Pacifier and Breastfeeding

Objectives
 Explain Rationale for Selected Clinical Question
 Identify Clinical Question
 Show Search Strategies
 Critical Appraisal of Selected Article
 Summarize Evidence & Synthesize Findings in Articles
 Discuss Implications for Practice
 Discuss Limitations and Recommendations for Future
Research
 Introduction
The debate of using a pacifier:
The pros: The cons:

-soothing -early weaning

-prevent SIDS -↑ otitis media
-analgesic effect -dental problems
-prevent sucking of fingers -pacifier addiction
 Background
Baby Friendly Hospital
Initiative (BFHI) in most
Local hospitals
Context
“Give no artificial teats
or pacifiers to
breastfeeding infants”
(WHO, 2016)
 Clinical Question
Does the use of pacifier affect duration of exclusive
breastfeeding in term infants?
P - Breastfeeding mothers with Term Infants
I - With Pacifier
C - Without Pacifier
O - Duration of Exclusive Breastfeeding
 Databases selected
EBSCO MEDLINE
Mosby’s Nursing
Consult Group A
Health Source
Cochrane Library

EBSCO CINAHL
PubMed
JBI COnNECT+ Group B
Science Direct
 Breastfeed*

Dummies Teats
Key
Words

Soother Pacifier

(Hopp & Rittenmeyer, 2012)

Inclusion Criteria
 Exclusion Criteria

• Review/ Report article

• Other aspects about
pacifier
• BF education
• Knowledge, attitudes
& experiences of BF
• Maternity care
• Policies & Practices of
BFHI
Search Outcome: Group A
EBSCO Mosby Cochrane Health
Medline Nursing Library Source
199 5 13 83

Inclusion
Criteria

10 3 1 11
Exclusion
Criteria

8
Search Outcome: Group B
Cinahl SD JBI PubMed
135 856 175 409

Inclusion
criteria

4 407 172 190

Exclusion
criteria

7
Final Search Outcome
Manual
Group A Group B
search
8 7 3

Total number
identified
18

After removal of
duplicate
15
 Screening of Articles
Study Design Number included
RCT 3
Controlled trials, cohort or case control 12
analytic studies
Descriptive case series 0
Narrative review 0
Others… 0
Total 15
Summarising the
Evidence
 Level of
Author/ Year/ Participant Intervention/ Major Findings
Evi-
Design/ Setting s Methods (relevant to this review)
dence
Jenik et al. - 1021  Random assignment:  Introducing a pacifier does Level 1.c
dyads  Offer Pacifier not affect the duration of
2009 - ≥37 G.A.  Not Offer Pacifier exclusive or any
breastfeeding
RCT - ≥2500g
B.W.  Structured questionnaire  Conditions:
 firm intention to
5 Tertiary - intended to  Telephone interview was breastfeed their
Hospitals in breastfeed
conducted at 1, 2, 3, 4, 5, 6, infants
Argentina ≥3 months
8, 10, and 12 months after  achieved successful
birth or until breastfeeding breastfeeding by 2
ended weeks

Howard et al. - 700 dyads  Random assignment:  Early pacifier introduction Level 1.c
- 36-42 G.A.  Early pacifier: in 1st 5 days lessened the likelihood of
2003  Late pacifier: after 4 weeks exclusive breastfeeding at 1
- ≥2200g
month.
RCT B.W.
 Standardised questionnaires
- breastfeed  Early pacifier introduction vs
Rochester
healthy  Telephone interview at 2, 5, late introduction had a
General
newborns
Hospital, 10, 16, 24, 38 and 52 weeks negative impact on overall
New York, postpartum breastfeeding duration
USA
 Level
Author/ Year/ Intervention/ Major Findings
Participants of Evi-
Design/ Setting Methods (relevant to this review)
dence

Kramer et al. - 281 dyads  Random assignment into 2  Experimental Level

- ≥37 G.A. breastfeeding promotion groups: interventions show no 1.c
2001  Intervention group: soothing causal link between
- ≥2500g options discussed, asked to avoid pacifier use and early
RCT with B.W. pacifiers weaning at age of 3
observational - intended to  Control group: all options months
analyses breastfeed discussed, including pacifier use
≥3 months  Pacifier use was
Royal Victoria  Interventions reinforced by telephone strongly associated
Hospital in calls at 10 days and 3 weeks with the risk of early
Montreal, postpartum weaning in
Quebec, observational analyses
Canada.  Validated behaviour diaries use were
completed by mothers when infant  Pacifier use is a
were 4, 6, and 9 weeks of age. marker of
breastfeeding
 Telephone interviews gathering difficulties or reduced
information about breastfeeding, motivation to
weaning and pacifier use were breastfeed, rather than
conducted at 3 months a true cause of early
weaning.
 Level
Author/ Year/ Intervention/ Major Findings
Participants of Evi-
Design/ Setting Methods (relevant to this review)
dence
Kronborg & - 570 dyads  Anonymous, self-administered  Pacifier use was Level
Væth questionnaire included independently associated 3.e –
- ≥37 G.A.
questions on breastfeeding with a shorter duration of observ-
2009 -started exclusive breastfeeding, and ational
breast- concerns and pacifier use
is not mediated by study
- Observational- feeding ineffective technique or without
analytic design  Home visits at about 16 days
  breastfeeding problems. a
and 5 months postpartum
control
5 BFHI hospitals
in western  Use of a pacifier should be group
 Data about weeks of exclusive avoided in the first weeks
Denmark
breastfeeding were obtained after birth.
from regular contacts with the
mother

Cunha et al. - 500 dyads  Structured questionnaires  Pacifier use was associated Level
- <3000g included questions about with the early termination of3.e –
2005 pacifier use and number of observ-
B.W. breastfeeding at 1st and 6th
days of exclusive month. ational
Observational- - stayed in breastfeeding. study
analytic design the city of without
Fortaleza  After controlling potential
 Interviews in hospital within 48 a
8 maternity confounders, evidence was
hours, and home visits 1 and 6 control
hospitals in not strong enough to confirm group
Fortaleza, Brazil months postpartum
a causal relationship.
 Synthesis Of Findings
Pacifier use is associated with early weaning of exclusive
breastfeeding (Cunha, 2005; Kronborg, 2009). 

Pacifier usage was more a marker of breastfeeding

Causative difficulties or reduced motivation to breastfeed rather
relationship than a true cause of early weaning (Kramer, 2001). 

Breastfeeding and pacifier use were complex behaviors

heavily influenced by other factors that were extremely
difficult to measure (Kramer, 2001).
 Synthesis Of Findings
Early pacifier introduction lessened
the likelihood of exclusive
breastfeeding at 1 month (Howard,
2003).
Timing
Late pacifier introduction after
breastfeeding is established doesn’t
affect the duration of exclusive
breastfeeding (Jenik, 2009).
 Implications for Practice
Allow pacifier use after breastfeeding is
established Grade B

Introduce pacifier as late as possible to

Grade B
maximise duration of breastfeeding

Consider other contributing factors

Grade B
impacting breastfeeding

Consider other implications of pacifier Grade B

use
Limitations
Few RCT done in recent years

Mainly non-Asian population

Sample size

Low compliance to suggested

intervention
Limitations
Reliability of questionnaire used

Data collection mainly relied on

maternal self-report

Inconsistency of definition and

measurement of pacifier use
and exclusive breastfeeding
 Recommendations
for Research

More Robust
RCT

Larger
samples
 Conclusions
 Debate of using pacifier lead us to review the topic
 Relevant research articles obtained by extensive
searching
 Articles are critically appraised by using JBI checklists
 Pacifier use after breastfeeding is well established does
not affect breastfeeding duration
 We recommend parents to establish good latching
before introducing the pacifier
 References
Cunha, A. J. L. A., Leite, A. M., & Machado, M. M. T. (2005). Breastfeeding
and pacifier use in Brazil. The Indian Journal of Pediatrics,
72(5), 13-16.

Hopp, L., & Rittenmeyer, L. (2012). Introduction to evidence-based

practice: A practical guide for nursing. Philadelphia:
E. A. Davis Company.

Howard, C. R., Howard, F. M., Lanphear, B., Eberly, S., DeBlieck, E. A.,
Oakes, D., & Lawrence, R. A. (2003). Randomized Clinical Trial of
Pacifier Use and Bottle-Feeding or Cupfeeding and Their Effect on
Breastfeeding. Pediatrics,111(3), 511-518.
 References
Jenik, A. G., Vain, N. E., Gorestein, A. N., & Jacobi, N. E. (2009). Does the
Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding?
The Journal of Pediatrics,155(3), 350-354.

Kramer, M. S., Barr, R. G., Dagenais, S., Yang, H., Jones, P., Ciofani, L., & Jane,
F. (2001). Pacifier use, Early Weaning, and Cry/Fuss Behavior: A Randomized
Controlled Trial. JAMA, 286(3), 322-326.

Kronborg, H., & Vaeth, M. (2009). How Are Effective Breastfeeding Technique and
Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration?
Birth, 36(1), 34-42.

World Health Organisations. (2016). Baby-friendly Hospital Initiative. Retrieved from

http://www.who.int/nutrition/topics/bfhi/en/