Link Between Pacifiers & Breastfeeding Unclear

by Heidi Green
May 04, 2012

“Breastfeeding not limited by pacifier use after all,” CBS News declares, in its coverage of a recent hospital study, while MSNBC proclaims there to be “no more nipple confusion.” A host of other media outlets concur.

Is it time, as Time magazine asks, to “bring back the binky?”

A surprising finding
The study that’s getting so much attention was conducted recently at Doernbecher Children’s Hospital of Oregon Health & Sciences University (OHSU). It has not been published in a peer-reviewed journal yet, but was presented at the 2012 Pediatric Academic Societies conference. (Please note that since it hasn’t been published, our sources of information are limited to the abstract, a summary by the American Academy of Pediatrics (AAP), OHSU’s press release, and media accounts.)

Unfortunately, this means we can’t know the researcher’s methodology, inclusion or exclusion criteria, and other pertinent details.

In December 2010, the OHSU Mother-Baby Unit halted the routine distribution of pacifiers to breastfeeding newborns. Pacifiers were instead kept in a locked supply management system that required the health care provider to type in a code, the patient’s name, and a reason for checking out a pacifier. Pacifiers were allowed in special circumstances, such as in conjunction with a painful procedure. In addition, parents were able to bring pacifiers from home, and these were not tracked.

Dr. Carrie Phillipi, associate professor of pediatrics at OHSU and resident pediatrician Laura Kair analyzed data on feeding of 2,249 infants. They determined that when pacifiers were still being distributed (July 2010–November 2010), about 79 percent of infants were breastfed exclusively during their hospital stay, but once the locked-pacifier policy was initiated, over the subsequent eight-month period (January 2011–August 2011), the percentage of breastfeeding infants decreased significantly to 68 percent. At the same time, the proportion of breastfed infants who received supplemental formula increased from 18 percent to 28 percent. The percentage of infants fed formula-only remained statistically unchanged.

Dr. Phillipi explained to The Oregonian’s Kathy Hinson that she and Dr. Kair “had sort of taken it on faith … that (avoiding pacifier use) would increase breastfeeding rates.” According to MSNBC, Dr. Kair notes that their expectation was in line with “the common belief among medical providers and the general public that pacifier use negatively impacts breastfeeding,” but instead they “found limiting pacifier use in the Mother-Baby Unit was associated with decreased exclusive [breastfeeding] and increased supplemental formula feeds.”

The researchers suggest that the seeming relationship between pacifier availability and breastfeeding should be viewed “as an interesting observation.” Dr. Kair explains that they “do not claim a cause and effect relationship,” but publicize this data “to stimulate dialogue and scientific inquiry into the relationship between pacifiers and breastfeeding.”

“Our overall goal,” she continues, “is to increase breastfeeding rates.”

Study raises questions
While the study raises some interesting questions about the researcher’s unexpected finding, it must be considered with caution in light of several facts:

• There’s a lot we don’t know about the research. As noted above, we don’t know the methodology, or the inclusion or exclusion criteria for this study. We also don’t know what process the hospital undertook in launching its “pacifier lockdown” initiative or staff response/compliance.
• There’s a lot we don’t know about the hospital environment. Dr. Kair has observed that this was an initial step in the hospital’s pursuit of Baby-Friendly status: “As our hospital is trying to get Baby-Friendly status, we anticipated that removing pacifiers would improve exclusive breastfeeding,” says Kair in an interview with the TODAY show. “Pacifiers were a low-hanging fruit, removing them was an easy thing to do.” Some previous research suggests that the steps of the Baby-Friendly Hospital initiative don’t work in isolation but rather in concert. For example, one study of maternity-care practices found that more of the practices led to better improvements in rates of breastfeeding assessed at six weeks. Another recent study of baby-friendly practices in a Hong Kong hospital found that mothers who experienced just one or fewer baby-friendly practices were almost three times more likely to discontinue breastfeeding by eight weeks postpartum.
• It’s unclear whether the hospital engaged in any parent education. Parental use of pacifiers as “hushers” to calm a crying baby, as the World Health Organization (WHO) explains, may inadvertently be used as a substitute for a feeding. This may lead infants who use them regularly to have fewer daily breastfeeds. Thus any effort to support breastfeeding ought to involve some education with regard to normal newborn behavior (including the meaning of different cries), infant feeding cues, and the need to put the baby to the breast as soon as possible in the first days postpartum to build the mother’s milk supply.
• Analysis is limited to the hospital stay. It seems the researchers looked only at infant feeding data in the hospital. A more complete analysis might follow the mother-baby dyads into the postpartum period, assessing breastfeeding behavior at a number of weeks or months.
• Analysis doesn’t address “why.” In November 2011, the AAP revised and reissued its SIDS policy statement, a primary component of which is a call for parents to give their babies pacifiers during sleep. This event was widely covered by the popular media, but it’s possible that the timing of this event—alone or in combination with other social messages in the community—influenced parents’ choices.
• It’s an observational study and cannot prove causality. As Dr. Phillipi has noted, no conclusions can be reached as to which came first: pacifier use leading to decreased breastfeeding, or decreased breastfeeding leading to increased pacifier use.
• It doesn’t account for parents who brought pacifiers in themselves, either before or after the lock-down policy was instituted.

Pacifier role still unclear
As explained elsewhere on baby gooroo, WHO and UNICEF recommend parents skip pacifiers since they may make it harder for parents to respond to their babies’ feeding cues, leading to a reduced milk supply and early cessation of breastfeeding. Meanwhile, the AAP continues to recommend pacifier use, on a restricted basis (e.g., when the baby is going to sleep), to reduce the risk of SIDS.

When it comes right down to it, each parent will need to weigh the risks and benefits of pacifier use and make a decision that feels right for their family. Breastfeeding mothers should remember that their baby’s sucking instincts are the “demand” that affects their milk “supply.” Some tips:

• Be attuned to your baby’s cues. Rather than reaching for the “husher” when your baby cries, recognize that this is one way your baby is trying to communicate with you. If she’s hungry—or if she just wants the comfort breastfeeding can provide—consider offering the breast before you offer a pacifier.
• Limit pacifier time to when your baby sleeps. In accord with the AAP’s recommendation, put your baby to bed with a pacifier to reduce the risk of SIDS, but don’t replace it if it falls out of your baby’s mouth.
• If you choose to give your baby a pacifier, take care of it. Check it often for cracks and tears. Clean it regularly and replace it as needed.
• Delay pacifier use until four to six weeks postpartum. Breastfeeding—and your milk supply—should be well-established by 4-6 weeks and use of a pacifier at that time should not interfere with your baby’s ability to breastfeed.