University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• Does pacifier use in the breast-fed infant negatively impact breast-feeding?

Clinical Bottom Lines

1. Several retrospective and cohort studies have shown a negative impact of pacifier use on duration and exclusivity of breast-feeding.4,5,6,7,8 Two randomized trials demonstrated no effect, however, they were limited to either the first week of life or randomized not to pacifier use but to counseling regarding use.2,3
   
2. UNICEF/WHO recommends avoiding both supplemental feedings as well as artificial teats as part of their “10 steps to successful breastfeeding”.
   
3. In this study supplemental feedings were associated with decreased breastfeeding duration regardless of method.1
   
4. Early pacifier use was associated with decreased overall duration of breastfeeding.1
   
5. Causality of pacifier use and shortened breastfeeding duration has not been established.

Summary of Key Evidence

1. 700 breastfed newborns randomly assigned to 1 of 4 groups -- 1) bottle/early pacifier, 2) bottle/late pacifier, 3) cup/early pacifier, or 4) cup/late pacifier. The early pacifier group started using a pacifier between 2-5days of life, and late pacifier users were supposed to start after 4 wks of life.1
   
2. Mothers of infants who received supplemental feedings were more likely to be primiparous, receive federal assistance, be first-time breast-feeders, or have a cesarean. 69% of infants received supplemental feedings; at least 51% of these were for maternal request. Infants receiving supplemental feedings had shorter exclusive, full, and overall duration of breastfeeding. (HR 1.49-1.53 with narrow CI and P<0.0001.)
   
3. Early pacifier use assoicated with decreased duration of exclusive breastfeeding (28 vs 21 days (p=0.04) unadjusted analysis, and adjusted analysis showed decreased duration of overall breastfeeding (HR 1.22, CI 1.03-1.44).
   
4. Cup feeding versus bottle feeding in babies born by cesarean is less likely to shorten breast-feeding duration.
   

Additional Comments

• Pacifier introduction was at a median of 7 days for the early group and 28 days for the late group. Almost all families had introduced the pacifier at 6 weeks. No data given for the percentage of cross-over pacifier users in the early and late pacifier groups. Data analyzed in intention-to-treat analysis.
  
• No biological basis established for pacifier use and decreased breastfeeding duration. Pacifier use may be a marker for differing attitudes and commitment regarding breast-feeding or differences in the baby’s temperament.
  
• There are very few detrimental effects of delaying pacifier introduction. It is important to teach parents alternative soothing techniques. Supplemental feedings cannot always be avoided, but we should try to limit to those that are medically necessary.
  
• Study participants fairly homogeneous (white, middle-class). The study may not be applicable to pre-term or high risk infants.
  

Citation

1. Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, Lawrence RA. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111(3): 511-18.
   
2. Schubiger G, Schwarz U, Tonz O. UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? European Journal of Pediatrics 1997;156: 874-7.
   
3. Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, Jane F. Pacifier use, early weaning, and cry/fuss behavior. JAMA 2001;286(3): 322-6.
4. Victoria CG, Tomasi E, Olinto MTA, Barros FC. Use of pacifiers and breastfeeding duration. Lancet 1993;341:404-6
   
5. Victora CG, Behague DP, Barros FC, Olinto MTA, Weiderpass E. Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997;99(3): 445-53.
   
6. Howard CR, Howard FM, Lanphear B, deBlieck EA, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics 1999;103(3):e33.
   
7. Aarts C., Hornell A, Kylberg E, Hofvander Y, Gebre-Medhin M. Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics 1999;104(4)e50.
   
8. Vogel A, Hutchison B., Mitchell EA. The impact of pacifier use on breastfeeding: a prospective cohort study. Journal Paediatric Child Health 2001;37:58-63.

CAT Author: Krista Hodne, MD

CAT Appraisers: John Frohna, MD

Date appraised: March 17, 2003