Ask EP: Pacifiers and SIDS

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Q:  I cant seem to find any good information on the pros/cons of early pacifier use for SIDS protection against BF’ing statistics for SIDS. The google search screams SIDS fearmongering and pro-pacifier. I’m looking for numbers and a more detailed explanation. Thanks!

[Additional comments after links were sent: Thank you for the links! Okay, so my confusion comes during the application of these studies... dummies can reduce rates of SIDS IF other risk factors are increased (mother who smokes, formula feeding, unsafe sleep habits, socioeconomic status) but what about for babies who already have reduced risk because of BF'ing? Where is the intersection of doing harm/preventing SIDS. If introduction of a dummy can possibly cause BF'ing issues, which would lead to higher SIDS rates because of low supply, the spread of thrush (dirty paci's can spread illness when not properly sterilized) and subsequent formula use increases that risk again... "It seems appropriate to stop discouraging the use of pacifiers. Whether it is appropriate to recommend pacifier use in infants is open to debate." I am concerned with the infant pacifier use specifically... when new mothers are told that a pacifier can prevent SIDS, but not typically provided with BF support, so a week or two after birth, new mum starts to experience PPD, is struggling to establish a good BF relationship then undermines herself out of fear of SIDS... I think it sends a very mixed message to mothers. http://www.llli.org/nb/nbjanfeb06p4.html The 3rd point in LLL is what interests me- why do dummies get promoted as reducing SIDS by 61% but nipples aren't?]

-          America C.

A:  This is a great question and unfortunately it seems the recommendations from the researchers don’t always get taken to heart.  The media and doctors see that pacifiers reduce the likelihood of SIDS and so jump on it, nuances be damned, but there are very important nuances with respect to breastfeeding.  Notably, it should be noted that many of the studies do say that pacifier use should not be undertaken until breastfeeding is fully established, and so there shouldn’t be the problem with respect to breastfeeding if the research were actually followed.  As you and the LLL rightly point out – breast is the best nipple there is; however, there is a confounder there.  I mentioned the research demonstrating that the suckling rate of infants who bedshare is much higher than those who do not in We Go Together Like Breastfeeding and Co-Sleeping and it seems that the rate of suckling is what is providing some of the protective factors against SIDS.  Thus, even in studies where breastfeeding is considered, pacifier use seems to reduce the risk even further (of course the breastfeeding measure is typically “ever breastfed” which is not what we really want to be concerned with).  One study that examined bedsharing found that bedsharing with a non-smoker was one of the only conditions which did not lead to a statistically significant decrease in SIDS risk by means of a pacifier.  Although the reason was not examined, it is possible that it is because bedsharers tend to breastfeed and breastfeed more often, meaning the infant is getting the sucking behaviour from the best nipple possible – the breast.

What does this mean?  Pacifier use may be contributing to the decrease above and beyond breastfeeding because infants who sleep away from their parents (even in a cot next to them) suckle less and thus don’t gain the benefits from constant breastfeeding or suckling.

Does this outweigh the numerous benefits of breastfeeding?  Hell no and that is exactly why the WHO, who knows of the research on pacifier use and SIDS has a statement against the use of pacifiers and other artificial nipples to breastfeeding babies.  It is also why all of the research that has comments on this suggests it not be used at all until breastfeeding is established or not at all with breastfed babies.  While pacifier use may actually lower the risk of SIDS more than breastfeeding on its own (that does seem to be the case, with breastfeeding being associated with about a 40-55% chance of SIDS relative to non-breastfed infants whereas pacifiers seem to get as low as a 10-15% chance, but the exact numbers will depend on the study), it is associated with early cessation of breastfeeding and the benefits of breastfeeding far outweigh the benefits of pacifier use.  I realize that may sound strange when SIDS is the issue, but the fact remains that breastfeeding protects against SIDS on its own (just not to the same degree, and as mentioned I imagine it has to do more with infants sleeping away from their mother, but that is just my own hypothesis) and it also protects against myriad other diseases and infections.  For example, while breastfeeding protects against SIDS, it also protects against type 1 diabetes, childhood cancers (including leukemia – see Two Bs and the Big C), childhood asthma, gastroenteritis, respiratory tract infections, and more.  The protections offered by breastfeeding for these diseases (and more) as well as the benefits to the developing brain, the bond with mom, etc. should never be discounted.

In conclusion, the use of a pacifier seems to offer protective benefits, even for families who breastfeed.  However, the research does not suggest that pacifier use should be done when breastfeeding has not been established.  Furthermore, we need a way to make sure the media and doctors understand the negative relationship between pacifier use and breastfeeding and work to ensure that breastfeeding isn’t compromised by the use of pacifiers.

Sources:

Bartick M, Reinhold A.  The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.  Pediatrics 2009; 125: 1048-56.

Hauck FR, Omojokun OO, Siadaty MS.  Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis.  Pediatrics 2005; 116: e716-e723.

Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM.  Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.  Pediatrics 2011; 128: 103-110.

Hauck FR.  Pacifiers and sudden infant death syndrome: what should we recommend?  Pediatrics 2006; 117: 1811-1812.

Li D-K, Willinger M, Petitti DB, Odouli R, Lui L, Hoffman HJ.  Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population based case-control study.  British Medical Journal 2006; 332: 18-22.

Mitchell EA, Blair PS, L’Hoir MP.  Should pacifiers be recommended to prevent sudden infant death syndrome?  Pediatrics 2006; 117: 1755-1758.

Nelson EAS, Yu L-M, Williams S, et al. International child care practices study: breastfeeding and pacifier use.  J Hum Lact 2005; 21: 289-295.

Comments

  1. says

    Shouldn’t be any great conflict here. Firstly, the evidence suggests that pacifier use has little or no effect on breastfeeding, and secondly, the risk of SIDS in the time period while breastfeeding is being established is vanishingly low anyway, to the point where the numbers saved by pacifier use would be absolutely negligible.

    By the way, in terms of figures, I think it worked out that pacifiers prevented 1 in 1500 SIDS cases, which means, considering SIDS is rare anyway, that the number of babies saved by pacis would be really, really low.

    • says

      Where have you seen the evidence that pacifier use has little to no effect on breastfeeding? I suggest you check out:
      1) Howard et al. The effects of early pacifier use on breastfeeding duration. Pediatrics 1999; 103: e33.
      2) Howard et al. Randomized clinical trial of pacifier use and bottle feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003; 111: 511-518.
      3) Victorio et al. Use of pacifiers and breastfeeding. The Lancet 1993; 341: 404-406.
      4) Victorio et al. Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997; 99: 447-453.
      5) Karabulut et al. Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. Turkish Journal of Pediatrics 2009; 51: 35-43.

      I realize the O’Connor et al. systematic review suggests that the effects are coincidental and so more work definitely needs to be done to establish whether there truly is a causal link. However, to suggest there is little to no effect on breastfeeding is, in my opinion, rather disingenuous given the current evidence. Which is most likely why the WHO suggests not using a pacifier at all.

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