Should breastfeeding babies be given pacifiers?

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Should breastfeeding babies be given pacifiers?

J Fam Pract. 2012 May;61(5):E1-E3

By

Laura Wellington, MD

Shailendra Prasad, MBBS, MPH

Tell breastfeeding moms who ask that question that pacifier use will not interfere.

References

1. Jaafar SH, Jahanfar S, Angolkar M, et al. Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2011;(3):CD007202.-

2. Chandra RK. Prospective studies on the effect of breastfeeding on the incidence of infection and allergy. Acta Paediatr Scand. 1979;68:691-694.

3. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeed Rev. 2001;9:11-18.

4. American Academy of Pediatrics Section on breastfeeding. Policy Statement. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-e841.

5. World Health Organization. Ten steps to successful breastfeeding. WHO/UNICEF statement. Available at: http://www.unicef.org/newsline/tenstps.htm. Accessed April 12, 2012.

6. Gomes CF, Trezza EM, Murade EC, et al. Surface electromyography of facial muscles during natural and artificial feeding of infants. J Pediatr (Rio J). 2006;82:103-109.

7. Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth. 1998;25:40-44.

8. Mascarenhes ML, Albernaz EP, DaSilva MB, et al. Prevalence of exclusive breastfeeding and its determiners in the first 3 months of life in the South of Brazil. J Pediatr (Rio J). 2006;82:289-294.

9. Scott JA, Binns CW, Oddy WH, et al. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics. 2006;117:e646-e655.

10. Barros FC, Victora CG, Semer TC, et al. Use of pacifiers is associated with decreased breast-feeding duration. Pediatrics. 1995;95:497-499.

11. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245-1255.

12. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). Available at: www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed April 17, 2012.

13. Howard CR, Howard FM, Lanphear B, et al. The effects of early pacifier use on breastfeeding duration. Pediatrics. 1999;103:E133.-

14. Karabulut E, Yalcin SS, Ozdemir-Geyik P, et al. Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. Turk J Pediatr. 2009;51:35-43.

15. Jackson JM, Mourino AP. Pacifier use and otitis media in infants twelve months of age or younger. Pediatr Dent. 1999;21:255-260.

16. Darwazeh AM, al-Bashir A. Oral candidal flora in healthy infants. J Oral Pathol Med. 1995;24:361-364.

17. Caglar E, Larsson E, Andersson EM, et al. Feeding, artificial sucking habits, and malocclusions in 3-year-old girls in different regions of the world. J Dent Child (Chic). 2005;72:25-30.

PRACTICE CHANGER

Do not discourage the use of pacifiers by healthy infants who are breastfeeding.¹

STRENGTH OF RECOMMENDATION

A: Based on a good-quality meta-analysis

Jaafar SH, Jahanfar S, Angolkar M, et al. Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2011;(3):CD007202.

ILLUSTRATIVE CASE

A 28-year-old first-time mother brings her 1-week-old full-term, healthy daughter to your clinic for a routine check-up. The baby is growing as expected. The mother is breastfeeding exclusively and would like to continue until the baby is at least 6 months old. She has begun giving the infant a pacifier and asks whether that’s OK. What should you tell her?

Breast milk is superior to formula for infant nutrition,^2,3 and the American Academy of Pediatrics (AAP), World Health Organization (WHO), and UNICEF recommend exclusive breastfeeding through the first 6 months of life.^4,5 “Ten steps to successful breastfeeding,” a document developed by the WHO and UNICEF, specifically states that artificial teats and pacifiers should not be given to breastfeeding infants.⁵

Concern about pacifiers for breastfeeding infants focuses on “nipple confusion”—that is, that pacifiers (and supplemental bottles) do not facilitate effective breast sucking and may contribute to incorrect latch.^6,7 Findings from earlier observational stud-ies suggest that early exposure to pacifiers leads to cessation of exclusive breastfeeding by 3 to 6 months and an end to all breastfeeding by 12 months.^8,9

Pacifiers have become a cultural norm in many parts of the world,¹⁰ and their use appears to be associated with a decrease in the incidence of sudden infant death syndrome (SIDS).¹¹ But both the AAP and the American Academy of Family Physicians recommend delaying paci-fier use until breastfeeding is established.^4,12

STUDY SUMMARY: Pacifier or no pacifier— no significant difference

Cochrane reviewers conducted a meta-analysis of randomized controlled trials (RCTs) that assessed the effects of pacifier use on healthy full-term infants whose mothers had initiated breastfeeding and intended to exclusively breastfeed.¹

The primary outcome was the duration of breastfeeding, as measured by (1) mean duration of full breastfeeding (in months); (2) mean duration of any or partial breastfeeding; or (3) the prevalence or proportion of infants who were fully or partially breastfed at 3, 4, and 6 months of age. Secondary outcomes were (1) rate of breastfeeding difficulties (cracked nipples, breast engorgement, mastitis); (2) maternal satisfaction and level of confidence in parenting; (3) frequency of infant crying and fussiness; and (4) infant health, including SIDS, oral candidiasis, otitis media, and dental malocclusion. Infants who were given pacifiers (ie, those who had unrestricted or actively encouraged pacifier use) were compared with infants who were not given pacifiers (ie, whose mothers were advised against pacifier use).

Two studies, with a combined total of 1302 infants, were included in the meta-analysis (a third was excluded because the method by which allocation was concealed was un-clear). Both reported blinding of the research nurses and outcome assessors. Blinding of par-ticipants was not feasible.

Each trial measured at least one primary outcome. The dropout rate was <10% in each arm of both studies.

When pacifier use was compared with no pacifier use, no significant difference was found in the proportion of infants who were exclusively breastfed at 3 months (risk ratio [RR]=1.00; 95% confidence interval [CI], 0.95-1.06) or 4 months of age (RR=0.99; 95% CI, 0.92-1.06). Nor was there a significant difference in the proportion of infants who were partially breastfed at 3 months (RR=1.00; 95% CI, 0.97-1.02) or 4 months (RR=1.01; 95% CI, 0.98-1.03).

Neither study reported on any of the secondary outcomes.