The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity. The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean. Ongoing quantitative and qualitative research is needed to better understand the relationship between pacifier use and breastfeeding.
The avoidance of pacifiers was included as 1 of 10 steps for successful breastfeeding in the 1990 Innocenti Declaration, although there was no epidemiologic evidence of an association at that time. Pacifiers are often used by infants in many less developed countries, and a short duration of breastfeeding may lead to increased morbidity and mortality attributable to infectious diseases. It is therefore important to establish whether pacifier use may indeed affect breastfeeding, because this will influence promotion policies.
The epidemiologic association between pacifier use and breastfeeding duration seems to have been initially documented in a cross-sectional study in 19936 and has been confirmed by other studies since then. However, none of these studies were specifically designed to test this association, and relevant data for its interpretation may not have been collected. In addition to the issue of confounding, two other major problems may be present: (1) reverse causalitybreastfeeding difficulties may lead to pacifier use rather than the reverse; and (2) self-selection biasbehavioral characteristics of the mother or infant that are often impossible to assess using standard epidemiologic techniques may lead both to pacifier use and to shorter breastfeeding.
The ethnographic study confirmed that pacifier use was considered a normal behavior. Pacifiers were often stated to be soothing, “cute,” “pretty,” and a symbol of social status (“a luxury”). Pacifiers are even regarded as growth promoters by leading to the earlier acceptance of foods other than breast milk, because liquid and semisolid foods such as soups and black beans are often first introduced by dipping the pacifier in them.
Pacifiers were offered to virtually every infant in early life, and nonuse seemed largely the infants’ decision. Infants who refused were labeled as “choosy,” and their parents were blamed for lack of discipline, that is, for not stimulating acceptance of the pacifier. A rejection of the pacifier also implied that the mother was most likely allowing the child to use her breast as a pacifier, because it is widely believed that most children prefer the breast if not taught otherwise. A general notion is that one should make the child wait to be breastfed rather than to give in to the demands of a whiny or overly needy child.
Although most mothers acknowledged that pacifiers might affect dental development, only 13 of 80 were explicitly aware of the association with breastfeeding. These mothers were both more likely to breastfeed at the time of the interview, and their children were less likely to use pacifiers. These results are similar to the epidemiologic questionnaire findings. However, the ethnographic study identified a group of 17 mothers who, although not openly admitting the association, reported using the pacifiers to make the infants wait to be breastfed either “on schedule” or once the mothers had free time. These mothers were labeled as having “implicit” awareness of the association. They were more likely to express anxiety and difficulty in making their infants accept the pacifiers and commonly reported withholding breastfeeding with the purpose of making the infants hungry and more likely to take the pacifiers. Women with implicit awareness also gave greater importance to the use of a pacifier, often praising its benefits. Investigating explicit awareness, therefore, did not seem to be the most adequate way of determining the role of the pacifier in weaning.
Previous epidemiologic reports on the association between pacifier use and breastfeeding raised the possibility that pacifier use might be a marker rather than a determinant of breastfeeding and, more recently, also of adult intelligence. The present results confirm that self-selection plays a role in this association, but the full picture is more complex. Pacifiers seem to contribute to earlier weaning among a group of women uncomfortable with breastfeeding but do not seem to affect breastfeeding duration among self-confident mothers. Pacifiers, therefore, might be seen as a contributing rather than a sufficient cause of early breastfeeding termination. Regardless of the discussion on causality, intense pacifier use is still an excellent marker for identifying mothers and infants facing breastfeeding difficulties toward whom supportive actions should be aimed. Although the ethnographic results refer to maternal behaviors that are mostly specific to the society under study, it is plausible that mothers from other societies who stimulate pacifier use may also have similar behaviors that curtail breastfeeding. Research in other settings, however, is needed to confirm our findings.
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