IMG_9542Welcome to Part 2 of my post investigating the link between pacifier use and otitis media (OM), a middle ear infection that most commonly affects children and babies. If you want to read Part 1, which explains more of what OM is, and the pros and cons pertaining to pacifier use, click here.

If you’re a regular Little Sproutings reader and/or know myself and/or Jia personally, you’ll know that Jia’s pacifiers have been practically attached to those little pink lips since we introduced them at 3 months old. So, for 19 months to have gone by with only one illness that lasted just two and a half days, I have my doubts about pacifiers pre-disposing infants/toddlers to ear infections. Particularly without pre-existing conditions, such as having an upper respiratory infection (URI), to begin with.

As I said, I have my suspicions.

As a parent that doesn’t believe everything right off the bat without digging deeper (one of my first LS posts was dispelling this irresponsibly titled bizarre headline that said “Tooth Decay Associated with Long-Term Breastfeeding”), I initially suspect that the association between pacifiers and ear infections would be due to the colonization of bacteria that just sits on the pacifier without being disinfected, then the bacteria or virus re-cycles, mutates, and then reinfects throughout the sinuses. (I’m serious, I wrote this theory prior to conducting any real research that follows!)

So my guess was that as long as Jia didn’t have an ear infection (and wasn’t susceptible to them), as long as we kept her pacifier relatively clean, she should be fine. 

Continue to keep in mind my mantra from previous research posts:   

Association DOES NOT equal causation! 

Again, if you’d like to read an overview of OM and it’s causes, read Part 1.  And if you want to jump to the LittleSproutings.com Verdict post-research explanation,  either scroll to the bottom of the post or click here.

What’s the Significance in this Relationship?

Otitis Media is one of the most common infections in childhood, and causes stress to parents, and often times, children are prescribed antibiotics for ear infections. The problem with this is over half of ear infections are resolved WITHOUT the use of antibiotics, so over-prescribing antibiotics is actually a problem. Not all ear infections are caused by a bacteria.

Bacteria (staph, strep, pseudomonas, clostridium, etc) = antibiotic treatment (when necessary)

Viruses (like common colds, most sore throats, flu, etc) = anti-viral treatment (when necessary)

When antibiotics are excessively or liberally prescribed, bacteria begin to learn how to exist even with the medication. Why? Because when antibiotics are introduced into the system and the bacteria present is not exactly causing a problem, it mutates and alters its DNA to become resistant to the antibiotic. Antibiotics are good when there is a legitimate bacterial infection to treat.  When antibiotics aren’t used, the immune system builds antibodies in fighting it.

Now, I’m not advocating for a medication-free treatment of bacterial or viral infections, but quickly turning to antibiotics isn’t always the answer and can actually do more harm than good. 

Enter: the pacifier part of this discussion. Identifying modifiable risk factors that contribute to an illness that so commonly is the reason for frequent prescribing of antibiotics so early in your child’s life is very valuable. If you can change what you’re doing that puts them at a risk for getting an ear infection, then the better. 


So that’s why researching this is important. If pacifiers are actually a problem, then children who frequently get ear infections may find have a sudden decrease in ear infection incidence (new infections) when pacifiers are discontinued. 

As mentioned in Part 1 of this series, there are many benefits to pacifiers. After breastfeeding is established, pacifiers can aid in soothing infant cries and fussiness (though I’ve read these claims may not be evidence-based as statistically significant, I can personally vouch that my then-infant and now toddler most assuredly is calmer with a pacifier when she’s fussy… but then again Jia has grown accustomed to her paci as a calming attachment item and I’ve seen Jia’s friends just as calm without them), pacifiers have been established as having evidence-based and statistically significant benefits in stabilizing hemodynamics (slowing of heart rate, calming a rapid breathing rate when associated with pain during minor procedures, anxiety, or stress, etc), and can aid in the prevention of Sudden Infant Death Syndrome (more can be read here and here). However, cons of pacifier use can be dental malocclusion, negatively influential in nipple confusion if introduced too early in the breastfeeding relationship, and as this topic is concerned, otitis media.

But the question posed in this article is – Is it really? And if so, how?

Proposed Mechanism of Infection

According to Ilia S. and Galanakis E., who published an article in the International Journal of Infectious Disease in 2013, called “Clinical features and outcome of acute otitis media in early infancy”1, identified two probable ways that pacifiers may have an influence in potentiating an OM infection:

  1. The pacifier itself can increase the reflux/reintroduction/transfer (whichever word you prefer) of infected secretions from the nasopharyngeal area (the sinuses, all the drainage and mucus you get from an illness) into the middle ear and infect that space or;
  2. The pacifier can actually induce a structural change to the mouth/dental structures and affect the function of the eustachian tube in the ear.

I know, interesting, right? Moving on…

What the Research Points To

An article published in the American Academy of Family Physicians by Sexton and Natale2 conducted a literature review of articles that investigated the risks and benefits of pacifiers, and addressed the topic of infections. What they found was:

  • latex pacifiers colonized a clinically significant higher bacterial load than silicone pacifiers
  • the bacteria/viruses present on those pacifiers weren’t even pathogenic (harmful) and none contained the “common pathogens of otitis media” (another source here)

The only part of the literature review that gave me pause was reading that a controlled cohort study published in Pediatrics in 2000 by Niemela et al3., found what I can only believe as being a statistically significant relationship (I’m trying to give them the benefit of the doubt here, since the AAP and AAFP regard this study so highly) between pacifier reduction/restriction and a 33% decrease in episodes of Acute Otitis Media (AOM). I tried to access the original reference article to get more detail into this very broadly stated conclusion but widely accepted and formulated recommendation to wean pacifiers at or around 10 months of age. Judging by the abstract alone, the intervention group was instructed to stop pacifier use DURING their pre-scheduled visits to the clinic. The parents in the intervention group were also  given instructional pamphlets that stated the dangers of pacifiers (really?).

The biggest conclusion that the authors in this study were able to come to was that there was a statistically significant reduction in AOM when pacifiers were only used for babies/infants when they were falling asleep. (Being a Devil’s Advocate – If they were only instructed to limit pacifier use during their clinic visits, how did they know the families were actually refusing their babies to use them otherwise?) This is the drawback to inaccessible literature! Sigh. 

Remember those researchers (Ilia and Galanakis) that identified the two probable mechanisms that pacifiers might play a role in AOM infections?

Well, they also found a statistically significant relationship between pacifier use and AOM episodes. HOWEVER – yes a BIG however – according to the researchers, “this relationship did not remain significant after applying multiple regression statistics” to control for other factors that might be correlated with AOM episodes, the relationship between pacifiers and AOM “did not remain significant”! Instead, they found that the only real significant association was having older siblings (catching an ear infection from an older sibling) family’s medical-seeking behaviors (the likelihood they will seek medical help for an illness), and family history of atopy (likelihood to be hyper allergic or especially pre-disposed to flare-ups, sicknesses, allergies, etc. and possibly genetics (ear structure, normal flora and resistance to infection, immune system, etc).

A Bit on “Recurrent Ear Infections” 

Throughout various research articles I came across in writing this particular blog post (literature reviews, randomized controlled studies, nonrandomized studies, etc),  many of them have found (inconsistent evidence and/or non-significant) associations not between pacifiers and an isolated ear infection, but rather pacifiers and recurrent ear infections4. The importance in understanding the term “recurrent infections” as it relates to this topic is valuable.

Recurrent acute otitis media infections mean they keep happening, the child has already had an OM infection, so therefore these children are at a higher risk of having a repeat OM infection if they are using pacifiers.

Why? How does that FIRST OM Infection + Pacifier = Recurrent OM Infection?

The thought is that the first OM infection does damage to protective mucosal layer of the ear canal, leaving it more susceptible to attacks by viruses or bacteria. Because of this pre-damaged mucosa, the use of a pacifier would likely reintroduce those infected sinus secretions during a cold or other infection, to the more/highly susceptible middle ear, leading to another case of AOM.

The LittleSproutings.com Verdict

If your child(ren) are susceptible to ear infections or has already had an OM infection, then pacifiers could be playing a role in subsequent OM infections. If your child has already had an AOM infection, you may want to strongly consider weaning them from the pacifier to avoid a recurrence.

However, if your child has not had an ear infection and/or very rarely gets sick, is at home and not attending an outside day care, and/or is receiving breast milk/nursing exclusively (little-to-no formula, receiving ample amounts of protective immunoglobulins via breastmilk), I would not lose sleep over deciding whether weaning is in the best interests of your baby solely for the purpose of avoiding an ear infection.

Remember: Association ≠ (does not equal) Causation!

Pacifiers don’t lead to OM infections, but an OM infection can make your child’s pacifier the transport mechanism for another ear infection!

A review of literature published in the British Journal of Community Nursing5 says it wonderfully:

“Rather than advising a parent not to use a pacifier for fear of causing otitis media, advice in relation to this issue might best be restricted to pacifier users suffering from the problem (OM) in order to reduce the chances of recurrence.” – Hannifin S, Griffiths P. (2002)

Sources:

NIH Ear Infections: http://www.nidcd.nih.gov/health/hearing/pages/earinfections.aspx#4

MedScape: Overview of Otitis Media: http://emedicine.medscape.com/article/994656-overview

1Ilia S., Galanakis E. Clinical features and outcome of acute otitis media in early infancy. Int J of Infectious Disease, 2013 vol 17. e317-e320. Full Text:  http://www.ijidonline.com/article/S1201-9712(12)01304-5/pdf

2Sexton S., Natale R. Risks and Benefits of Pacifiers. Amer Fam Phys, 2009. 79(8): 681-685. Full Text: http://www.aafp.org/afp/2009/0415/p681.pdf

3Niemela M.,  Pihakari Ol, Pokka T., Uhari M., Uhari M. Pacifier as Risk Factor for Acute Otitis Media: A Randomized, Controlled Trial of Parental Counseling. Pediatrics, 2000. 106(3): 483-488. http://pediatrics.aappublications.org/content/106/3/483.abstract

4Rovers M., Numans M., Langenbach E., Grobbee D., Verheij T., Schilder A. Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Family Practice, 2008 vol 25: 233-236. Full Text:  http://fampra.oxfordjournals.org/content/25/4/233.full.pdf+html

5Hanafin S., Griffiths P. Does pacifier use cause ear infections in young children? Br J Community Nurs. 2002 7(4): 208-211. http://www.ncbi.nlm.nih.gov/pubmed/11979200

NHS.uk Dummy use linked to ear infection (dissecting a BBC News article) http://www.nhs.uk/news/2008/06June/Pages/Dummyuselinkedtoearinfection.aspx