I’ve been wanting to write about this topic for a while now, but another topic seemed to always win out for the week. I remember hearing speculation that frequent pacifier use was linked to the common middle ear infection, otitis media, but I don’t remember where I heard it, if the source was credible, or if it was just a myth; an old wives’ tale. Every time we went to the pediatrician’s office after breastfeeding was well-established, (and we went a lot in the first 6 months, due to Jia’s soy and milk protein intolerance, see My Little Non-Soy Non-Dairy Sprout) Jia had a pacifier hanging from her mouth. Usually it was one of many Wubbanubb animals (pictured). But, they never warned us about a possible otitis media infection if she continued to use a pacifier. So I guess the speculation took a back seat in my mind, especially since in her 20 months, Jia hasn’t even come down with a common cold, let alone a painful and uncomfortable middle ear infection.

Since there is a lot of information in here, this will be Part 1: Otitis Media & Pacifier Use. We’ll get to the research in Part 2:

So here we go…

What is Otitis Media?

Otitis Media (OM) is a middle ear infection. The “otitis” meaning inflammation (the -itis part) of the ear (from the word otic, ot-), and “media” meaning, the middle. It is caused by bacteria that grows in the (naturally occurring) fluid in the ear. Bacteria (or viruses) causing OM originate from a cold, sore throat, or any other upper respiratory infection (URI) and travel and thrives in the fluid behind the eardrum. More fluid accumulates because of the infection, and the build-up causes the symptoms of ear pain and discomfort. Remember, when you have a URI like the common cold, your ears, throat, and sinuses are affected because the virus or bacteria are circulating in that area, and the whole system is interconnected. The ear is sometimes a very appealing home for these bugs.

The middle ear is the section that is wedged between the outer ear that is exposed, and the inner ear, where your cochlea rests (the part that affects balance) as well as the auditory nerve. The 3 little bones in the middle ear (malleus, incus, stapes if you wanna get anatomical) are what’s responsible for the transmission of sound vibrations to the inner part of the ear.  There are many other details of the ear that you can read about, but basically, when there is inflammation and fluid build-up in the middle ear, sound is affected, as well as a pushing on the inner ear where the balance is affected. 

OM is a very common infection that occurs in children. According to the National Institute on Deafness and Other Communication Disorders (NIDCD), 5 out of every 6 children will have at least one ear infection by their third birthday.

Why are Children Susceptible?

As many things with children, their eustachian tubes (inner ear that leads to sinuses) are shorter and more level (vs more curved downward), so any fluid that is present is harder to drain behind the eardrum (the middle part of the ear). This means that when there is inflammation and fluid build-up in an infection, that fluid is is harder to drain and there is a greater chance of introducing bacteria into its environment. And, bacteria love and thrive in moist dark environments. This may be a little more info than you anticipated, but like females having shorter urethras than males, they are also more susceptible to urinary tract infections than their counterparts with much longer urethras. It’s a much quicker access for bacteria to travel. 

Another factor that makes children more susceptible is, much like the reason to get your child vaccinated early, children have less developed immune systems to fight off a potential ear infection. 

What are the Causes?

As mentioned, an originating virus or bacterial infection that presents as a cold or sore throat (primary infection) creeps its way up to the ear and infects the membranes, leading to a secondary infection.

Symptoms in Babies

Since it’s hard for babies and toddlers to tell you what’s wrong, look for any combination of the following:

  • pulling or tugging at the ears
  • having trouble sleeping
  • fussing or crying
  • fever (if over 101.4 F)
  • fluid draining from the ear
  • problems with balance
  • trouble hearing or responding to quiet sounds

Now, I know. Infants and toddlers, especially those learning to crawl or walk, will naturally have trouble with balance. And, what baby doesn’t fuss or cry? Don’t many babies have trouble sleeping? Especially in the early years. BUT the thing you want to consider, is if they have a sudden change in balancing ability, if they are excessively fussy or crying more than usual, if they “seem” more irritated. You want to use your intuition for some of these, if the whole picture looks like there may be something wrong.

As parents of young ones, we sometimes feel like something could always be wrong. This happened to me too, especially as a nurse, because I was considering the whole realm of what could be wrong, because of what I know. But, when you have a little one who is more difficult to soothe than normal, and they’re suddenly not responding to noises or sounds that usually make them perk up or laugh, look to see what else she’s telling you. Does it activate your spidey senses? Sometimes babies pull at their ears when they’re tired, but if she is also inconsolable and feels warm, take her temperature. If it’s elevated, then call the doctor.

You know your baby best, so if he seems out of character and just not feeling “right,” ask your doctor. 

Remember, some doctors will teach their parents how to take rectal temperatures, others will encourage you to take an axillary (armpit) reading, and call if it is over 100 or 101 F (armpit temperatures are usually 1 degree lower than an oral temperature, and rectal temperatures are usually 1 degree higher than an oral temperature). Take your baby’s temperature BEFORE treating your baby with infant Tylenol or Motrin. Your doctor will want to know your little ones’ temperature before medications started to take effect.

A Brief Description of Diagnosis and Treatment of OM

Without going into a lot of detail here, your child’s pediatrician will do an exam that will include looking in your child’s mouth and in his ear. This is to check for inflammation, redness, and to evaluate the fluid behind the ear drum.

That pokey instrument that goes into your child’s ear is called a pneumatic otoscope, and she will puff a little bit of air into the ear canal, to see if the ear drum responds to it normally (a normal eardrum will show normal back and forth movement if fluid levels are normal. If there is fluid buildup, the eardrum won’t move as easily). Another way to assess his ear is to perform tympanometry (the tympanic membrane is what forms the eardrum), which is to measure the amount of pressure behind the ear, by testing the flexibility of the eardrum to varying air pressure and tones. 

Antibiotics may be prescribed if your doctor suspects an infection, and if your child is experiencing a lot of pain associated with it. But, not always. Sometimes ear infections can clear without antibiotics. Conservative prescribing of antibiotics should be done, since overexposure to antibiotics (moreso than is necessary) can cause them to become very resistant against antibiotics in the future, making treatment more and more difficult later down the road. 

Benefits of Pacifiers (Non-Nutritive Sucking)

  • Analgesic (pain relief) effect
  • Shorter hospital stays for pre-term infants
  • Reduced risk of Sudden Infant Death Syndrome (opens oral airway and suckling helps build a strong swallow ability, oropharynx development
  • Soothing/calming effect of non-nutritive sucking, especially during first six months of life

Risks of Pacifiers

  • If used prior to establishing breastfeeding, can have negative effect on latching and nipple confusion, leading to shortened periods of breastfeeding (Luckily Jia and I made it to 15 months with exclusive breastfeeding + solids)
  • Dental malocclusion (affecting tooth/bite development, can be seen after 2 years and usually after four years old)
  • Possible recurrent otitis media infections (lowest risk of OM is 6 months and under, when risk of SIDS is highest)
  • May be difficult to wean from pacifiers (I feel this is where we are right now)

My Opinion on Pacifiers

Good golly, they have been lifesavers!!!! Especially those Wubbanubb pacifiers! Jia was able to grab a pacifier early on (around 4 months old) and soothe herself while we were in the car, rather than continuing to wail from being in her carseat. It easily became something that she liked to have when she was upset, and it worked like a charm. The non-nutritive sucking allowed her to drift off to dreamland much quicker than when she didn’t have a pacifier, and if she cried during the night, placing the pacifier in her mouth while we rocked her soothed her instantly. However, I’m dreading the day when I have to really tell her that her paci’s have to go away, to be “given” to other babies in the hospital. She’s so attached to them, but I know it has to end!

The pacifier has helped when receiving vaccinations, since it offered a bit of a distraction to the poke in her thighs. 

Our breastfeeding relationship was unaffected by the pacifier. She liked nursing just as much, with or without the pacifier. She never denied nursing or preferred the pacifier. Of course, if she was upset, offering the breast always soothed her, but if I needed to place her down in the crib, it was a pretty easy hand-off to offer her the pacifier. Fifteen months was perfect for us, I wanted to make it to 1 year, and she seemed to naturally wean from it. 

Jia hasn’t had an ear infection, or any other infection. I do consider us very lucky, but there are lots of kids who aren’t as lucky. Especially those in daycare, who are exposed to a myriad of viruses and bacteria, and having a pacifier around may only cause those bugs to linger, with possible exposures becoming more significant via the pacifier. I firmly believe that Jia receiving breastmilk for all that time helped build her immunity, since breastfeeding really has a protective effect against OM infections, in addition to many other things. 

So if you are considering the presence of pacifiers with your baby and are interested to know about their possible connection with OM, please… 

Stay tuned for next week’s Part 2: Investigating The Link!


NIDCD at National Institutes of Health, Ear Infections in Children.

Medline Medscape: Otitis Media

Sexton S., Natale R. Risks and Benefits of Pacifiers.  Am Fam Physician. 2009 79(8): 681-685.

Mayo Clinic: Pacifiers

American Academy of Pediatrics PACT: Oral Habits