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The Effects of Early Pacifier Use on Breastfeeding Duration

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The Effects of Early Pacifier Use on Breastfeeding Duration The Effects of Early Pacifier Use on Breastfeeding Duration Cynthia R. Howard, MD, MPH*; Fred M. Howard, MD‡; Bruce Lanphear, MD, MPH\; Elisabeth A. deBlieck, MPA*; Shirley Eberly, MS§; and Ruth A. Lawrence, MD* ABSTRACT. Objective. To evaluate the effects of pac- n infant must learn to attach and suckle prop- ifier use and the timing of pacifier introduction on erly at the breast during the first few days of breastfeeding duration, problems, and frequency. life to successfully establish breastfeeding.1,2 Methods. A cohort of 265 breastfeeding mother–infant A Early oral experiences that require sucking mechan- dyads was followed prospectively. Maternal interviews ics different from those required for breastfeeding were conducted at delivery, 2, 6, 12, and 24 weeks, and thereafter every 90 days until breastfeeding ended. Infor- are believed to contribute to the development of mation was obtained regarding pacifier use, infant feeding, improper latch and subsequent breastfeeding fail- 2–4 use of supplemental foods and breastfeeding frequency, ure—a problem described as nipple confusion. The duration, and problems. The effect of pacifier introduction avoidance of pacifiers was included as 1 of 10 steps by 6 weeks of age on breastfeeding duration was evaluated for successful breastfeeding in the 1990 Innocenti with Kaplan-Meier and Cox proportional hazards models. Declaration on maternity services and breastfeeding, The effect of the timing of pacifier introduction (<2 weeks and many experts recommend that mothers who are < and 6 weeks) on breastfeeding duration at 2 and 3 months breastfeeding avoid exposing their infants to artifi- was evaluated using logistic regression modeling. cial suckling experiences including use of pacifiers.5–7 Results. A total of 181 mothers (68%) introduced a Exposure to artificial nipples among breastfed in- pacifier before 6 weeks. In adjusted analyses, pacifier fants remains commonplace in routine newborn care introduction by 6 weeks was associated with a signifi- 5,6,8 cantly increased risk for shortened duration of full (haz- in hospitals throughout the United States. A num- ard ratio, 1.53; 95% confidence interval: 1.15, 2.05) and ber of observational studies and one randomized overall (hazard ratio, 1.61; 95% confidence interval: trial have evaluated the effect of pacifier use on 1.19,2.19) breastfeeding. Women who introduced pacifi- breastfeeding. Although the majority of evidence in- ers tended to breastfeed their infants fewer times per dicates that pacifier use is associated with significant day, with significant differences noted at 2 (8.1 6 2.6 vs declines in breastfeeding duration,2,9–11 two studies 6 6 6 9.0 2.3) and 12 weeks’ (6.3 2.0 vs 7.4 1.6) postpar- dispute a causal association between pacifiers and tum. At 12 weeks postpartum, women who introduced shortened breastfeeding duration.12,13 Most pub- pacifiers also were more likely to report that breastfeed- ing was inconvenient and that they had insufficient milk lished studies of pacifier use have examined the ef- supplies. Pacifier use begun either before 2 weeks or fects on breastfeeding duration in less developed before 6 weeks’ postpartum was not significantly associ- countries. Although pacifier use is common in devel- ated with breastfeeding duration at 2 and 3 months. oped countries,14 there are no published reports of Conclusions. Pacifier use was independently associ- the effects of pacifier use on the duration of breast- ated with significant declines in the duration of full and feeding in a cohort of US mothers and infants. Ad- overall breastfeeding. Breastfeeding duration in the first ditionally, many factors known to influence breast- 3 months’ postpartum, however, was unaffected by pac- feeding duration, including cultural practices, ifier use. Women who introduced pacifiers tended to prenatal education, hospital practices, and postpar- breastfeed their infants less frequently and experienced tum support, are likely to vary between less devel- breastfeeding problems consistent with infrequent feed- ing. Findings from this study suggest that the decreases oped countries and the United States. Therefore, it in breastfeeding duration associated with pacifier use remains unclear whether pacifier use should be ac- may be a consequence of less frequent breastfeeding tively discouraged. among women who introduce pacifiers to their infants. It also has been hypothesized that the timing of Pediatrics 1999;103(3). URL: http://www.pediatrics.org/ exposure to artificial nipples is important in mediat- cgi/content/full/103/3/e33; breastfeeding, pacifiers. ing effects on breastfeeding.2–4,15 Thus, according to this hypothesis, mother–infant dyads who begin pac- ABBREVIATIONS. HR, hazard ratio; CI, confidence interval. ifier use before breastfeeding is well established in- cur a higher risk for problems than do couplets who have successfully established breastfeeding before pacifier introduction. A randomized clinical trial of From the Departments of *Pediatrics, ‡Obstetrics and Gynecology, and §Biostatistics, University of Rochester School of Medicine and Dentistry and restricted supplemental formula and pacifier use the Children’s Hospital Medical Center, Rochester, New York; and the during the first 5 days of life demonstrated no sig- \Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio. nificant effects on breastfeeding.13 Longer periods of Received for publication Mar 20, 1998; accepted Nov 12, 1998. avoidance, however, have not been assessed. Reprint requests to (C.R.H.) Department of Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621. The purpose of this analysis was to evaluate the PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- effects of pacifier use on breastfeeding duration in a emy of Pediatrics. cohort of US mother–infant dyads and the influence http://www.pediatrics.org/cgi/content/full/103/3/Downloaded from www.aappublications.org/newse33 by PEDIATRICSguest on September Vol. 30,103 2021 No. 3 March 1999 1of6 that timing of pacifier introduction exerts on any not differ significantly from those retained to follow-up for race associated declines in breastfeeding duration. (P . .5), age (P . .7), marital status (P 5 .10), or educational attainment (P 5 .06), but they had significantly lower socioeco- nomic status (P 5 .01). METHODS This cohort of 265 breastfeeding mother–infant dyads was fol- Data from a cohort of 265 breastfeeding mother–infant dyads lowed with serial telephone interviews conducted by nurse inter- participating in a larger randomized clinical trial of obstetric in- viewers blinded to the study hypothesis and group assignment. fluences on infant feeding choices and breastfeeding duration Interviews were conducted at 2, 6, 12, and 24 weeks’ postpartum, were analyzed.16 A brief summary of the methods used to develop and every 90 days thereafter until breastfeeding ended. Standard- this cohort is presented. ized interviews with categorical and quantitative responses were A total of 547 consecutive pregnant women presenting for their used. At each telephone contact, extensive information was gath- first prenatal visit were randomized to receive one of two distinct ered regarding infant feeding including breastfeeding frequency, educational packs about infant feeding, one containing formula duration, and maternal and infant problems; proportion of diet company produced materials (commercial) and the other contain- composed of breast milk; and timing of introduction and use of ing materials with similar subject matter but selected to eliminate various supplemental foods and/or liquids. Additionally, moth- all forms of formula advertising (noncommercial). Both packs ers were questioned at each contact regarding regular (daily) use contained information about infant feeding emphasizing breast- of a pacifier while the infant was breastfed. feeding as optimal infant nutrition, and neither contained infor- At each contact, nurses offered to answer any infant, maternal mation about pacifiers. Packs were distributed to women at the care, or breastfeeding question. Advice regarding pacifier use was end of their first prenatal visit. offered only if a mother questioned the use of a pacifier specifi- Two randomly assigned study groups of expectant mothers cally. Consistent with postpartum hospital instruction and breast- were formed over a 7-month period (12/94–6/95) from three feeding protocols used by the hospital breastfeeding support line, independent, obstetric practices in six clinical offices in and women were encouraged to avoid pacifier use until breastfeeding around the Greater Rochester, NY, area. Clinical sites for this was well established, generally at 3 to 4 weeks of age. study included one urban site, four suburban sites, and one rural site. Each obstetric practice comprised five to six obstetrician/ gynecologists, each of whom performed deliveries exclusively at Analysis Rochester General Hospital, a level II, 526-bed community hospi- Data were entered and analyzed using SAS, BMDP, and Epi tal affiliated with the University of Rochester School of Medicine Info version 6.17 Statistical tests used to compare sociodemo- and Dentistry. Obstetric practices were selected based on an affil- graphic characteristics (Tables 1 and 2) included Student’s t test, x2 iation with Rochester General Hospital, the proportion of obstetric test, and Fisher’s exact test as appropriate.18 Analyses of breast- patients choosing to breastfeed, and willingness
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