Abstract
Question As a family physician who frequently attends deliveries and follows up with neonates, parents often ask me if they can provide their newborns with pacifiers in order to calm infants down, reduce crying, and improve sleep. Is pacifier use safe in the first month of life?
Answer While pacifiers are useful for soothing, there is concern that their use might cause early weaning of breastfeeding owing to “nipple confusion.” Several organizations, such as the World Health Organization and the United Nations Children’s Fund, recommend avoiding use of pacifiers in term infants who breastfeed. However, evidence suggests that it might not be pacifier use that causes premature cessation of breastfeeding, and that use of pacifiers might only be a sign of a maternal decision to stop breastfeeding.
Breastfeeding has been promoted heavily in recent decades as the sole means of nutrition for infants up to 6 months of age. The Canadian Paediatric Society1 and the American Academy of Pediatrics2 recommend exclusive breastfeeding for the first 6 months of life for healthy, term infants, recognizing breast milk as the optimal food for infants. After that period, additional food should be introduced, and breastfeeding can be continued as a complementary source of food.
Infants have a strong sucking reflex that helps with breastfeeding. The process of sucking was also found to be helpful in calming and soothing babies. In one Canadian study, more than 80% of parents used pacifiers for their babies.3 However, in recent years a potential “nipple confusion” between breast, bottle, and pacifier was suspected.
Should parents avoid pacifiers?
Owing to the possibility of premature weaning, the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children’s Fund recommends avoiding pacifier use in term infants who breastfeed.4
One Canadian study found that pacifier use was possibly a marker of breastfeeding difficulties or a potential lack of motivation to breastfeed among mothers rather than a true cause of early weaning.3 In this randomized trial in Montreal, Que, 140 mothers were asked to avoid pacifier use (experimental group) and were compared with a similar group that was not asked to restrict use (control group). The experimental group avoided pacifier use more often (38.6% vs 16.0% in the control group) and reduced infants’ daily use of pacifiers (40.8% vs 55.7% in the control group); however, similar rates of early weaning were reported (18.9% in the experimental group vs 18.3% in the control group in the intention-to-treat analysis). Interestingly, in a separate analysis based on treatment given (ignoring randomization), an association was found between daily exposure to pacifiers and weaning by 3 months of age (25.0% of the exposed group vs 12.9% of the unexposed group).3
Recent evidence—more confusion
A 2011 Cochrane review5 looked at randomized and quasi-randomized controlled trials investigating the effects of pacifiers in healthy, breastfeeding, full-term newborns. In 2 trials with almost 1300 newborns, pacifier use had no significant effect on the proportion of infants exclusively breastfed at 3 months of age (risk ratio [RR] 1.00; 95% CI 0.95 to 1.06) and at 4 months of age (RR 0.99; 95% CI 0.92 to 1.06). Similarly, there was no effect on partial breastfeeding at 3 months of age (RR 1.00; 95% CI 0.97 to 1.02) and at 4 months of age (RR 1.01; 95% CI 0.98 to 1.03). However, Jaafar et al cautioned that short-term breastfeeding difficulties faced by mothers and the long-term effects of pacifier use on infants’ health were not investigated.
Most recently, a retrospective before-and-after study attempting to determine the association between removing routine distribution of pacifiers in a mother-baby unit and breastfeeding initiation was conducted in Oregon.6 Restricting pacifiers (while not restricting access to formula) actually decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding.
The issue of pacifier use is still under some debate. While awaiting more definitive studies, the Pediatric Research in Emergency Therapeutics program recommends following current guidelines: avoid pacifier use in the first month of life for healthy, breastfeeding newborns.
Notes
PRETx
Child Health Update is produced by the Pediatric Research in Emergency Therapeutics (PRETx) program (www.pretx.org) at the BC Children’s Hospital in Vancouver, BC. Dr Goldman is Director of the PRETx program. The mission of the PRETx program is to promote child health through evidence-based research in therapeutics in pediatric emergency medicine.
Do you have questions about the effects of drugs, chemicals, radiation, or infections in children? We invite you to submit them to the PRETx program by fax at 604 875–2414; they will be addressed in future Child Health Updates. Published Child Health Updates are available on the Canadian Family Physician website (www.cfp.ca).
Footnotes
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Competing interests
None declared
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