erupt at the same time that babies lose their inborn immunities so many problems are incorrectly blamed on teething. Teething does not cause unrelated symptoms such as vomiting, lack of appetite or diarrhoea, although it can sometimes cause the child to have difficulty in feeding.

When a baby is teething, the gums will be red and swollen at the site of the tooth that is about to emerge. This may make the baby fretful and disrupt sleep as the swollen gums throb painfully. Teething usually makes babies dribble more than usual and they may put their fists into their mouth and bite on them for comfort. Symptoms will not be continuous, but can be observed each time a new tooth is about to appear.

What is dental caries and periodontal disease?
The UN Health Education Authority considers dental decay as “The World’s most common disease.” Two major dental diseases exist:

•   Dental Caries
•   Periodontal disease

Dental caries (the disease process leading to tooth decay) is a transmissible oral infection. When food is consumed, cariogenic bacteria (especially Streptococcus mutans) are able to break down carbohydrates (e.g., glucose, fructose, sucrose) in the mouth, producing acids that cause mineral loss from teeth (demineralization). This mineral loss results in cavities when the attack is prolonged and exceeds an individual’s resistance and the ability of the teeth to heal (remineralisation). Resistance and healing ability are determined partly by an individual’s physiology and partly by health behaviours.

The first stage of dental disease is the formation of Pellicle. This is a layer which forms on the tooth enamel within a few hours of cleaning. The Pellicle layer (which is like a clear cuticle) is then colonised by micro-organisms (bacteria) to form Dental Plaque. Organisms in dental plaque will produce organic acids if certain sugars are eaten.

Both Periodontal Disease and Dental Caries are caused by plaque. If allowed to accumulate, especially in the areas between the gums and the teeth, the bacteria cause inflammation of the gums resulting in Periodontal Disease. Neglect of oral hygiene creates favourable conditions for the spread of this disease. Initially periodontal disease causes inflammation of the gums. If this condition, which is painless (and you may not realise you have it), is allowed to continue, the inflammation may spread to the root of the tooth and destroy the periodontal fibres that anchor it in place. Eventually the tooth becomes loose and may have to be extracted.

What is Early Childhood Caries (ECC)?
Early childhood caries (ECC), previously termed nursing caries or baby bottle tooth decay, can occur any time after teeth erupt. ECC may occur in infants or children with frequent and prolonged exposure to beverages high in sugar (e.g. fruit drinks, soda, fruit juice), milk, or formula in a bottle or covered cup during the day or at night.

ECC has been associated with

•  frequent and prolonged breastfeeding
•  frequent snacking on foods high in sugar (e.g., candy, cookies, cake)
•  coating pacifier with sweeteners (e.g., sugar, honey, syrup).

Other risk factors for ECC include altered salivary composition and volume (resulting from the use of certain medications or malnourishment) and blockage of saliva flow in a bottle-fed infant. EEC is particularly prevalent in the front lower teeth where these sweet beverages, formula and breast milk etc. can pool. The younger the age at which dental caries begins, the greater the risk of future decay. Both the level of caries attack and the infant’s or child’s resistance can be managed through oral health supervision that promotes positive health behaviours including good oral hygiene, use of fluorides and dental sealants, good dietary habits, and chemical or physical reduction of dental plaque.

What are the factors that influence dental caries?
As a generalisation there are three major factors which influence the occurrence and severity of dental caries: Diet, especially sugar-like materials, micro-organisms (Bacteria) and saliva.

What does Saliva do?
Like a “liquid enamel”, saliva is super-saturated with calcium and phosphate – the basic minerals that make up tooth enamel. Fluoride, from dietary and topical sources, is also present in saliva. Together, these three elements work continually to shore up tooth enamel. When the essential ingredients are all present in the mouth, small breaches in the tooth caused by the activities of caries bacteria can actually “heal” before any serious damage is done. Another property of saliva is its buffering capacity, that is, its ability to neutralise acid. Acid is formed in the mouth when food debris is broken down by bacteria. This acid, held against the tooth in plaque, destroys the enamel and makes decay possible. The particular make up of saliva enables it to neutralise these acids. Saliva even seems to have antimicrobial properties that help inhibit bacterial growth in the mouth. It also contains an enzyme that aids oral clearance of starchy foods that can promote tooth decay.

How can the production of Saliva be increased?
Chewing and/or sucking promote the production of saliva, which is why sugar free chewing gum is recommended just after eating a meal. Saliva production is stimulated at the precise time it may do the most good, that is, when oral bacteria are most active. Similarly, the sucking of a pacifier by a baby to help it sleep just after the child has been fed will have exactly the same effect as outlined above. Research work indicates the positive effect of pacifier use on the bacterial count in the mouth. 

How can I keep my infant’s teeth clean?
Dental plaque is a sticky film that adheres to the teeth. It is composed of bacteria, food debris, and salivary components. Left undisturbed, it can cause tooth decay. Parents should clean the infant’s gums with a soft cloth after feedings. As the first tooth erupts, a brush that is easy for the parent to hold and small enough to fit in the infant’s mouth is recommended. To ensure that brushing is safe and effective, the infant should be seated in the parent’s lap, with both parent and infant facing the same direction. The parent should try to clean all tooth surfaces, “lifting the lip” to brush at the gum line and then behind the teeth.

Why is fluoride so important?
A primary factor in reducing the prevalence of cavities among children has been the widespread availability of fluoride and fluoridated products. Frequent exposure to small amounts of fluoride each day is the best way to reduce the risk for developing tooth decay. It is important to understand the benefits of fluoride and to know how infants and children can safely ingest it in appropriate quantities. Mechanisms by which fluoride prevents or reduces decay include:

•   Increased resistance of the tooth structure to
     demineralisation.
•   Enhanced remineralisation of early carious lesions.
•   Reduced cariogenic activity of plaque, through disruption
     of bacterial metabolic function.

 What are the most important actions to be taken as anticipatory guidance against dental diseases in my child? 

•   During your pregnancy visit your dentist and endeavour
     to get your own teeth in the best condition.
•   Once your infant is born, to prevent transmission of
     bacteria that cause tooth decay from the parent
     (especially the mother) via saliva to the infant, avoid
     testing the temperature of the bottle with the mouth,
     sharing utensils (e.g., spoons), or cleaning a pacifier
     or bottle teat with saliva.
•   Do not allow your infant to suck on a bottle for comfort,
     especially when going to sleep. As an alternative provide
     a pacifier, which can also stimulate the production of
     protective saliva during sleep.
•   Make an appointment for your infant’s first dental visit
     within 6 months of the eruption of the first primary
     tooth, and no later than age 12 months.
•   Clean your infant’s gums with a clean damp cloth or
     toothbrush and plain water after each feeding. Use a
     soft-bristled toothbrush with a small head, preferably
     one designed specifically for infants.
•   Brush your infant’s teeth as soon as the first tooth erupts,
     usually around age 6- 10 months. Use a soft-bristled
     toothbrush with a small head, preferably one designed
     specifically for infants, and plain water. Lift the lip to
     brush at the gum line and behind the teeth.
•   Remember not to give your infant anything to eat or
     drink (except water) after brushing at night.
•   Give your infant age 6 months or older fluoride
     supplements only as recommended by a dentist or
     physician based on the infant’s risk for developing tooth
     decay and the known level of fluoride in the infant’s
     drinking water.
•   Both you and your child should eat foods containing sugar
     at mealtimes only, and limit the amount. Frequent
     consumption of foods high in sugar, such as candy,
     cookies, cake, and sweetened beverages (e.g., fruit
     drinks, soda), and fruit juice increases the risk for tooth
     decay. In addition, frequent consumption of foods that
     easily adhere to the tooth surface, such as dried fruit,
     fruit roll-ups, and candy, increases the risk for tooth
     decay. When checking for sugar, look beyond the sugar
     bowl and candy dish. A variety of foods contain one or
     more types of sugar, and all types of sugars can promote
     tooth decay.
•   Avoid carbonated beverages during pregnancy and for the
     first 30 months of your infant’s life.