by Jeanmarie Burigo Connor
May 18, 2009

Knowing the many benefits of breastfeeding, health care providers are quick to discourage any obstacles to achieving breastfeeding success. In the late 1980s, pacifiers received a negative nod when the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) listed avoidance of pacifiers as one of the Ten Steps to Successful Breastfeeding. Whether pacifiers are truly obstacles or simply innocent bystanders was the subject of a recent review article published in the April 2009 issue of Archives of Pediatric and Adolescent Medicine.

Research
Nina R. O’Connor and colleagues conducted a systematic review to assess the link between pacifier use and breastfeeding. Twenty-nine studies were identified: four randomized controlled trials, 20 cohort studies, and five cross-sectional studies were evaluated.

The studies varied in terms of their definitions of pacifier use. Some studies classified pacifier use as only while the infants were in the hospital; however, most studies looked at pacifier use at 2 weeks, 1 month, 2 months, or 6 months of age. In addition, the classification of infants as “pacifier users” varied between any pacifier use, frequent use, and occasional use.

Breastfeeding outcome measures varied as well and included overall duration of breastfeeding, breastfeeding at set time points ranging from hospital discharge to 12 months of age, exclusive breastfeeding, predominant breastfeeding, and any breastfeeding (not specified as exclusive or predominant breastfeeding).

Results
Of the four randomized controlled trials that were evaluated, none found significant differences in breastfeeding outcomes based on pacifier use. Of the observational studies, 17 found that pacifier use was linked with an odds ratio, relative risk, or hazard ratio of shortened breastfeeding duration or shortened period of exclusivity. However, unlike randomized controlled trials, observational studies cannot prove causality, therefore no conclusions can be reached as to which came first—pacifier use leading to decreased breastfeeding or decreased breastfeeding leading to increased pacifier use. The remaining eight observational studies did not find statistically significant associations between pacifier use and breastfeeding outcomes.

In short, this review article highlights the need for more research on the relationship between pacifier use and breastfeeding. However, based on the strongest existing evidence, there is no indication that pacifier use has a detrimental effect on breastfeeding.

Recommendations
Ever since recent case-control studies suggested that pacifiers may provide a protective benefit for infants against SIDS (Sudden Infant Death Syndrome), the American Academy of Pediatrics (AAP) has recommended the use of pacifiers throughout the first year of life according to the following guidelines:

1. Pacifiers should be used only at naptime or bedtime and if the baby refuses the pacifier, he or she should not be forced to take it.
2. Pacifiers should not be coated with anything sweet.
3. Pacifiers should be cleaned often and replaced regularly.
4. For breastfed babies, pacifier use should be delayed until 1 month of age to ensure breastfeeding is firmly established.

None of the studies performed to date have directly assessed the effect of the AAP’s SIDS prevention recommendations on breastfeeding. Until such a study is conducted, we must rely on current evidence which shows that pacifier use does not directly cause adverse breastfeeding outcomes but may actually foretell breastfeeding difficulties. For now, pacifiers remain innocent until proven guilty.