Pacifiers and Breastfeeding: Is There Really A Problem?

Esther Entin, M.D.

The pros and cons of the use of pacifiers have been widely debated, by both healthcare professionals and parents. Concerns range from the potential impact on breastfeeding, to concern about dental complications or increased ear infections, to the anticipated agony of weaning the infant or toddler at the appropriate time. Opinions are strongly held and fiercely defended.

In November of 2005, an article published in Pediatrics looked at numerous studies that investigated the association between pacifier use and a decreased risk Sudden Infant Death Syndrome (SIDS) and reviewed seven studies that contained a control (non-pacifier) group as well as a pacifier group. All of these studies showed a significant decrease of the risk of SIDS in the group of infants who used pacifiers, particularly when they were put to sleep. Based on their finding, the study group recommended encouraging the use of pacifiers during daytime naps and nighttime sleep for the first year of life as a method of reducing SIDS risk. They recommended that the introduction of the pacifier to breastfeeding infants be delayed until breastfeeding was well established.

All of these studies showed a significant decrease of the risk of SIDS in the group of infants who used pacifiers, particularly when they were put to sleep.

While this paper was in progress, another report was published in the March 2005 issue of the American Journal of Epidemiology which noted a 90% reduced risk of SIDS among pacifier users compared to a control group.

Debate and concern over the impact of pacifier use on breastfeeding has continued, however. Parents and physicians have often felt caught between a rock and a hard place, weighing the strong pros of breastfeeding against the legitimate fear of SIDS. Breastfeeding has significant short and long term positive health outcomes for infants and mothers, and practices which discourage breastfeeding would have potential negative public health implications, especially in countries where clean water and appropriate infant formula are not routinely available. Discouraging pacifier use is still considered one of the "Ten Steps to Successful Breastfeeding" in a program adopted by the World Health Organization and UNICEF in the late 1980s. But in 2005, the American Academy of Pediatrics began to recommend offering a pacifier at naptime and bedtime.

A recent review, published in the April, 2009 issue of Archives of Pediatric and Adolescent Medicine looked at the literature from 1950 to August, 2006 for appropriate studies to answer the question: Does pacifier use alter the breastfeeding patterns of infants, either in the duration of breastfeeding, or the exclusivity (no supplementary bottle use). Twenty-nine studies were considered appropriate for this review, based on their design and their inclusion of a control or comparison group. The 29 studies represented 12 countries, including the United States, and a range of demographic and socioeconomic backgrounds.

None of the studies found a significant difference between breastfeeding outcomes in infants who did and did not use pacifiers. One study reported an intervention in which half of the mothers were educated to avoid pacifiers and half received no educational intervention. The same percentage of infants had been weaned from the breast by three months in each group.

The authors of this recent review speculate that the appearance of a negative effect of pacifier use on breastfeeding may in fact be revealing a maternal desire to wean the infant. They propose that there may be an increased use of pacifiers when mothers are weaning their babies from the breast or trying to lengthen the interval between feedings. Furthermore, pacifier use may be a marker for breastfeeding problems or a mother's mixed feelings about breastfeeding.

The current guideline offered by the American Academy of Pediatrics — using pacifiers at nap and bedtime — seems to provide a common sense approach to the important goals of supporting breastfeeding and preventing SIDS. None of the studies looked specifically at the effect of pacifier use on breastfeeding when used in this fashion but the strong evidence from this recently published study dispels concerns of a negative impact of pacifiers on breastfeeding and should provide parents and doctors with the knowledge that they can navigate the channel of the SIDS and breastfeeding safely and effectively.

Parents of young infants, and women who are pregnant should discuss the issue of pacifiers and breastfeeding with their babies' doctors as early as possible. Many doctors have "meet and greet" visits with prospective parents when such issues can be raised. Additionally, if mothers are encountering difficulty with breastfeeding, they should seek the support of their medical providers or lactation consultants whether or not their babies use pacifiers. Most problems related to changing milk supply, increasing infant demand, and effective latching on and suckling can be solved with appropriate counseling.

June 29, 2009

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