It is well recognized that breast milk is superior to formula feeding in providing balanced nutrition, protection against allergy and infection in newborns; and several Cochrane Reviews have investigated ways to promote and prolong breastfeeding. As a consequence, it is widely recommended that babies should be exclusively breastfed for up to the first six months of their lives and there are concerns that the use of a pacifier (a non-nutritive sucking device to calm an infant) might be a barrier to this. For example, the World Health Organization’s Ten Steps to Successful Breastfeeding recommends that pacifiers should not be given to breastfeeding infants. However, their use is relatively widespread and they have become a cultural norm in many parts of the world with a belief that they are harmless or, potentially, necessary and beneficial for an infant’s development.

This updated Cochrane Review, published in July 2012, sets out to identify and present the evidence that might resolve this uncertainty, by assessing the effect of unrestricted versus restricted pacifier use in healthy full-term newborn babies whose mothers initiated breastfeeding with the intention of exclusively breastfeeding. The outcomes of primary interest for the review relate to the duration of breastfeeding, with secondary outcomes including breastfeeding difficulties experienced by the mother, maternal satisfaction and level of confidence in parenting, infant crying and fussing, and infants’ health. However, the included studies did not provide data for analyses of these secondary outcomes.

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The authors relied mainly on the Cochrane Pregnancy and Childbirth Group’s Trials Register to identify studies for the review. This comprehensive register has been compiled over two decades and includes regular searches of the Cochrane Central Register of Controlled Trials, the MEDLINE bibliographic database and dozens of journals relating to maternity care. The eligibility criteria for the review sought randomised and quasi-randomised trials in which an intervention with unrestricted use of pacifiers was compared with one in which there were restrictions on the use of pacifiers, in healthy full-term babies, for whom breastfeeding had been started. However, because of the potential for bias, if more than one in five of the randomized participants had been excluded from the final analyses, the trial was deemed ineligible. This was the case with one of the three potentially eligible studies identified. This had randomized 602 babies to either a group in which bottles, teats and pacifiers were to be avoided (with any medically indicated supplements to be administered by cup or spoon) or a group in which pacifiers were offered to all babies without restriction and supplements were conventionally offered by bottle after breastfeeding. In this trial, which was conducted in Switzerland, nearly 40% of the babies in the first group were excluded due to protocol violation in the first week, most of which related to the used of bottles or pacifiers, and further babies were lost from the other group and from the overall follow-up, leading to its exclusion from the review on the grounds of high attrition.

The other two eligible trials that were identified could be included in the meta-analyses of some of the primary outcomes, contributing data from a total of 1302 babies. The larger of these studies recruited just over 1000 women from five centres in Argentina, who were highly motivated to breastfeed. They were randomly assigned to a group given a pack of silicone pacifiers, a written guide and advice to use other pacifiers if they wished (528 babies) or to a group that were given a guide with alternative strategies for a crying baby. The other trial, from a single hospital in Canada, recruited a total of 281 healthy breastfeeding women who had given birth to a healthy singleton baby at term. They were randomly allocated to one of two counselling interventions, provided by a trained research nurse. In one group (140 babies), the mother was asked to avoid pacifier use when the infant cried or fussed and to offer her breast first and then to try carrying or rocking the infant if this proved unsuccessful. The other 141 mothers and babies were in a group where all options for calming the infant were discussed, including pacified use, along with breastfeeding, carrying and rocking.

The results of these two studies could be combined in a meta-analysis of the proportion of babies who were exclusively breastfed at three months of age. This showed no significant difference between the babies in the pacifier-use and the pacifier-avoidance groups, with a risk ratio (RR) of 0.99, and a 95% confidence interval (CI) running from 0.93 to 1.05. The larger study also provided data on exclusive breastfeeding at four months, and the result was similar (RR: 0.99; 95% CI 0.92-1.06).

The authors of the Cochrane Review conclude that pacifier use in healthy term breastfeeding infants with motivated mothers, did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age. They recommend that until further information becomes available on the effects of pacifiers on the infant, mothers who are well motivated to breastfeed be enabled to make a decision on the use of a pacifier based on personal preference. The authors suggest that further research should explore additional outcomes, such as the rate of breastfeeding difficulties experienced by mothers associated with pacifier use and the long-term effect of pacifier use on mother and infant health; as well as examining the effects on breastfeeding when the parents are less motivated than those in the trials included in the review.

Sourece: Cochrane Library