1. NEWS
❙❙❙clinical update
Pacifiers, breastfeeding and soothing
Kramer MS, Barr RG, Dagenais S, Results: Baseline demographic charac- determine whether pacifier use was a
Yang H, Jones P, Ciofani L, et al. Paci- teristics were similar in the 2 groups, al- predictor of early weaning. Among the
fier use, early weaning, and cry/fuss though there was a slightly higher pro- infants reportedly exposed to daily use
behavior. JAMA 2001;286:322-6. portion of single women (21% v. 16%) of a pacifier, 25.0% were weaned before
and smokers (15% v. 10%) in the exper- 3 months of age, as compared with
Background: Many modern-day clini- imental group. There were no differ- 12.9% of infants not given a pacifier
cians and public health caregivers be- ences between the 2 groups in the pro- (RR 1.9, 95% CI 1.1–3.3). This is con-
lieve that pacifiers promote nipple con- portion of women who participated in sistent with other observational stud-
fusion and lead to early weaning.1 In the interview (91%) or who completed ies.3–10 The authors suggest that such
fact, avoidance of pacifiers constitutes the surveys at 4 (70.9%), 6 (60.5%) and observational results may indicate that
step 9 of the World Health Organiza- 9 weeks (57.4%). The women who pacifier use is a marker for breastfeed-
tion/UNICEF Baby-Friendly Hospital dropped out were more likely to be ing difficulties or low motivation to
Initiative.2 Most of the evidence to sup- younger, single and smokers than the breastfeed rather than a cause of early
port this arises from observational stud- women who completed the study. weaning.
ies that, by design, fail to control for the Significantly more women in the ex-
confounding influences of cultural atti- perimental group than in the control Practice implications: The effects of
tudes and personal motivations.3 group reported completely avoiding pacifier use have not been rigorously
pacifier use (38.6% v. 16.0%) (relative studied. This study suggests that paci-
Question: Does advice to avoid pacifier risk [RR] 2.4, 95% confidence interval fier use does not increase the risk of
use, delivered to new mothers during [CI] 1.5–3.8). Also, the mean number of early weaning per se or reduce the du-
their postpartum stay in hospital, re- pacifier insertions per day was signifi- ration of fussing and crying episodes of
duce the risk of weaning from the cantly lower in the experimental group infants. However, a positive response to
breast before 3 months or increase the than in the control group at weeks 4 an enquiry about frequent use of a paci-
frequency or duration of crying and (0.8 v. 2.4), 6 (0.8 v. 3.0) and 9 (1.3 v. fier may identify women who require
fussing by the infant? 3.0). However, there was no difference extra breastfeeding support and encour-
between the experimental and control agement. — Erica Weir, CMAJ
Design: This randomized controlled groups in the proportion of infants
trial, conducted over 20 months in a weaned from the breast (18.9% and References
maternity hospital in Montreal, in- 18.3% respectively; RR 1.0) or not ex- 1. Neifert M, Lawrence R, Seacat J. Nipple confu-
volved 281 healthy women who in- clusively breastfed (63.8% and 66.4% sion: toward a formal definition. J Pediatr 1995;
126:S125-9.
tended to breastfeed their healthy, respectively; RR 1.0) at 3 months, or in 2. WHO/UNICEF. Protecting, promoting and sup-
term, singleton infants. The mothers cry/fuss behaviour at weeks 4, 6 or 9. porting breastfeeding: the special role of maternity ser-
were randomly allocated either to an vices. Geneva: World Health Organization; 1989.
3. Aarts C, Hornell A, Kylberg E, Hofvander Y,
experimental postpartum breastfeeding Comments: These results fail to sub- Gebre-Medhin M. Breastfeeding patterns in rela-
interview, in which the lactation consul- stantiate claims of a direct link between tion to thumb sucking and pacifier use. Pediatrics
1999;104:1-10.
tant advised the avoidance of pacifier pacifier use and a higher risk of early 4. Victora CG, Tomasi E, Olinto MTA, Barros FC.
use when the baby fussed, or to a con- weaning from the breast. Advice to Use of pacifiers and breastfeeding duration.
trol interview, in which all options for avoid pacifier use did not reduce the Lancet 1993;341:404-6.
5. Barros FC, Victora CG, Semer TC, Filho ST,
calming the infant, including pacifier risk of early weaning, although it is pos- Tomasi E, Weiderpass E. Use of pacifiers is asso-
use, were discussed. At weeks 4, 6 and 9 sible that women who were advised not ciated with decreased breastfeeding duration. Pe-
the mother recorded her infant’s beha- to use pacifiers may have been biased diatrics 1995;95:497-9.
6. Victora CG, Behague DP, Barros FC, Olinto
viour, including the frequency and du- toward falsely reporting that they com- MTA, Weiderpass E. Pacifier use and short
ration of episodes of crying or fussing, plied with the advice. The effect of such breastfeeding duration: Cause, consequence, or
coincidence? Pediatrics 1997;99:445-3.
over 3 consecutive days. At 3 months an a bias would be to reduce the strength 7. Richard L, Alade MO. Sucking technique and its
interviewer, blinded to group alloca- of treatment effect of this advice (if it effect on success of breastfeeding. Birth 1992;19:
tion, asked mothers whether they were existed) and possibly to conceal a real 185-9.
8. Clements MS, Mitchell EA, Wright SP, Esmail A,
still breastfeeding and, if not, the date difference. Jones DR, Ford RP. Influences on breastfeeding
of weaning. Multiple logistic regression The authors did not report on the in southest England. Acta Paediatr 1997;86:51-6.
analysis was conducted to calculate the ethnic and cultural backgrounds of the 9. Ford RP, Mitchell EA, Scragg R, Stewart AW,
Taylor BJ, Allen EM. Factors adversely associ-
risk of weaning in the experimental mothers, 2 important determinants of ated with breast feeding in New Zealand. J Paedi-
group relative to the control group. breastfeeding that may have con- atr Child Health 1994;30:483-9.
10. Howard CR, Howard FM, Lanphear B, deBlieck
The mean number of episodes of fuss- founded the analysis. Finding no effect EA, Eberly S, Lawrence RA. The effects of early
ing and minutes of crying were com- of the intervention, the investigators pacifier use on breastfeeding duration. Pediatrics
pared using t-tests. conducted an observational analysis to 1999;103:E33.
CMAJ • OCT. 16, 2001; 165 (8) 1089