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CMAJ • OCT. 16, 2001; 165 (8) 1089

Kramer MS, Barr RG, Dagenais S,Yang H, Jones P, Ciofani L, et al. Paci-fier use, early weaning, and cry/fussbehavior. JAMA 2001;286:322-6.

Background: Many modern-day clini-cians and public health caregivers be-lieve that pacifiers promote nipple con-fusion and lead to early weaning.1 Infact, avoidance of pacifiers constitutesstep 9 of the World Health Organiza-tion/UNICEF Baby-Friendly HospitalInitiative.2 Most of the evidence to sup-port this arises from observational stud-ies that, by design, fail to control for theconfounding influences of cultural atti-tudes and personal motivations.3

Question: Does advice to avoid pacifieruse, delivered to new mothers duringtheir postpartum stay in hospital, re-duce the risk of weaning from thebreast before 3 months or increase thefrequency or duration of crying andfussing by the infant?

Design: This randomized controlledtrial, conducted over 20 months in amaternity hospital in Montreal, in-volved 281 healthy women who in-tended to breastfeed their healthy,term, singleton infants. The motherswere randomly allocated either to anexperimental postpartum breastfeedinginterview, in which the lactation consul-tant advised the avoidance of pacifieruse when the baby fussed, or to a con-trol interview, in which all options forcalming the infant, including pacifieruse, were discussed. At weeks 4, 6 and 9the mother recorded her infant’s beha-viour, including the frequency and du-ration of episodes of crying or fussing,over 3 consecutive days. At 3 months aninterviewer, blinded to group alloca-tion, asked mothers whether they werestill breastfeeding and, if not, the dateof weaning. Multiple logistic regressionanalysis was conducted to calculate therisk of weaning in the experimentalgroup relative to the control group.The mean number of episodes of fuss-ing and minutes of crying were com-pared using t-tests.

Results: Baseline demographic charac-teristics were similar in the 2 groups, al-though there was a slightly higher pro-portion of single women (21% v. 16%)and smokers (15% v. 10%) in the exper-imental group. There were no differ-ences between the 2 groups in the pro-portion of women who participated inthe interview (91%) or who completedthe surveys at 4 (70.9%), 6 (60.5%) and9 weeks (57.4%). The women whodropped out were more likely to beyounger, single and smokers than thewomen who completed the study.

Significantly more women in the ex-perimental group than in the controlgroup reported completely avoidingpacifier use (38.6% v. 16.0%) (relativerisk [RR] 2.4, 95% confidence interval[CI] 1.5–3.8). Also, the mean number ofpacifier insertions per day was signifi-cantly lower in the experimental groupthan in the control group at weeks 4(0.8 v. 2.4), 6 (0.8 v. 3.0) and 9 (1.3 v.3.0). However, there was no differencebetween the experimental and controlgroups in the proportion of infantsweaned from the breast (18.9% and18.3% respectively; RR 1.0) or not ex-clusively breastfed (63.8% and 66.4%respectively; RR 1.0) at 3 months, or incry/fuss behaviour at weeks 4, 6 or 9.

Comments: These results fail to sub-stantiate claims of a direct link betweenpacifier use and a higher risk of earlyweaning from the breast. Advice toavoid pacifier use did not reduce therisk of early weaning, although it is pos-sible that women who were advised notto use pacifiers may have been biasedtoward falsely reporting that they com-plied with the advice. The effect of sucha bias would be to reduce the strengthof treatment effect of this advice (if itexisted) and possibly to conceal a realdifference.

The authors did not report on theethnic and cultural backgrounds of themothers, 2 important determinants ofbreastfeeding that may have con-founded the analysis. Finding no effectof the intervention, the investigatorsconducted an observational analysis to

determine whether pacifier use was apredictor of early weaning. Among theinfants reportedly exposed to daily useof a pacifier, 25.0% were weaned before3 months of age, as compared with12.9% of infants not given a pacifier(RR 1.9, 95% CI 1.1–3.3). This is con-sistent with other observational stud-ies.3–10 The authors suggest that suchobservational results may indicate thatpacifier use is a marker for breastfeed-ing difficulties or low motivation tobreastfeed rather than a cause of earlyweaning.

Practice implications: The effects ofpacifier use have not been rigorouslystudied. This study suggests that paci-fier use does not increase the risk ofearly weaning per se or reduce the du-ration of fussing and crying episodes ofinfants. However, a positive response toan enquiry about frequent use of a paci-fier may identify women who requireextra breastfeeding support and encour-agement. — Erica Weir, CMAJ

References1. Neifert M, Lawrence R, Seacat J. Nipple confu-

sion: toward a formal definition. J Pediatr 1995;126:S125-9.

2. WHO/UNICEF. Protecting, promoting and sup-porting breastfeeding: the special role of maternity ser-vices. Geneva: World Health Organization; 1989.

3. Aarts C, Hornell A, Kylberg E, Hofvander Y,Gebre-Medhin M. Breastfeeding patterns in rela-tion to thumb sucking and pacifier use. Pediatrics1999;104:1-10.

4. Victora CG, Tomasi E, Olinto MTA, Barros FC.Use of pacifiers and breastfeeding duration.Lancet 1993;341:404-6.

5. Barros FC, Victora CG, Semer TC, Filho ST,Tomasi E, Weiderpass E. Use of pacifiers is asso-ciated with decreased breastfeeding duration. Pe-diatrics 1995;95:497-9.

6. Victora CG, Behague DP, Barros FC, OlintoMTA, Weiderpass E. Pacifier use and shortbreastfeeding duration: Cause, consequence, orcoincidence? Pediatrics 1997;99:445-3.

7. Richard L, Alade MO. Sucking technique and itseffect on success of breastfeeding. Birth 1992;19:185-9.

8. Clements MS, Mitchell EA, Wright SP, Esmail A,Jones DR, Ford RP. Influences on breastfeedingin southest England. Acta Paediatr 1997;86:51-6.

9. Ford RP, Mitchell EA, Scragg R, Stewart AW,Taylor BJ, Allen EM. Factors adversely associ-ated with breast feeding in New Zealand. J Paedi-atr Child Health 1994;30:483-9.

10. Howard CR, Howard FM, Lanphear B, deBlieckEA, Eberly S, Lawrence RA. The effects of earlypacifier use on breastfeeding duration. Pediatrics1999;103:E33.

Pacifiers, breastfeeding and soothing

❙❙❙clinical update