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REVIEW ARTICLE |
a Department of Paediatrics, University of Auckland, Auckland, New Zealand
b Institute of Child Health, Education Centre, Bristol, United Kingdom
c Department of Medical Psychology, Division of Pediatrics, University Medical Center, Wilhelmina Children’s Hospital, Utrecht, Netherlands
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ABSTRACT |
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RESULTS. There is a remarkably consistent reduction of SIDS with pacifier use. The mechanism by which pacifiers might reduce the risk of SIDS is unknown, but several mechanisms have been postulated. Pacifiers might reduce breastfeeding duration, but the studies are conflicting.
CONCLUSIONS. It seems appropriate to stop discouraging the use of pacifiers. Whether it is appropriate to recommend pacifier use in infants is open to debate.
Key Words: sudden unexplained death
Abbreviations: SIDS—sudden infant death syndrome • OR—odds ratio • CI—confidence interval
In 1979, Cozzi et al1 postulated that pacifiers (also called "dummies" or "soothers") might protect against sudden infant death syndrome (SIDS). Support for this hypothesis was first reported in 1993.2 Since then there have been other studies that have supported this observation,2–10 although evidence is lacking for a biological underlying mechanism, and outside this field pacifier use has mainly been associated with detrimental effects. Our aim with this article is to review the evidence for a reduction in the risk of SIDS with pacifier use, discuss possible mechanisms for the reduction in SIDS risk, and briefly review other possible effects of pacifiers on infants and children.
There have been 7 case-control studies (refs 2–5, 8, and 9 and B. Alm, written correspondence, 2002) and 1 prospective study (E.A.M., unpublished data) that examined routine pacifier use and SIDS, all but one of which8 observed an increased prevalence of use among the control subjects compared with case subjects (Table 1). The reduced risk of SIDS with routine pacifier use is significant when pooling the results (pooled odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.75–0.93). Eight case-control studies2–4,6–10 have also examined pacifier use for the last sleep, and all of them showed a reduced risk of SIDS (Table 2) (pooled OR: 0.48; 95% CI: 0.43–0.54), the significance of which actually increased in all but 1 study when adjustment was made for potential confounders. These studies come from New Zealand, the Netherlands, United Kingdom, Republic of Ireland, Germany, Scandinavia and other European countries, and the United States and have occurred both before and after the reduction in SIDS that followed the recommendation to place infants supine to sleep. The results are remarkably consistent, showing that the use of pacifiers is associated with an approximate halving of the risk of SIDS, and come from many countries in the world, suggesting that the results are generalizable to other countries.
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The use of pacifiers varies considerably between countries and also within countries. In New Zealand, the prevalence of pacifier use was low (10.4%) but within the country varied from 3.6% in southern South Island to 32.3% in northern North Island.2 In other countries, much higher pacifier use has been reported. In European countries pacifier use varies between 36% and 71%.15 There is little information as to the reasons for such wide variation between countries and why pacifiers are introduced.16 Turkish and Moroccan people dislike thumb-sucking and they actively try to prevent this by offering the breast and/or a pacifier.17
Other potential advantages of pacifier use are the management of pain or discomfort during blood sampling,18 reduction of gastroesophageal reflux,19 and reduction of dental malocclusion that occurs as a consequence of thumb- or finger-sucking in a child not given a pacifier.20,21 However, Winberg16 has asked if there is a risk that prolonged use of a pacifier would replace more adequate soothing measures. The authors of a recent systematic review of nonpharmacologic and nonsurgical therapies for gastroesophageal reflux concluded that the impact of pacifier use on gastroesophageal reflux was equivocal and depended on infant position.19
Before recommending the use of pacifiers, the potential disadvantages must be considered. From observational studies,22–25 there seems to be a clear relationship between frequent or continuous pacifier use and a reduction in breastfeeding, although it was unclear from these studies whether the effect is causal or whether pacifier use is a marker for breastfeeding difficulties or reduced motivation to breastfeed. However, the interval between the introduction of the pacifier and weaning may be several months, which suggests that the use of the pacifier might reduce stimulation from suckling, thus resulting in a gradual reduction in breast milk production.24,25 Randomized, controlled studies of pacifier use in term infants have produced conflicting results, with 1 study suggesting that pacifiers were detrimental to exclusive and overall breastfeeding26 and the other not showing a detriment.27 In preterm infants, 1 randomized, controlled study showed no effect of pacifier use on breastfeeding.28
Pacifier use has been associated with significantly higher risk of infective symptoms, especially otitis media.29,30 Again, this may be a result of reverse causality; mothers try and soothe their infant with a pacifier when the infant has otitis media. Pacifier use is also positively associated with oral yeast infection.31 Infrequent use of a pacifier, however, does not seem to be associated with these infective symptoms.32
Other potential disadvantages include accidents (airway obstruction,33 strangulation by cords tied to the pacifier,34 and eye injuries35) and dental malocclusion.36 The association of pacifier use and lower IQ is controversial. Suspected developmental delay was higher in pacifier users than nonusers in one study,37 but this effect disappeared after adjusting for duration of breastfeeding, suggesting that breast milk affects child development rather than not using a pacifier. However, a study by Gale and Martyn38 looking at adult intelligence came to the opposite conclusion, namely that intelligence in adult life may have more to do with the child’s social environment than with type of infant feeding.
So what should be advised? The evidence that pacifiers reduce the risk of SIDS is convincing. However, its use needs to be balanced against the established risks, especially the probable reduction in breastfeeding duration. Recent studies show that other behavioral and psychological factors are important predictors of breastfeeding duration, such as maternal intention,39 timing of decision-making about breastfeeding,39 depressive symptoms,40 and maternal perception of the adequacy of breast milk supply.41
It certainly seems appropriate to stop discouraging the use of pacifiers. Whether it is appropriate to recommend pacifier use in infants is open to debate. If parents choose to use one, which many do, evidence-based advice on how to use it needs to be given. Breastfeeding mothers should offer a pacifier only when breastfeeding is established, after the neonatal period. Parents who wish to give a pacifier should do so only for sleeping periods. At the end of the first year of life, pacifier use should be phased out.
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FOOTNOTES |
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Address correspondence to E.A. Mitchell, FRACP, DSc, Department of Paediatrics, University of Auckland, Private Bag 92019, Auckland, New Zealand. E-mail: e.mitchell{at}auckland.ac.nz
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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This article has been cited by other articles:
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  R. Y. Moon, T. Calabrese, and L. Aird Reducing the Risk of Sudden Infant Death Syndrome in Child Care and Changing Provider Practices: Lessons Learned From a Demonstration Project Pediatrics, October 1, 2008; 122(4): 788 - 798. [Abstract] [Full Text] [PDF]
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 R. H. Schwartz and K. L. Guthrie Infant Pacifiers: An Overview Clinical Pediatrics, May 1, 2008; 47(4): 327 - 331. [PDF]
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 M. Eisenhut, G. Haycock, and A. Greenough Hyperchloraemic acidosis in patients given rapid isotonic saline infusions * Sudden infant death, bed-sharing and dummies: authors' reply Arch. Dis. Child., June 1, 2007; 92(6): 560 - 560. [Full Text] [PDF]
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E A Mitchell Recommendations for sudden infant death syndrome prevention: a discussion document Arch. Dis. Child., February 1, 2007; 92(2): 155 - 159. [Abstract] [Full Text] [PDF]
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F. R. Hauck Pacifiers and Sudden Infant Death Syndrome: What Should We Recommend? Pediatrics, May 1, 2006; 117(5): 1811 - 1812. [Full Text] [PDF]
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