Pacifier Use During Lactation
by Anne Eglash MD, IBCLC, FABM
Whether pacifiers interfere with breastfeeding has been a decades-old debate. It has been a few years since the last systematic review, so let’s dive into what is new.
The authors of this recently published systematic review and meta-analysis from Finland remind us that the Baby Friendly Hospital Initiative 10 Steps for Successful Breastfeeding recommend counseling mothers on the risks of using artificial teats or pacifiers for fear of masking hunger cues.
On the flip side, pacifiers have been shown to decrease the risk of sudden infant death syndrome while non-nutritive sucking increases physiologic stability in preterm infants.
The authors performed a comprehensive systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of restricted vs free pacifier use on breastfeeding success during the first 6 months of life among term infants (>37 weeks gestation). They also measured the effect of pacifier use on duration of hospitalization and timing of oral feeding among preterm infants (<37 weeks). All observational studies were excluded.
Ten RCTs met criteria for this review and were considered moderate to high quality evidence. Five studies included term infants and the other five focused on preterm infants. Among the studies with term infants, the intervention groups were instructed to not offer pacifiers during the hospital stay or longer. The intervention groups for the preterm studies were given pacifiers during hospitalization.
Despite observational studies suggesting a negative effect of pacifiers on breastfeeding, all of the RCTs on term infants demonstrated no effect of pacifier use on breastfeeding duration through 6 months of age.
What else? See the question!
- Early pacifier use had no effect on ‘any’ breastfeeding until 6 months of age, but early pacifier use decreased exclusive breastfeeding rates at 6 months.
- Hospitalized preterm infants who received pacifiers were discharged on an average of 7 days earlier than those who did not receive pacifiers.
- Hospitalized preterm infants who received pacifiers transitioned from gavage feeding to full oral feeding on an average of 3 days earlier than those who did not receive pacifiers.
See the Answer
The purpose of this study is to assess whether pacifier use is associated with breastfeeding success in term and preterm newborns and whether it influences hospitalization time in preterm newborns. Four databases were searched for randomized controlled trials (RCTs), and a systematic review and meta-analysis were conducted. The risk of bias and evidence quality, according to the GRADE methodology, were analyzed. Risk ratios with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) for continuous outcomes were used. The random effect model was used if heterogeneity was high (I 2 over 40%). We screened 772 abstracts, assessed 44 full texts, and included 10 studies, of which 5 focused on term and 5 on preterm newborns. There were a few concerns about the risk of bias in 9 of the 10 studies. Breastfeeding rates were analyzed at 2, 3, 4, and 6 months, and the success rates were similar between the restricted and free pacifier use groups (evidence quality was moderate to high). In preterm neonates, the use of a pacifier shortened the duration of hospitalization by 7 days (MD 7.23, CI 3.98–10.48) and the time from gavage to total oral feeding by more than 3 days (MD 3.21 days, CI 1.19–5.24) (evidence quality was ranked as moderate). Conclusions: Based on our meta-analysis, pacifier use should not be restricted in term newborns, as it is not associated with lower breastfeeding success rates. Furthermore, introducing pacifier to preterm newborns should be considered, as it seems to shorten the time to discharge as well as the transition time from gavage to total oral feeding.
Early pacifier use was not found to affect either partial or exclusive breastfeeding rates through 6 months of age.
The studies on preterm infants mainly measured the effect of pacifier use on the timing of hospital discharge and transition from gavage to oral feedings. Pacifier use in the NICU shortened hospitalization time by an average of 7 days, and shortened gavage feeding by an average of 3 days.
Why do observational studies suggest that pacifier use among term neonates may interfere with breastfeeding but strong RCTs do not?
I suspect this is due to the Hawthorne effect. The Hawthorne effect is when subjects in a study change their behavior because it is being evaluated.
Let’s do a thought experiment- let’s say you are enrolled in a pacifier study. You are not in the intervention group that restricts pacifiers, but rather in the group that allows you to use pacifiers whenever you want to, starting immediately after birth. As a subject of a high-quality study, you undoubtedly receive information on the risks of the study, including information on how pacifier use might decrease suckling at the breast. Knowing this, you would likely be extra cautious about when you offer the pacifier and offer the breast first before the pacifier.
Therefore, I don’t believe the results of this high-quality pacifier research should lead to removal of the BFHI recommendation to educate new parents on the possible effect of bottles and artificial nipples on infant feeding. I suspect what these studies have really found is that when pacifiers are used among individuals who have been counseled on the risks, they do not interfere with breastfeeding.