Abstract
Pacifiers and teething devices are commonly introduced during infancy to soothe and comfort. This study aimed to investigate the incidence of emergency room visits for pediatric craniofacial injuries associated with pacifiers and teething devices. All craniofacial injuries due to “Pacifiers or Teething Rings” in children less than 2 years old were retrieved from the National Electronic Injury Surveillance System (NEISS). Age, sex, race, context of injury, cause of injury, and patient disposition were collected. Query revealed an estimated nationwide incidence of 5424 injuries from the years 2012 to 2021, with a mean age of 12.1 months at the time of injury. Most injuries occurred at home (70.2%), often resulting from falls while using the pacifier/teething device (71.0%). An estimated 97.6% of patients were released after emergency room treatment. Education regarding abstaining from pacifier and teething device use during activity may reduce the incidence of these injuries.
Introduction
Many infants in the United States are given pacifiers and teething devices as a means to soothe and comfort. 1 Pacifiers are beneficial during the first few months of life, while teething devices provide comfort to children beginning at around 6 months of age when their first teeth erupt. Pacifiers in particular have noted benefits, including a reduction in the risk of sudden infant death syndrome (SIDS). 2 However, the use of pacifiers and teething devices in infants is often debated. While beneficial, these devices can also pose risks to the developing infant, such as decreased breastfeeding, dental malocclusion, and otitis media. 3
A less studied risk of pacifier and teething device use is craniofacial injury. One retrospective analysis of children less than 3 years old treated in the emergency department for injury related to bottle, pacifier or sippy cup in the years 1991 to 2010 connected pacifier use to over 8000 injuries. 4 The same study associated falling with a pacifier in the mouth with an increased risk of injury in infants and toddlers. 4 However, this risk is not discussed in the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), or the American Academy of Pediatric Dentistry (AAPD) discussions of teething device and pacifier use in children.3,5,6
Currently, the AAFP and AAP recommend the use of pacifiers in children as an intervention to reduce the incidence of SIDS and soothe developing infants. However, they also suggest weaning use by 12 months due to the potential for infection and bite malalignment. 3 Few recommendations are offered surrounding teething device use. Given the limited availability of research surrounding craniofacial injuries from these devices, the purpose of the current study was to provide an updated analysis of the incidence of emergency room visits for craniofacial injuries due to pacifiers and teething devices in the pediatric population.
Methods
Study Design
A retrospective review of the free, public National Electronic Injury Surveillance System (NEISS) database was conducted. National Electronic Injury Surveillance System is provided by the US Consumer Product Safety Commission (CPSC) and can be queried for a variety of emergency department admissions. There are over 100 participating emergency departments throughout the United States that have employed coders to review patient charts and input into the NEISS database. These coders classify patient demographics, characteristics of the injuries, and disposition based on a coding document provided by the CPSC. The NEISS database employs weights that are given to each reported injury. These weights can be utilized to calculate national incidence with 95% upper and lower confidence intervals.
The Institutional Review Board of all universities affiliated with the authors of this article waived the need for ethics approval and patient consent for the collection, analysis, and publication of the retrospectively obtained and anonymized data for this non-interventional study.
Data Collection
National Electronic Injury Surveillance System was retrospectively reviewed for injuries with the following “Body Part Codes”: Head (75), Face (76), Eyeball (77), Mouth (88) due to “Pacifiers or Teething Rings” (1525). The year of injuries was limited to the range of 2012 to 2021 and only injuries involving children less than 2 years of age were included. Age and sex of the patient were collected. Location where the injury took place, mechanism of the injury, and patient disposition from the emergency room were analyzed.
Data Analysis
Weights for each injury provided by the NEISS database were utilized to determine estimated national incidences. SPSS version 27 (IBM Corporation, Armonk, NY) was utilized to calculate descriptive statistics.
Results
A total of 207 injuries were identified, for an estimated nationwide incidence of 5424 injuries from 2012 to 2021. The yearly incidence trended downward throughout the study period (Figure 1). Table 1 displays the demographic information of the patients. The most common age was 12 months (n = 565, 10.4%), with a mean age of 12.1 months.
Teething injuries in children—year.
Patient Demographics.
Table 2 illustrates the frequency of body parts affected and diagnoses associated with the injuries. The data were sourced from the NEISS database, with contributions from NEISS hospital coordinators who are trained to collect detailed information on injuries according to their training and the NEISS coding sheet. National Electronic Injury Surveillance System coders review the emergency department records and designate a code to the injury related to the consumer product, in this case, a pacifier. It is thereby added to the database, on which our study was based, ensuring consistency. The most common diagnoses were lacerations (52.4%) followed by contusions/abrasions (12.3%). Three hundred fifty-six cases (6.6%) were diagnosed as internal organ injuries, all of which were attributable to head injuries. One case involved a 4-month-old male who broke a teething ring while chewing on it and swallowed the fluid within the ring. He was diagnosed with poisoning, and his injury was classified as affecting all parts of the body. Burns were observed in patients with the use of frozen or heated teething devices.
Frequency of Body Part Injuries and Diagnoses.
Table 3 presents the types of consumer products that were most frequently involved in the injuries. All 5424 injuries involved pacifiers or teething rings, as this was one of the inclusion criteria for the study; 50.9% of injuries were caused by the teething device alone, whereas 49.1% involved at least one additional product. The most common product besides teething devices was floors or flooring materials, which played a role in 24.1% of all injuries.
Frequency of Primary and Secondary Product Involvement.
Most injuries took place at home (70.2%). However, over a quarter of the injuries occurred in an unknown location (27.4%). Falls were a common mechanism of teething device-related injury, making up 3852 (71.0%) of cases. In particular, many falls resulted in hitting one’s head or face on the floor. A total of 1164 falls included some mention of floors or flooring materials, with falls encompassing 89% of all floor-related injuries. Although many fall injuries occurred while the pacifier or teething device was in the patient’s mouth, this was not always the case; other scenarios included falling onto a loose pacifier or falling while reaching for a pacifier.
The vast majority of patients were released from the emergency room after examination and treatment (97.6%), while only 1.3% were admitted to the hospital (Table 4). All instances of hospitalization occurred in 2012, the first year of the study period, and only involved male patients.
Patient Disposition.
Discussion
While the advantages of pacifiers and teething devices are often discussed in the literature, there remains a noticeable paucity of discourse surrounding the potential hazards of these devices, particularly those unrelated to development and infection. Case studies in the literature have documented severe injury to craniofacial structures with pacifier misuse. In one instance, prolonged pacifier use in the prone position led to nasal alae with black eschar and pressure breakdown on an infant’s chin and upper lip. Another case reported ulceration of the mouth, undersurface of the mid-upper lip, and deep erosion of the columella of an infant’s nose. 7 Thus, the aim of this study was to determine the incidence of emergency room visits for craniofacial injuries due to pacifiers and teething devices in the pediatric population.
Pacifiers are historically intended to soothe infants. Forms of pacifiers have been found in Italy, Cyprus, and Greece dating back to 3000 years ago. 7 As of recent, pacifiers have been popularly used by parents to alleviate teething pains. Teething pain occurs due to the eruption of the tooth from the enamel epithelium. 8 This leads to inflammation and tenderness in the surrounding gums. 8 The dental follicle containing the emerging tooth produces eicosanoids, cytokines and growth factors that stimulate pain impulses in the nerve fibers. 8 To reduce teething pain, non-pharmacological advice is to gently rub the irritated gums and provide pressure. 8 This is where the idea of pacifiers originates. 8
Other notable benefits of pacifiers include analgesia for minor procedures, reduced hospital stays for preterm infants, and reduced risk for SIDS. 3 As research has progressed, the benefits and risks of pacifiers are slowly becoming dependent on the needs of the infant and their age. As the infant ages, there is more potential for complications to arise. For instance, pacifier use past the age of 6 months may contribute to otitis media and dental complications after 2 years of age, as well as infection. 3 In general, pacifier use is most beneficial up to 6 months of age. Thereafter, the complications outweigh the benefits after 6 months of age. 3 Nevertheless, some parents continue to provide their children with pacifiers after the recommended timeline since their child has an attachment to the pacifier and it is an effortless solution to soothe them or to replace habits of thumb sucking.
A noticeable finding of this study was that children aged 12 months were most likely to suffer from the injuries associated with the pacifiers and teething devices. There are a few plausible factors that may have played a role in this demographic distribution. At 12 months of age, most developing infants begin to walk. With the transition to walking comes the risk for falls. Thus, it is not surprising that this study also found a high rate of falls associated with these injuries as well as a high frequency of flooring involvement. Infants and toddlers can experience oral trauma due to the opposing forces of the pacifier or teething device in the mouth and the object of impact. The object in a child’s mouth can come into harmful contact with their teeth, gums, or surrounding anatomical structures. Through this impact, it may dislodge their teeth from the periodontal ligament anchoring them. 9
An analysis of bottle, pacifier, and sippy cup injuries between 1991 and 2010 in the United States similarly found a high risk of injury with falls while a pacifier was in the mouth of the child. 4 Keim et al 4 concluded that control over mobility as well as fewer children using the pacifiers by the age of 2 resulted in fewer falls and subsequently, fewer injuries.
Thus, altogether, these findings demonstrate that it is crucial to supervise children when they are using pacifiers and teething devices, especially once they are mobile. Childproofing surrounding environments and removing any fall risks may decrease the risk of these injuries as well.
Another factor that may have played a role in the age distribution of these injuries was the general timeline of use of these products. As previously discussed, the AAFP, AAP, and AAPD recommend weaning the use of pacifiers to prevent complications surrounding infection, dental health, and speech, and most children stop using pacifiers by the age of 2 when they are able to self-soothe. 3 In addition, while teething continues in a developing child up until approximately the age of 3, parents often give their children teething devices when their first teeth erupt between 6 and 18 months. 10 These factors combined explain why the number of injuries was normally distributed in terms of patient age with a mean of 1-year age.
The AAP also has strict guidelines surrounding teething devices. Due to the risks associated with teething bracelets, necklaces, and other jewelry, they recommend rubbing infants’ gums with a clean finger or providing teething rings made of firm rubber and discourage use of topical medication to treat teething, including over-the-counter benzocaine products, creams, gels, and homeopathic remedies. 10 The AAP also specifically advises against freezing and heating teething rings.10,11 Nevertheless, multiple cases in this study involved burns from teething devices that were not rubber in quality. One case involved a teething device that was placed in the microwave and subsequently caused a burn to the mouth, scalp, neck, and shoulder, and another case involved a mouth burn from a frozen teething ring. The trend in our data of increased injuries at ages older than 8 months, further underscores previous research on the potential complications outweighing the benefits past 6 months of age. 8 Moreover, AAP and AAFP recommend weaning children off pacifiers after 6 months old. 3 In light of the clear deviance from these guidelines, it is crucial that pediatricians and safety advocates encourage adherence to these recommendations and disseminate AAP guidelines to parents and caregivers.
The present study found a downward trend in the incidence of teething device injuries from 2012 to 2021. These may be the result of AAP guideline updates as well as CPSC efforts for product safety regulations. Both pacifiers and teething devices have strict regulations and guidelines surrounding their characteristics.12,13 These include, but are not limited to, the size and shape, construction, materials, and testing of the devices. These regulations have been instituted to prevent risks of choking and suffocating, ingestion of harmful levels of toxic substances, and injury from sharp edges or small portions breaking off. Guidelines surrounding the safety of these objects continue to be updated to ensure user safety. However, few changes to the AAP and CPSC guidelines have changed during the study period. Nevertheless, the Food and Drug Administration (FDA) did issue a warning in 2018 against the use of teething jewelry and the CPSC has continued to recall teething products. 11 The CPSC also specifically has classified teethers and teething toys as separate entities from teething devices that are used to ease teething pain. 12 While the former falls under the CPSC’s jurisdiction, the latter falls under the Federal Drug Administration’s jurisdiction. Unfortunately, we are unable to distinguish these groups with the NEISS data collected. Further research could potentially explore the implications of this distinction.
In today’s world, more parents turn to the internet for advice regarding their child’s safety. Thus, access to accurate information regarding pacifier and teething device use on the internet is of utmost importance. Unfortunately, a systematic review of 16 parenting websites found that general information for pacifier use varied significantly on each site. 14 Thus, standardized guidance from credible organizations, such as the AAP that is accessible to parents online is important. Discussion of safety precautions, including fall risk reduction, in an accessible online format could be of benefit to reduce injuries surrounding teething devices and pacifiers.
Limitations
The limitations of this study surround the inherent nature of the NEISS database. While the database is comprehensive and includes many emergency rooms throughout the United States, the use of multiple hospital systems results in the possibility of inaccurate or unstandardized reporting methods. In addition, this database does not include injuries that did not result in emergency department visits. Thus, less severe injuries may be underreported in the present study.
Conclusions
Young children, especially in the 9-month to 1-year age group, are at risk for injuries inflicted by pacifiers and teething rings. Education surrounding these devices should emphasize abstaining from pacifier and teething ring use during periods of activity and limiting use to times when the child is at rest. Pacifiers and teething devices have minimal benefit past the age of 6 months. Alternative non-pharmacological management may prove more beneficial for soothing teething pains. Expansion of nationwide guidelines surrounding pacifier and teething device use, as well as distribution of these guidelines in an online, parent-accessible format could prove beneficial and reduce the incidence of these injuries.
Author Contributions
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
