COMMENTARY

Do Pacifiers Interfere With Breastfeeding Success?

William T. Basco, Jr., MD

Disclosures

November 18, 2009

Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding?

Jenik AG, Vain NE, Gorestein AN, Jacobi NE, Pacifier and Breastfeeding Trial Group
J Pediatr. 2009;155:350-354

Study Summary

One of the World Health Organization's recommended best practices for assuring successful breastfeeding is for nursing mothers to use no artificial nipples or pacifiers with newborn infants who are breastfeeding. The American Academy of Pediatrics recommends waiting to introduce pacifiers until infants are at least 1 month old. Data are mixed on whether pacifier use affects breastfeeding. Observational studies suggest that pacifier use has a negative effect on nursing success, but randomized trials in developed countries suggest either no effect of pacifiers on nursing success, or reduced nursing success only with very early pacifier introduction.

This study sought to evaluate the effect of pacifier use on breastfeeding success in infants up to 3 months of age -- a longer period than has been assessed in previous studies. Participants were enrolled at 5 tertiary care centers in Argentina, which were a mixture of public and private institutions. All hospitals, as part of routine care, encouraged mothers to avoid use of pacifiers. Infants were enrolled at 2 weeks of age after meeting the following inclusion criteria:

  • Gestational age ≥ 37 weeks;

  • Birth weight ≥ 2500 g;

  • Exclusively breastfed;

  • Mothers intended to nurse for at least 3 months;

  • Not using pacifiers; and

  • Well-established nursing (infant had regained birth weight and mom was routinely experiencing let-down reflexes).

The investigators excluded infants who had medical problems or whose mothers' medical problems would interfere with successful nursing, and infants whose mothers expressed a definite preference (either for or against) pacifier use.

Infants were randomly assigned to either an intervention group whose mothers received pacifiers and instructions on pacifier use or to a control group whose mothers received information on how to comfort infants without pacifiers. The main outcome of interest was the prevalence of exclusive breastfeeding at 3 months of age. The investigators also compared the prevalence and duration of any breastfeeding, as well as compliance with group assignment instructions (e.g. the number of mothers in the no-pacifier group who used a pacifier). A research assistant, blind to group assignment, conducted phone follow-up with the mothers at monthly intervals through 6 months, then at 8, 10, and 12 months of infant age.

In 2005 and 2006, 1021 infants were enrolled (528 assigned to pacifier use group). The groups were virtually identical on pre-enrollment characteristics, including birth weight, rate of cesarean section, maternal age, previous breastfeeding by the mothers, maternal education and smoking status, and percentage with fathers in the home. Approximately 95% of the subjects in both groups completed the trial.

The prevalence of exclusive breastfeeding at 3 months of age was 85.8% in the pacifier group and 86.2% in the no-pacifier group, for a risk difference of 0.4%, (95% confidence interval -4.7% to 4%) In both groups, > 75% of the mothers were exclusively breastfeeding their study infants at 4 months. The rates of "any breastfeeding" were also virtually identical and remained > 97% for both groups through the 3 and 4 month assessments. Of note, only 67% of the infants in the pacifier use group actually used a pacifier, but 40% of the infants in the no-pacifier group also used a pacifier. The investigators concluded that pacifier use does not alter the prevalence of exclusive breastfeeding at 3 months of age among infants born at term who had successful breastfeeding established at 2 weeks of life.

Viewpoint

The study authors noted that because previous trials enrolled fewer participants or followed infants for shorter periods, this study adds a great deal to the literature around this question. Although the investigators caution that this was a highly selected population (motivated mothers and infants who had established successful early nursing), such women likely constitute large percentages of the population at many US maternity hospitals. These data strike me as highly useful and practical when offering advice to expecting or new mothers on "what to do about pacifiers?" Coupled with data on decreased risk for sudden infant death syndrome with pacifier use,[1] these new data should reassure both moms and pediatric providers that pacifier use is not harmful and may, in some scenarios, be beneficial.

Abstract

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