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PEDIATRICS Vol. 111 No. 3 March 2003, pp. 511-518

Randomized Clinical Trial of Pacifier Use and Bottle-Feeding or Cupfeeding and Their Effect on Breastfeeding

Cynthia R. Howard, MD, MPH*, Fred M. Howard, MD{ddagger}, Bruce Lanphear, MD, MPH§, Shirley Eberly, MS||, Elisabeth A. deBlieck, MPA*, David Oakes, PhD§ and Ruth A. Lawrence, MD*

* Departments of Pediatrics,
{ddagger} Obstetrics and Gynecology
§ Biostatistics, University of Rochester School of Medicine and Dentistry, Rochester, New York
|| Department of Pediatrics, Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio

--> Objective. To enhance breastfeeding practices, the World Health Organization discourages pacifiers and bottle-feeding. However, the effect of artificial nipples on breastfeeding duration is poorly defined. The effects of 2 types of artificial nipple exposure on breastfeeding duration were evaluated: 1) cupfeeding versus bottle-feeding for the provision of in-hospital supplements and 2) early (2–5 days) versus late (>4 weeks) pacifier introduction.

Methods. A total of 700 breastfed newborns (36–42 weeks, birth weight >=2200 g) were randomly assigned to 1 of 4 intervention groups: bottle/early pacifier (n = 169), bottle/late pacifier (n = 167), cup/early pacifier (n = 185), or cup/late pacifier (n = 179). The cup/bottle intervention was invoked for infants who received supplemental feedings: cup (n = 251), bottle (n = 230). Data were collected at delivery and at 2, 5, 10, 16, 24, 38, and 52 weeks’ postpartum. Intervention effects on breastfeeding duration were evaluated with logistic regression and survival analyses.

Results. Supplemental feedings, regardless of method (cup or bottle), had a detrimental effect on breastfeeding duration. There were no differences in cup versus bottle groups for breastfeeding duration. Effects were modified by the number of supplements; exclusive and full breastfeeding duration were prolonged in cup-fed infants given >2 supplements. Among infants delivered by cesarean, cupfeeding significantly prolonged exclusive, full, and overall breastfeeding duration. Exclusive breastfeeding at 4 weeks was less likely among infants exposed to pacifiers (early pacifier group; odds ratio: 1.5; 95% confidence interval: 1.0–2.0). Early, as compared with late, pacifier use shortened overall duration (adjusted hazard ratio: 1.22; 95% confidence interval: 1.03–1.44) but did not affect exclusive or full duration.

Conclusions. There was no advantage to cupfeeding for providing supplements to the general population of healthy breastfed infants, but it may have benefitted mother–infant dyads who required multiple supplements or were delivered by cesarean. Pacifier use in the neonatal period was detrimental to exclusive and overall breastfeeding. These findings support recommendations to avoid exposing breastfed infants to artificial nipples in the neonatal period.

Key Words: breastfeeding • pacifiers • bottle-feeding • cupfeeding

Abbreviations: WHO, World Health Organization • ITT, intention-to-treat • CI, confidence interval • OR, odds ratio • HR, hazard ratio

Received for publication Dec 27, 2001; Accepted Jul 22, 2002.




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