“A sucker born every minute”: pacifiers and breastfeeding

For new moms, deciding about whether to offer a pacifier to a newborn, like deciding whether to breastfeed, can be an emotionally loaded decision.  Newborns need to suck – for non-nutritive (comfort) as well as nutritive (food) reasons.  I can’t count the number of times I’ve heard “that baby is using [me/you/her mom] as a pacifier!” from parents and nursery nurses during the first hours of life.

When I hear that, I can’t help but to cringe and comment that pacifiers were invented as a substitute for moms, not vice versa.   The physiology of lactation requires frequent suckling and emptying of the breast to establish and maintain a mom’s milk supply.  So it makes sense that giving a pacifier to a newborn who wants to suckle, instead of letting him nurse, could adversely affect his mom’s milk supply as well as his own growth.  Thus physicians who want to support breastfeeding usually caution new parents about the use of pacifiers before breastfeeding is well established, usually about two weeks after birth. ( Avoidance of artificial teats or pacifiers is, in fact, one of the WHO/UNICEF Ten Steps to Successful Breastfeeding.)

However, it has been difficult to find definitive scientific evidence to support this advice.  And as a mom, I well remember the frustration of seemingly incessant newborn breastfeeding.  That’s why I was hopeful when I saw the abstract for a new Cochrane meta-analysis that suggests pacifiers need not be avoided.

A meta-analysis is an especially powerful kind of scientific study because it combines the results of more than one research study, for a more statistically powerful analysis than any one study alone could provide.  The Cochrane library contains hundreds, if not thousands, of peer-reviewed systematic reviews, including meta-analyses, in 53 different medical subject areas.

This particular review, Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding, states that “for mothers who are motivated to breastfeed their infants, pacifier use before or after breastfeeding was established did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age”.

Taken at face value, this means that it didn’t matter whether pacifiers were given early in the newborn period or after breastfeeding was established –the groups of babies whose moms were advised for or against pacifiers breastfed equally long and equally as much.

The only qualifier, that the mothers had to be “motivated to breastfeed”, fascinated me.  I wondered what measure of motivation had been used, since “motivation” can be a tricky thing to study in expectant and new moms.  I also wondered how I had missed more than one large RCT of this sort in the recent literature.

So I went and looked at the entire review.  And I was disappointed.

The authors found only two studies worthy of inclusion, including 1302 babies and their moms.  One of these (Jenik et al 2009), with 1021 of the 1302 babies (78%), looked at the effects of advice about pacifier use at 2 weeks of age after breastfeeding was well established, with moms who planned to breastfeed at least 3 months. There was no difference in breastfeeding outcomes between the groups advised for or against pacifier use.

The other study (Kramer et al 2001), with only 12% of the babies, looked at the effects of advice about pacifiers before newborn hospital discharge (less than 4 days of life) with moms who “intended to breastfeed longer”. This study found that many moms ended up using pacifiers without having been advised to by study personnel, and while this may have affected long-term breastfeeding outcomes, there was no difference in the groups as they were initially randomized and advised  “(intention to treat” analysis).

To make a long story short, in my view the meta-analysis combined two dissimilar studies of babies at different ages (birth, versus 2 weeks) and moms at different stages of lactation (lactogenesis 1/lactogenesis 2 versus lactogenesis 2/galactopoiesis).

Without a doubt, the reviewers are correct that “motivation” plays a part in long-term breastfeeding outcomes.   Because of this, I think it’s fair to say that advice given about pacifiers in the newborn period may not make a big difference in long-term outcomes.

But I don’t think it’s fair to say that the new moms in the smaller study who had less successful outcomes were necessarily less motivated to breastfeed.  There are others giving advice besides study personnel (family members, friends, primary health care providers) and clearly these moms were not listening only to the study personnel.

To move briefly to anecdote:  our own child #1 was given a pacifier in the newborn period even though I was “motivated” to breastfeed. That child was jaundiced and by 2 weeks of age was not yet back to birthweight.  Our pediatrician (a well-intentioned friend and colleague) advised formula supplements.  We chose instead to nurse more frequently, with no detriment to long-term breastfeeding.  Child #2 had no pacifier, no jaundice, and gained birthweight back in less than a week.

Had we followed all the advice given with child #1, we would have had less breastfeeding success and quite possibly less healthy children.

Bottom line: Until we are better able to assess “motivation” in new moms and tailor advice accordingly, I think it still behooves those of us who care for breastfeeding women and babies in the immediate newborn period to exercise caution in our discussion of pacifier use.  However, it is nice to be reassured that pacifiers are probably “safe” once breastfeeding is well-established.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.