Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1811-1812 (doi:10.1542/peds.2006-0268)

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COMMENTARY

Pacifiers and Sudden Infant Death Syndrome: What Should We Recommend?

Fern R. Hauck, MD, MS

Departments of Family Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia

Abbreviations: SIDS, sudden infant death syndrome • AAP, American Academy of Pediatrics • OR, odds ratio • CI, confidence interval

The association between pacifiers and sudden infant death syndrome (SIDS) has been known for some time. A possible protective effect was proposed as early as 1979¹ and subsequently supported by findings from a large case-control study in 1993,² followed by several others.^3–11 However, there has been reluctance among SIDS researchers and health professionals to recommend pacifier use as a potentially protective measure; they state the need to know more about the mechanisms of its effects and the role of possible confounding factors, thoroughly evaluate potential harm as well as potential benefits, and validate this apparent protective effect.^2,4,12

Pacifiers have been recommended for all infants in Germany¹³ and in the Netherlands initially for bottle-fed infants⁹ and now for all infants.¹⁴ In October 2005 the American Academy of Pediatrics (AAP) published updated guidelines for the reduction of SIDS risk and included a recommendation that parents consider offering a pacifier to infants at bedtime, up to the age of 12 months.¹⁵ For breastfed infants, the pacifier should be delayed for 1 month, a relatively low-risk period for SIDS, to ensure that nursing is well established. The AAP Task Force on Sudden Infant Death Syndrome made its recommendation on the basis of a thorough review of the literature including data describing the association between pacifiers and SIDS and the possible adverse effects of pacifier use. This review included an article in the same issue of Pediatrics that presented the results of a meta-analysis that found that pacifier use may reduce the risk of SIDS by as much as 61%.¹⁶ Since that analysis was completed, 2 additional studies have been published, one from Germany¹⁰ and the other from the United States,¹¹ further corroborating these findings. The latter report from Kaiser Permanente in California, which included a wide sociodemographic cross-section of families, reported a 92% reduction in risk when used at last sleep. This strong association was present among breastfed and bottle-fed infants.

The study by Mitchell et al¹⁷ in this issue of Pediatrics reports the pooled odds ratios (ORs) from case-control studies that examined the association between pacifiers and SIDS. On the basis of routine pacifier use from 7 studies (2 of which were unpublished), the pooled OR was 0.83 (95% confidence interval [CI]: 0.75–0.93). On the basis of 8 studies that examined pacifier use at last sleep, the pooled OR was 0.48 (95% CI: 0.43–0.54). Not surprisingly, their results are similar to those of mine¹⁶ for routine and last sleep (OR: 0.90 [95% CI: 0.79–1.03] and 0.47 [0.40–0.55], respectively). There were a few differences in the studies that were included; Mitchell et al did not provide their search strategy or define eligibility criteria for inclusion of studies. These authors report pooled ORs based on unadjusted ORs. My group used adjusted ORs as well, taking into account possible confounding factors, and these adjusted pooled ORs indicated even greater reductions in risk associated with pacifier use.

Mitchell et al reach a similar conclusion to that of the AAP Task Force on Sudden Infant Death Syndrome, that is, that the body of research supports a protective effect of pacifiers against SIDS. However, their recommendations are slightly different. The study authors write, "It seems appropriate to stop discouraging the use of pacifiers,"¹⁷ whereas the AAP Task Force on Sudden Infant Death Syndrome write, "Consider offering a pacifier at nap time and bedtime."¹⁵ For breastfeeding mothers who do choose to use a pacifier, the recommendations of the 2 groups are identical: it should be offered after the neonatal period (after breastfeeding is established) and only for sleep periods.

How can we rectify the subtle differences in recommendations? What advice should we give parents about pacifiers? I believe that the reluctance to recommend pacifiers is comparable to the initial concerns associated with recommendations against prone sleeping. As stated by van Wouwe and HiraSing: "Despite the harsh effects of SIDS on parents and professionals, it takes a long time to change medical and parental practice."¹⁸ Time will tell if pacifier use has a beneficial impact similar to changing sleep position. In the meantime, physicians should tell parents about the AAP recommendation to consider offering a pacifier at nap time and bedtime and share both sides of the controversy. It is especially important to tell mothers who are not breastfeeding, because they tend to have other characteristics that may place their infants at greater risk for SIDS. Breastfeeding mothers, if highly motivated, are unlikely to find that using a pacifier as recommended will interfere with their ability to nurse and comfort their infants. As with every infant care practice, parents are ultimately responsible. It is our responsibility to provide them with well-balanced, unbiased information to help them make these important decisions.

	FOOTNOTES

 
Accepted Jan 27, 2006.

Address correspondence to Fern R. Hauck, MD, MS, Department of Family Medicine, University of Virginia School of Medicine, PO Box 800729, Charlottesville, VA 22908-0729. E-mail: frh8e{at}virginia.edu

The author has indicated she has no financial relationships relevant to this article to disclose.

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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