Should We Just Say Yes to Pacifiers?

William T. Basco, Jr., MD, MS

Jun 28, 2013

Pacifier Restriction and Exclusive Breastfeeding

Kair LR, Kenron D, Etheredge K, Jaffe AC, Phillipi CA

Pediatrics. 2013;131:e1101-1107

Study Summary

Kair and colleagues conducted a quasi-experimental study in which they evaluated changes in exclusive breastfeeding rates in a hospital before and after an initiative that involved reducing pacifier access in the newborn nursery. Conflicting evidence has raised the concern that pacifier use interferes with initiation of breastfeeding. Observational studies suggest a potential negative effect of pacifier use on breastfeeding outcomes, whereas randomized trials do not show a difference in breastfeeding outcomes with different times and types of pacifier use. The World Health Organization and the United Nations Children's Fund urge hospitals to implement 10 steps designed to increase the frequency of successful breastfeeding. Among the 10 precepts are:

• Increase maternal education about the benefits of breast-feeding;

• Limit exposure to any food or drink other than breast milk; and

• Avoid pacifiers or other artificial nipples in the newborn nursery.

The large, university teaching hospital where this study was conducted began a program that included 5 of the 10 precepts: initiation of breastfeeding immediately after birth, feeding only breast milk in the hospital, rooming-in of the mother and child, no use of pacifiers, and provision of postdischarge breastfeeding support. The analysis of breastfeeding outcomes covered the latter months of 2010 and the early months of 2011. A changeover month between the 2 periods was not analyzed because staff were in the process of implementing the 5 precepts.

Access to pacifiers was made difficult but not impossible, with employees required to sign for any pacifiers taken from supply and given to an infant. Parents could bring pacifiers to the hospital, and the frequency of this practice was not monitored. The 5 desired breastfeeding behaviors were communicated to parents, including specific discussions about limiting pacifier use. The bulk of the data for this report was obtained from the electronic medical records of the hospital.

The study involved 2249 infants (812 in the "preintervention" group and 1278 in the "postintervention" group). The 2 groups were generally similar except that the postintervention group was more likely to be privately insured than the preintervention group. The medical histories and physical examinations of the infants in both groups were similar. When looking at the primary outcome, the proportion of infants who were exclusively breastfed in the preintervention period was 79% compared with 68% in the postintervention group. This was associated with a 10 percentage-point increase in the proportion of children who were receiving some degree of formula supplementation. Kair and colleagues concluded that restricting access to pacifiers without also restricting access to formula was associated with reduced rates of exclusive breastfeeding.

Viewpoint

This study points out the limitations of quasi-experimental and observational study designs. Certainly, it is important for hospitals to track the outcomes associated with process of care changes. However, implementation of a program such as the Baby-Friendly Hospital Initiative, whether complete or partial, does not occur in a vacuum. System-wide changes are often necessitated by the implementation, along with a great deal of provider and staff education. If an intervention is successful, it can be very difficult to determine which component of the intervention was responsible for success. On the reverse side, when an intervention does not work but was not tightly controlled, it can be difficult to identify the reasons why it failed.

Kair and colleagues seem to think that the failure to entirely limit access to pacifiers and to limit access to formula were associated with the lower percentage of exclusive breastfeeding, but the true reasons for this unexpected change are unknown. A shift towards more privately insured mothers in the postintervention group was identified, but this should have biased the results towards a higher frequency of breastfeeding based on historical epidemiologic data. It makes the change in frequency of exclusive breastfeeding observed at this hospital even more intriguing.