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Routine pacifier use in infants: pros and cons Please cite this article as: Buccini G, Pérez-Escamilla R, Venancio SI. Routine pacifier use in infants: pros and cons. J Pediatr (Rio J). 2019;95:619-21.

We read with great interest the editorial "Routine pacifier use in infants: pros and cons,"11 Eidelman AI. Routine pacifier use in infants: pros and cons. J Pediatr (Rio J). 2019;95:121-3. which brought relevant information on the subject. However, the emphatic final recommendation on the routine use of pacifiers in breastfed infants, from our standpoint, deserves reconsideration.

There is strong evidence of the positive impact of breastfeeding on the health of children, lactating women, and the countries' economies.22 Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475-90. Considering the low worldwide breastfeeding rates, especially of exclusive breastfeeding (EBF) among children under 6 months of age, researchers have aimed to identify risk factors that can be modified.33 Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices?. Lancet. 2016;387:491-504. Among them is the use of pacifiers - a cultural habit, which can be modified. A systematic review of EBF risk factors in Brazil identified the use of pacifiers as the factor most strongly associated with EBF interruption (i.e., 15 of the 16 studies that included the pacifier in their analytical models found this association).44 Boccolini CS, de Carvalho ML, de Oliveira MI. Fatores associados ao aleitamento materno exclusivo nos primeiros seis meses de vida no Brasil: revisão sistemática. Rev Saude Publica. 2015;49:91. However, we recognize that there are gaps in the understanding of the potential mechanisms, involved in this association.

Based on the best level of evidence, systematic reviews55 O'Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr Adolesc Med. 2009;163:378-82.,66 Neto S, Oliveira AE, Zandonade E, Molina MdC. Pacifier use as a risk factor for reduction in breastfeeding duration: a systematic review. Rev Bras Saúde Mater Infan. 2008;8:377-89. and meta-analyses 77 Buccini GDS, Pérez-Escamilla R, Paulino LM, Araujo CL, Venancio SI. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13:e12384.

8 Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016;:CD007202.
-99 Karabulut E, Yalcin SS, Özdemir-Geyik P, Karaagaoglu E. Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. Turk J Pediatr. 2009;51:35. that investigated the association between pacifier use and breastfeeding found divergent results. As described in the editorial, publications that included only randomized controlled trials (RCTs) did not observe any differences regarding the duration of breastfeeding in response to different pacifier interventions 55 O'Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr Adolesc Med. 2009;163:378-82.,88 Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016;:CD007202. (i.e., education to discourage pacifier use1010 Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, et al. Pacifier use early weaning cry/fuss behavior: a randomized controlled trial. JAMA. 2001;286:322-6.vs. indication of use1111 Jenik AG, Vain NE, Gorestein AN, Jacobi NE. Does the recommendation to use a pacifier influence the prevalence of breastfeeding?. J Pediatr. 2009;155, 350-4.e1.vs. no use in the hospital, including the population of preterm infants1212 Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles cups dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ. 2004;329:193-8.vs. delay in pacifier introduction up to 4 weeks of age1313 Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111:511-8.). It is noteworthy that factors that may influence the association between pacifier use and breastfeeding77 Buccini GDS, Pérez-Escamilla R, Paulino LM, Araujo CL, Venancio SI. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13:e12384. were not controlled for in these RCTs. For instance, there was no systematization regarding the intensity of pacifier use, i.e., "regular" use vs. "partial" use. Another example is that, in the review published in The Cochrane Library,88 Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016;:CD007202. the RCTs samples consisted of mothers highly motivated to breastfeed (i.e., committed to continue breastfeeding even in the face of multiple breastfeeding challenges) and one of the RCTs had a possible conflict of interest.1414 Di Mario SCA, Basevi V, Magrini N. Feedback 1. In: Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding (authors, Jaafar SH, Jahanfar S, Angolkar M Ho JJ). Cochrane Database of Syst Rev. 2011;7:CD007202. In view of these limitations and biases, we consider it premature to issue a recommendation categorically stating that pacifier use does not interfere with breastfeeding duration.

Aiming to advance the knowledge on the subject, we carried out a meta-analysis that inlcuded RCTs and observational studies, with comprehensive eligibility criteria, including no restriction of year and language of publication.77 Buccini GDS, Pérez-Escamilla R, Paulino LM, Araujo CL, Venancio SI. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13:e12384. Considering the limitations of cross-sectional studies to establish causality, we favored the analysis of prospective observational studies, considering the use of pacifiers as a breastfeeding predictor. Based on 46 included publications, 14 of which were prospective observational studies, we concluded that pacifier use is associated with a shorter duration of EBF.77 Buccini GDS, Pérez-Escamilla R, Paulino LM, Araujo CL, Venancio SI. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13:e12384. This type of evidence has raised concerns amongresearchers in the breastfeeding field and led them to search for innovative strategies to reduce pacifier use, as done in the study published by Giugliani et al.1515 Giugliani ER, Nunes LM, Issler RM, Santo LC, Oliveira LD. Involvement of maternal grandmother and teenage mother in intervention to reduce pacifier use: a randomized clinical trial. J Pediatr (Rio J). 2019;95:166-72. We learned from that study that counseling sessions to promote breastfeeding with the involvement of family members (in this case, the grandmothers) can have a positive impact on the mothers' behavior change regarding pacifier use. As demonstrated by the same authors in previous publications,1616 Nunes LM, Giugliani ER, do Espírito Santo LC, de Oliveira LD. Reduction of unnecessary intake of water and herbal teas on breast-fed infants: a randomized clinical trial with adolescent mothers and grandmothers. J Adolesc Health. 2011;49:258-64.

17 Bica OC, Giugliani ER. Influence of counseling sessions on the prevalence of breastfeeding in the first year of life: a randomized clinical trial with adolescent mothers and grandmothers. Birth. 2014;41:39-45.
-1818 Oliveira LD, Giugliani ER, do Espírito Santo LC, Nunes LM. Counselling sessions increased duration of exclusive breastfeeding: a randomized clinical trial with adolescent mothers and grandmothers. Nutr J. 2014;13:73. this same intervention also had an impact on the increased frequency of breastfeeding. Consitent with this finding, an analysis of Brazilian population data, found that pacifier was the risk factor most strongly associated with the interruption of EBF between 1999 and 2008,1919 Buccini G, Pérez-Escamilla R, Venancio SI. Pacifier use and exclusive breastfeeding in Brazil. J Hum Lact. 2016;32:NP52-60. and also showed that the reduction of its use (17% in the period) contributed significantly to increasing the EBF rates (a 15% increase) during this nine-year period.2020 Buccini G, Pérez-Escamilla R, D'Aquino Benicio MH, Giugliani ER, Venancio SI. Exclusive breastfeeding changes in Brazil attributable to pacifier use. PLOS ONE. 2018;13:e0208261. Considering the stagnation in breastfeeding indicators in Brazil, including EBF ,2121 Boccolini CS, Boccolini PdM, Monteiro FR, Venâncio SI, Giugliani ER. Breastfeeding indicators trends in Brazil for three decades. Rev Saude Publica. 2017;51:108. simple and effective interventions based on modifiable risk factors, such as pacifier use reduction, may be crucial to promote breastfeeding.

In light of the available evidence, it is clear that the association between pacifier use and EBF interruption is complex, and may have components of cause, consequence, coincidence and be associated with the infant's personality and the profile of the mother and the family.2222 Buccini G [thesis] Evolução do uso de chupeta e sua influência no aleitamento materno exclusivo no Brasil 1999-2008. São Paulo: Faculdade de Saúde Pública da Universidade de São Paulo; 2017. Consequently, recommendations for pacifier use vary globally.2323 Eidelman AI, Schanler RJ. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-41.

24 Sexton S, Natale R. Risks and benefits of pacifiers. Am Fam Physician. 2009;79:681-5.

25 Ponti M. Recommendations for the use of pacifiers. Paediatr Child Health. 2003;8:515-9.
-2626 World Health Organization (WHO). UNICEF. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative implementation guidance. Geneva: WHO; 2018. Those who advocate the use of pacifiers do so for the prevention of sudden infant death syndrome (SIDS). 2323 Eidelman AI, Schanler RJ. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-41.,2727 Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138:e20162940. However, a recent systematic review concluded that there is no evidence from RCTs to support or reject pacifier use and, therefore, it is not possible to justify such a specific recommendations.2828 Psaila K, Foster JP, Pulbrook N, Jeffery HE. Infant pacifiers for reduction in risk of sudden infant death syndrome. Cochrane Database Syst Rev. 2017;4:CD011147. The sleep position2727 Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138:e20162940.and breastfeeding itself, especially EBF,2929 Hauck FR, Thompson JM, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128:103-10. have been identified as protective factors against SIDS. On the other hand, those who promote, protect, and support breastfeeding have been using a risk-benefit counseling approach on pacifier use, as suggested by the World Health Organization in their review of the 10 Steps of the Baby-Friendly Hospital Initiative (BFHI).2626 World Health Organization (WHO). UNICEF. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative implementation guidance. Geneva: WHO; 2018. This recommendation was recently endorsed by the Brazilian Society of Pediatrics (Sociedade Brasileira de Pediatria [SBP]) with the publication of a report on the evidence of pros and cons regarding the use of pacifiers in breastfed children and how to work with families. The goal of this recommendation is to guide the advise of pediatricians and healthcare professionals, as well as the parents' choice, avoiding to simply recommend pacifier use for all.3030 Buccini G, Venancio SI. Uso de chupeta em crianças amamentadas: prós e contras. Sociedade Brasileira de Pediatria. 2017. Available from: https://www.sbp.com.br/fileadmin/user_upload/Aleitamento-Chupeta_em_Criancas_Amamentadas.pdf [cited 30.05.19].
https://www.sbp.com.br/fileadmin/user_up...

Finally, it is important to take into account the potential influence from industries, which make millions of dollars out of the sale of pacifiers,3131 Lopes AG, Pereira AC, Fonseca EPd, Mialhe FL. Irregularidades sanitárias na promoção comercial em rótulos de produtos para lactentes e os riscos para a saúde. Saúde em Debate. 2017;41:539-52. and make strong efforts to promote their products and reinforce deeply engrained cultural practices that are not based on evidence.3232 Sertório SC, Silva IA. As faces simbólica e utilitária da chupeta na visão de mães. Rev Saude Publica. 2005;39:156-62. Considering the balance between the pros (e.g., reduction in SIDS, stimulation of non-nutritive sucking, pain management in the newborn, and modulation of the baby's agitated behavior) and cons (e.g., changes in oral functions, sucking, breastfeeding, chewing and swallowing, dentition alterations, increased incidence of otitis media, increased SIDS as a result of shorter EBF duration, etc.) possibly related to pacifier use, we consider it important that healthcare professionals inform parents about the available evidence so they can make an individualized and informed decision, as proposed by the new BFHI recommendations.2626 World Health Organization (WHO). UNICEF. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative implementation guidance. Geneva: WHO; 2018.

  • Please cite this article as: Buccini G, Pérez-Escamilla R, Venancio SI. Routine pacifier use in infants: pros and cons. J Pediatr (Rio J). 2019;95:619-21.

References

  • 1
    Eidelman AI. Routine pacifier use in infants: pros and cons. J Pediatr (Rio J). 2019;95:121-3.
  • 2
    Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475-90.
  • 3
    Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices?. Lancet. 2016;387:491-504.
  • 4
    Boccolini CS, de Carvalho ML, de Oliveira MI. Fatores associados ao aleitamento materno exclusivo nos primeiros seis meses de vida no Brasil: revisão sistemática. Rev Saude Publica. 2015;49:91.
  • 5
    O'Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr Adolesc Med. 2009;163:378-82.
  • 6
    Neto S, Oliveira AE, Zandonade E, Molina MdC. Pacifier use as a risk factor for reduction in breastfeeding duration: a systematic review. Rev Bras Saúde Mater Infan. 2008;8:377-89.
  • 7
    Buccini GDS, Pérez-Escamilla R, Paulino LM, Araujo CL, Venancio SI. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13:e12384.
  • 8
    Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016;:CD007202.
  • 9
    Karabulut E, Yalcin SS, Özdemir-Geyik P, Karaagaoglu E. Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. Turk J Pediatr. 2009;51:35.
  • 10
    Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, et al. Pacifier use early weaning cry/fuss behavior: a randomized controlled trial. JAMA. 2001;286:322-6.
  • 11
    Jenik AG, Vain NE, Gorestein AN, Jacobi NE. Does the recommendation to use a pacifier influence the prevalence of breastfeeding?. J Pediatr. 2009;155, 350-4.e1.
  • 12
    Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles cups dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ. 2004;329:193-8.
  • 13
    Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111:511-8.
  • 14
    Di Mario SCA, Basevi V, Magrini N. Feedback 1. In: Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding (authors, Jaafar SH, Jahanfar S, Angolkar M Ho JJ). Cochrane Database of Syst Rev. 2011;7:CD007202.
  • 15
    Giugliani ER, Nunes LM, Issler RM, Santo LC, Oliveira LD. Involvement of maternal grandmother and teenage mother in intervention to reduce pacifier use: a randomized clinical trial. J Pediatr (Rio J). 2019;95:166-72.
  • 16
    Nunes LM, Giugliani ER, do Espírito Santo LC, de Oliveira LD. Reduction of unnecessary intake of water and herbal teas on breast-fed infants: a randomized clinical trial with adolescent mothers and grandmothers. J Adolesc Health. 2011;49:258-64.
  • 17
    Bica OC, Giugliani ER. Influence of counseling sessions on the prevalence of breastfeeding in the first year of life: a randomized clinical trial with adolescent mothers and grandmothers. Birth. 2014;41:39-45.
  • 18
    Oliveira LD, Giugliani ER, do Espírito Santo LC, Nunes LM. Counselling sessions increased duration of exclusive breastfeeding: a randomized clinical trial with adolescent mothers and grandmothers. Nutr J. 2014;13:73.
  • 19
    Buccini G, Pérez-Escamilla R, Venancio SI. Pacifier use and exclusive breastfeeding in Brazil. J Hum Lact. 2016;32:NP52-60.
  • 20
    Buccini G, Pérez-Escamilla R, D'Aquino Benicio MH, Giugliani ER, Venancio SI. Exclusive breastfeeding changes in Brazil attributable to pacifier use. PLOS ONE. 2018;13:e0208261.
  • 21
    Boccolini CS, Boccolini PdM, Monteiro FR, Venâncio SI, Giugliani ER. Breastfeeding indicators trends in Brazil for three decades. Rev Saude Publica. 2017;51:108.
  • 22
    Buccini G [thesis] Evolução do uso de chupeta e sua influência no aleitamento materno exclusivo no Brasil 1999-2008. São Paulo: Faculdade de Saúde Pública da Universidade de São Paulo; 2017.
  • 23
    Eidelman AI, Schanler RJ. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-41.
  • 24
    Sexton S, Natale R. Risks and benefits of pacifiers. Am Fam Physician. 2009;79:681-5.
  • 25
    Ponti M. Recommendations for the use of pacifiers. Paediatr Child Health. 2003;8:515-9.
  • 26
    World Health Organization (WHO). UNICEF. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative implementation guidance. Geneva: WHO; 2018.
  • 27
    Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138:e20162940.
  • 28
    Psaila K, Foster JP, Pulbrook N, Jeffery HE. Infant pacifiers for reduction in risk of sudden infant death syndrome. Cochrane Database Syst Rev. 2017;4:CD011147.
  • 29
    Hauck FR, Thompson JM, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128:103-10.
  • 30
    Buccini G, Venancio SI. Uso de chupeta em crianças amamentadas: prós e contras. Sociedade Brasileira de Pediatria. 2017. Available from: https://www.sbp.com.br/fileadmin/user_upload/Aleitamento-Chupeta_em_Criancas_Amamentadas.pdf [cited 30.05.19].
    » https://www.sbp.com.br/fileadmin/user_upload/Aleitamento-Chupeta_em_Criancas_Amamentadas.pdf
  • 31
    Lopes AG, Pereira AC, Fonseca EPd, Mialhe FL. Irregularidades sanitárias na promoção comercial em rótulos de produtos para lactentes e os riscos para a saúde. Saúde em Debate. 2017;41:539-52.
  • 32
    Sertório SC, Silva IA. As faces simbólica e utilitária da chupeta na visão de mães. Rev Saude Publica. 2005;39:156-62.

Publication Dates

  • Publication in this collection
    28 Oct 2019
  • Date of issue
    Sep-Oct 2019
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