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POSITION STATEMENT ON THE USE OF PACIFIERS (DUMMIES)

FOR THE HEALTHY TERM BREASTFED BABY

Date of Issue: 2018

1st Edition

© 2018. Australian College of Midwives. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No express written permission is required. Preferred Citation Australian College of Midwives (2018). Position Statement on the Use of Pacifiers (Dummies) for the Healthy Term Breastfed Baby. Retrieved from https://www.midwives.org.au/position-statements

The Australian College of Midwives’ Position Statement on the Use of Pacifiers (Dummies) for the Healthy Term Breastfed Baby

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The Australian College of Midwives (ACM) supports and encourages women to pursue and achieve their personal breastfeeding and infant feeding goals. The ACM unreservedly supports parental preference without prejudice.

Definition

The pacifier (also commonly referred to as a dummy, soother or binky) is a silicone, rubber or plastic oral device given to an infant or other young child for non-nutritive sucking purposes (International Baby Food Action Network, 2013).

Key Principles

1. Women will be provided with unbiased evidence-based information duringpregnancy and early parenthood to facilitate informed decision-makingregarding pacifier use.

2. Midwives and health professionals will provide appropriate sensitive non-judgemental care to fully support parents with their decision.

3. Midwives and health professionals should reaffirm the standards of the TenSteps to Successful Breastfeeding.

4. Midwives and other health professionals should not promote, offer orsupply pacifiers to healthy term exclusively breastfeeding babies, includingunder the following circumstances:

• birth weight greater than 2,500 grams;

• less than four weeks of age; or

• before breastfeeding has been established (NHMRC, 2012).

5. Midwives and health professionals should discuss, demonstrate andprovide written information on a range of settling techniques for newparents to provide alternatives to the introduction of a pacifier.

Achieving Best Practice

Midwives and health professionals should:

1. Use flexibility, assessing the unique situation and needs of the family whenmaking practice suggestions.

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2. Sensitively inquire about maternal reasons for introducing the pacifier.Determine there is no underlying maternal or infant pathology if concernabout increased crying is the stated rationale. Refer to a medical officer forreview if a concern is noted.

3. Continue to support and encourage breastfeeding according to baby’snutritional needs, rather than using the pacifier to develop a set feedingschedule. Encourage mothers not to substitute a feed with a pacifier.

4. Discuss with the parents the importance of appropriately responding to thebaby’s feeding cues. Offer recommended settling strategies in the firstinstance (including wrapping, rocking, patting and breastfeeding forcomfort). If a pacifier has been introduced, use only after the feed has beencompleted.

5. Encourage breastfeeding as a source of analgesia to reduce any painassociated with invasive procedures.

6. Identify that there are mandatory Australian Standards (AS 2432:1991Standard for Babies’ Dummies Product Safety Australia, 2015). Furtheridentify to parents that Internet purchases will only comply with the countryof origin, and not necessarily Australia.

7. Discuss harm minimisation strategies to decrease any risk of adverseevents. Adverse events include choking, contamination, allergy and dentalcaries. Inclusion of the following points is recommended.

a. Choking:

Any material attaching the pacifier to the baby’s clothing needs to beless than 35 cm long (Ponti, 2003).

Use a pacifier that is appropriately sized to the age and size of thebaby, pacifiers are generally labelled for babies either under or oversix months of age (raisingchildren.net.au, 2017).

A one-piece model with a soft teat is preferred. Pacifiers that are intwo pieces may separate in the baby’s mouth (raisingchildren.net.au,2017).

A pacifier with a firm plastic shield more than 3cm across and airholes will be less likely to fit whole in the baby’s mouth(raisingchildren.net.au, 2017).

b. Contamination:

Regularly checking the pacifier for wear and tear and replace if worn(raisingchildren.net.au, 2015).

If the pacifier falls on the floor, clean thoroughly before reuse.Consider having several pacifiers to rotate through cycles of cleaningand use throughout the day (Adair, 2003).

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Cleaning by a recognised method and according to the manufacturer’s recommendation. Babies less than six months old need the pacifier sterilised daily. Babies older than six months can have the pacifier regularly washed with soap and water (raisingchildren.net.au, 2015).

c. Allergic sensitisation:

Consider a silicone pacifier to decrease the potential risk of latexallergy (Adair, 2003).

d. Dental caries:

Avoid using a sweet coating on the pacifier to entice sucking (Adair,2003).

Suggest ceasing pacifier use from around six months (raisingchildren.net.au, 2015) as there is an increased risk of middle ear infections (otitis media) from three months of age.

Resources to Guide Practice

The ACM supports the use of the following resources to guide midwives and health professionals in their practice:

1. Australian Competition and Consumer Commission. (2017). ConsumerGoods (Babies’ Dummies and Dummy Chains) Safety Standard 2017.Retrieved from: https://www.productsafety.gov.au/standards/baby-dummies-and-dummy-chains

2. National Health and Medical Research Council. (2012). Infant FeedingGuidelines. Canberra: National Health and Research Council. Retrieved from:https://www.nhmrc.gov.au/guidelines/publications/n56

3. UNICEF/WHO. 10 steps to successful breastfeeding. (no date). Retrievedfrom: https://www.unicef.org/newsline/tenstps.htm

4. The Australian Parenting Website. (2017). Dummies: advantages anddisadvantages. Retrieved from:http://raisingchildren.net.au/articles/should_you_use_a_dummy.html

5. Red Nose. (2017). National Scientific Group (NSAG). Information Statement:Using a dummy or pacifier. Retrieved from:https://rednose.com.au/article/using-a-dummy-or-pacifier

Appendix: Background

Australian national breastfeeding recommendations include exclusivity1 to six months, with the introduction of solids and continued breastfeeding to twelve months and beyond or as long as both mother and baby desire (National Health

1 Breastmilk (including milk expressed or from wet nurse or breastmilk donor); allows prescribed drops or syrups (vitamins, minerals, medicines); does not allow anything else (NHMRC, 2012 p.129)

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and Medical Research Council, 2012). International guidelines recommend the same exclusivity timeframe with the extension of breastfeeding up to two years and beyond (World Health Organization, 2011).

The ACM endorses international recommendations and Declarations including the International Code of Marketing of Breast-milk Substitutes (World Health Organization, 1981) and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (United Nations International Children's Emergency Fund, 1990), which incorporates the global program the Baby Friendly Hospital Initiative. The ACM supports Australian programs, the Baby Friendly Health Initiative (BFHI) Ten Steps to Successful Breastfeeding and 7 Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services. The ACM strongly encourages all midwives and health professionals to adopt these standards as best practice.

The pacifier (also commonly referred to as a dummy, soother or binky) is a silicone, rubber or plastic oral device given to an infant or other young child for non-nutritive sucking purposes (International Baby Food Action Network, 2013).

Pacifier use appears to be a well-entrenched lifestyle practice and may have become a cultural ‘norm’ in many societies (Scott & Binns, 2006). Non-evidence-based information on pacifiers is easily accessed through parenting websites. The information presented suggests that pacifiers provide satisfaction in cases where a baby has an increased ‘need’ to suck; are a means of providing comfort; encourage a baby to self-soothe through increasing his or her sense of relaxation and security and provide the parent with a sense of control. The uptake of popularly reported information is reflected in the findings of an observational study of 670 Australian first time mothers (Mauch, Scott, Magarey & Daniels, 2012). The most commonly reported reasons for introducing a pacifier were to soothe the baby, encourage sleep, stretch out feeds and facilitate a sense of comfort due to a perceived natural sucking need. Various sources of advice for introducing a pacifier were also identified. In 30.6% of cases, women reported they acted without advice, 28.7% identified a mother or mother in law, 22.7% reported they acted on the advice of a midwife and 20.2% used a friend’s recommendations. Partners and other family members also contributed to the decision-making process. These figures suggest a degree of influence on the part of the midwife in women’s feeding practices.

There are a number of issues associated with pacifier use. Of primary concern is the potential association between pacifier use and both ineffective sucking patterns and delayed/missed feeds (Vogel, Hutchinson & Mitchell, 2001). Ineffective sucking may be the result of ‘confusion’ between nutritive and non-nutritive sucking patterns. Early work in the field of imprinting and breastfeeding (Mobbs, 1989) suggests some babies may be become preferentially fixated on an artificial teat to the detriment of an effective sucking mechanism. The rigid shape of the artificial teat of the pacifier, when pushed into the baby’s mouth places the tongue in an abnormal position. Levrini and colleagues (2007) found that stress from pacifier use alters the palatal arch, which also negatively impacts on sucking. The human nipple on the other hand is soft and flexible; the baby needs to open his/her mouth wide to draw it in and in doing so the tongue is in an optimal position for effective sucking (Mobbs, 2007). Ineffective sucking patterns may contribute to

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a number of feeding issues: sore nipples, engorgement, mastitis, low breast milk supply and slow weight gain of the baby. A Danish cohort study (Kronborg & Væth 2009) with a sample of 579 mothers reported that pacifier use in the first two weeks was independently associated with a shorter duration of exclusive breastfeeding and if ineffective technique was present the risks of cessation increased. Alternatively, pacifier use has been suggested as being a ‘marker’ rather than a cause of breastfeeding difficulties and or signalling a reduced motivation to breastfeed (Kramer et al, 2001).

There is controversy in the published peer reviewed literature surrounding the use and timing of pacifiers and the exclusively breastfed baby. Its use in the neonatal2 period has been investigated mostly through observational studies. An association has been shown with a reduced rate of breastfeeding (DiGirolamo, Grummer-Strawn & Fein, 2008). Mauch and colleagues (2012) found that mothers who had given their baby a pacifier before four weeks of age were more likely to have weaned. Kronborg & Væth (2009) demonstrated an association between early pacifier use and a decrease in exclusive breastfeeding. A strong recommendation against early pacifier use is included in the “Ten Steps to Successful Breastfeeding” (Baby Friendly Health Initiative, 2016) with professional and government bodies making similar recommendations (American Academy of Pediatrics, 2012; Ponti M: Canadian Pediatric Society Community Paediatrics Committee, 2003; National Health and Medical Research Council, 2012).

A meta-analysis conducted by Karabulut and colleagues (2009) reviewed 12 trials with weaning from exclusive breastfeeding and 19 trials with cessation of any breastfeeding published from 1980 to 2006. They compared outcomes for pacifier use beginning at less than four weeks and less than six weeks, versus no use. Their meta-analysis indicated that pacifier use at these time frames was associated with a two times increased risk of early weaning and cessation of any breastfeeding. The proposed mechanism for the relationship was a reduction in sucking activity at the breast, reduced milk supply and subsequently ended breastfeeding.

In contrast, Jaafar and colleagues’ (2016) Cochrane review reanalysed the results of two randomised controlled trials (1302 babies) out of 29 potential studies on restricted pacifier use. They concluded that in motivated mothers there is moderate-quality evidence 3that pacifier use in healthy term breastfeeding infants starting from birth or after lactation was established does not reduce the duration of full or partial breastfeeding to four months of age. The authors identified further research was required however until available, women who were well motivated to breastfeed should be enabled to make a decision on pacifier use based on personal preference.

Criticism of their previous Cochrane review (Jaafar et al 2012) by Binns & Lee (2012) included commentary that while the conclusions were valid for pacifiers introduced at 14 days or later there was no evidence to support ‘started from birth.’ Furthermore, the inclusion criteria limited the review’s generalisability and applicability. Maternal motivation was identified as a key factor as in both studies only women who were keen to breastfeed were recruited. In the larger study (1021

2 The period of the first four weeks or 28 completed days, commencing on the day of birth (AIHW, 2012 p.3507) 3 Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate (Jaafar et al 2016)

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babies) women were recruited no earlier than two weeks postpartum and when breastfeeding was well established4. Binns and Lee’s conclusion was that the message clinicians should give to women and their families is that the evidence is incomplete, and that pending further evidence the recommendation is for pacifiers not to be used in the first weeks of life and only after lactation is well established3. ”The Lancet Series on Midwifery” by Renfrew and colleagues (2014) also criticised the 2012 Cochrane review findings, commenting that they represented an ineffective practice, which is in contrast with the approach of not routinely interfering with normal processes.

The literature on the use of pacifiers for other issues is more straightforward. Cochrane reviews have examined the evidence surrounding the relationship between breastfeeding and procedural pain. Shah and colleagues (2012) reported that breastfeeding is the best option in reducing procedural pain compared to pacifier use, oral water, cuddling and swaddling for term babies and should be the first line of management. Johnston and colleagues (2014) reviewed procedural pain with reference to skin-to-skin contact (Kangaroo Care). Due to sample sizes, their inclusion categories included both preterm and term babies. Skin-to-skin either in combination with breastfeeding or alone were favoured over no treatment; however, there was no difference to breastfeeding in reducing procedural pain.

Pacifier use has been positively associated with decreasing the risk of Sudden Unexpected Death in Infancy, including Sudden Infant Death Syndrome (SIDS) (AAP, 2005). However, the mechanisms which underpin this protection are not fully understood, and it has been acknowledged that this association may be a marker for something else, as yet not measured (Horne et al 2014). The International Society for the Prevention of Infant Death does not provide a definitive recommendation, however advises that for breastfed babies, parents do not introduce a pacifier before breastfeeding has been established, and that parents of newborns be educated about the evidence of risks and benefits of pacifier use in order to make informed decisions (Horne et al 2014). More recently, exclusive and partial breastfeeding has been shown to have the same effect (Hauck 2011), with its subsequent inclusion in the Australian Safe Infant Sleeping guidelines (Young, 2012).

Long term pacifier use is also associated with an increased risk of otitis media and dental malocclusion. As the Eustachian tubes in a baby are effectively horizontal, long term use of a pacifier contributes to a build-up of fluid in the inner ear (Niemela’ et al, 2000; Rovers et al, 2008). Due to the displacement of the jaw and palate, long-term pacifier use increases the risk of dental malocclusion and dentition problems in late childhood (Duncan et al, 2008).

For the woman, any alterations in the normal lactation physiology as a result of the baby’s pacifier use may have an adverse effect on her hormonal profile. Decreases in the number of feeds, increases in the length of time between feeds and/or reduction in sucking time may stimulate ovarian function and negatively affect breastfeeding’s contraceptive effect (ILCA, 2014).

4 A natural regular pattern has established, with unrestricted effective feeding both day and night that has resulted in optimal breastmilk production (NHMRC 2012, p.31)

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Adair’s (2003) literature review of pacifier use in children explored the relationships between pacifier use, infections and safety. Pacifier use is clearly linked to middle ear infections (otitis media) starting from three months of age. Pacifiers are known to carry microorganisms and require regular preventative cleaning. There is some evidence of an association between pacifier use and Candida albicans infections, less so with silicone pacifiers. There are issues related to the safety of pacifier styling, with asphyxia resulting in cases where the pacifier had come apart and been inhaled, or a long cord had been attached that became entangled around the baby’s neck. Latex allergy, although rare has been reported.

There are also opposing views about the cleaning of pacifiers by parents’ own mouths. There is potential for transferring streptococcus mutans and increasing the risk of dental caries (Adair, 2003; Binns & Lee, 2012), however Hesselmar and colleagues (2013) suggest the practice may stimulate the baby’s immune system by microbes transferred from the parent’s saliva.

References

Adair S. (2003). Pacifier use in children: a review of recent literature. Pediatric Dentistry, (25), 5, 449-458.

American Academy of Pediatrics. (2012). Policy statement: breastfeeding and the use of human milk. Pediatrics (129 ), 3, e827-e841. Retrieved from http://pediatrics.aappublications.org/content/129/3/e827

American Academy of Paediatrics. Task Force on Sudden Infant Death Syndrome., & Moon, R. (2005). SIDS and other sleep related infant deaths expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128, e1341-67. Retrieved from http://pediatrics.aappublications.org/content/early/2011/10/12/peds.201

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Australian Institute of Health and Welfare. (2003). Perinatal national minimum data set: national health data dictionary, version 12. Cat. No. HWI 59. Canberra: AIHW. Retrieved from http://www.aihw.gov/au/publication-detail/?id=6442467499

Australian Institute of Health and Welfare. (2012). National health data dictionary 2012 version 16. National health data dictionary no.16. Cat. No. HWI 119. Canberra: AIHW. Retrieved from http://www.aihw.gov.au/publication-detail/?id=10737422826

Baby Friendly Health Initiative. (2016). The ten steps to successful breastfeeding in Australia. Retrieved from http://www.babyfriendly.org.au

Binns, C., & Lee, S. (2012). Commentary on: ’Pacifiers use in term infants and breastfeeding: caution with the Cochrane results.’ Evidence-Based Child Health, 7, 1180-1181.

DiGirolamo, A., Grummer-Strawn, L., & Fein, S. (2008). Effect of maternity-care practices on breastfeeding. Pediatrics 122, Suppl2, S43-49

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Duncan, K., McNamara, C., Ireland, A., & Sandy, J. (2008). Sucking habits in childhood and the effects on primary dentition: findings of the Avon Longitudinal Study of Pregnancy and Childhood. International Journal of Paediatric Dentistry ,18, 178-88.

Hesselmar, B., Sjöberg, F., Saalman, R., Åberg, N., Adlerberth, I., & Wold, A. (2013). Pacifier cleaning practices and risk of allergy development. Pediatrics, 131, e1829-1837. Retrieved from http://pediatrics.aappublications.org/content/early/2013/04/30/peds.20

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Hauck, F., Thompson, J., Tanabe, K., Moon, R., & Vennemann, M. (2011). Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics, 128, 103-10.

Horne, R., Hauck, F., Moon, R., L’Hoir. M., Blair, P., & Physiology and Epidemiology Working Groups of the International Society for the Study and Prevention of Perinatal and Infant Death. (2014). Dummy (pacifier) use and Sudden Infant Death Syndrome (SIDS): potential advantages and disadvantages. Journal of Paediatrics and Child Health, 50, 170-174. DOI: 10.1111/jpc.12402.

International Baby Food Action Network. (2013). Marlo S. Guest Editor. Pacifiers and breastfeeding. Breastfeeding Briefs No 54, March. Retrieved from http://ibfan.org/breastfeedingbreafs/bb54.pdf

International Lactation Consultant Association. (2014). ILCA Clinical guidelines for the establishment of exclusive breastfeeding (3rd ed.). North Carolina, USA: ILCA.

Jaafar, H., Jahanfar, S., Angolkar, M., & Ho, J. (2012). Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database of Systematic Reviews, 7. DOI: 10.1002/14651858.CD007202.pub3. Retrieved from http://www.cochrane.org/CD007202/PREG_effect-of-pacifier-use-on-duration-of-breastfeeding-in-full-term-infants

Johnston, C., Campbell-Yeo, M., Fernandes, A., Inglis, D., Streiner, D., & Zee, R. (2014). Skin-to-skiin care for procedural pain in neonates. Cochrane Database of Systematic Reviews, 1. DOI:10.1002/14651858.CD008435.pub2 Accessed at: http://www.cochrane.org/CD008435/NEONATAL_skin-to-skin-kangaroo-care-with-newborns-cuts-down-procedural-pain

Karabulut, E., Yalçin, S., Özdemir-Geyik, P., & Karaağaoğlu, E. (2009). Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. The Turkish Journal of Pediatrics, 51, 35-43.

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Kramer, M., Barr, R., Dagenais, S., Yang, H., Jones, P., Ciofani, L., & Jané, F. (2001). Pacifier use, early weaning, and cry/fuss behaviour: a randomized controlled trial. JAMA, 286, 322-326. DOI: 10.1001/jama.286.3.322

Kronberg, H., & Væth, M. (2009). How are effective breastfeeding technique and pacifier use related to breastfeeding problems and breastfeeding duration? Birth, 36, 34-42.

Levrini, L., Merlo. P., & Paracchini, L. (2007). Different geometric patterns of pacifiers compared on the basis of finite element analysis. European Journal of Paediatric Dentistry, 8, 173-178.

Mauch, C., Scott, J., Magarey, A., & Daniels, L. (2012). Predictors of and reasons for pacifier use in first-time mothers: an observational study. BMC Pediatrics, (12), 7. Retrieved from http://www.biomedcentral.com/1471-2431/12/7

Mobbs, E. (2007). Thumb-sucking & dummy -sucking: evidence for human imprinting (1st ed.). Sydney: G.T. Crarf Pty Ltd.

National Health and Medical Research Council. (2012). Infant feeding guidelines. Canberra: National Health and Research Council. Retrieved from https://www.nhmrc.gov.au/guidelines/publications/n56

Niemela’, M., Pihakari, O., Pokka, T., & Uhari M. (2000). Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counselling. Pediatrics, 106, 438-8.

Ponti, M., & Canadian Pediatric Society Community Paediatrics Committee. (2003). Recommendations for the use of pacifiers. Paediatric Child Health, (8), 8, 515-518.

Product Safety Australia (2015). Baby dummies. Retrieved from https://www.productsafety.gov.au/content/index.phtml/itemId/971564

Raising Children Network. (2017). Dummies: advantages and disadvantages. Retrieved from http://raisingchildren.net.au/articles/should_you_use_a_dummy.html

Renfrew, M., McFadden, A., Bastos, M., Campbell, J., Channon, A., Cheung, N.,…Declerq, E. (2014). Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet, 384, 1129-45. Retrieved from http://dx.doi.org/10.1016/S0140-6736(14)60789-3

Rovers, M., Numans, M., Langenbach, E., Grobbee, D., Verheij, T., & Schilder, A. (2008). Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Family Practice, 25, 233-6.

Scott, J., Binns, C., Oddy, W., & Graham, K. (2006). Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics, 117, e646-655. Retrieved from http://pediatrics.aappublications.org/content/117/4/e646

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Shah, P., Herbozo, C., Aliwalas, L., & Shah, S., & Cochrane Neonatal Group. (2012). Breastfeeding or breast milk for procedural pain in neonates. The Cochrane Database of Systematic Reviews 2012, 12. DOI:10.1002/14651858.CD004950.pub3. Retrieved from http://www.cochrane.org/CD004950/NEONATAL_breastfeeding-or-breast-milk-for-procedural-pain-in-neonates

United Nations International Children's Emergency Fund. (1990). Innocenti declaration on the protection, promotion and support of breastfeeding. New York: UNICEF. Retieved from http://www.unicef.org/programme/breastfeeding/innocenti.htm

World Health Organization. (1981). International code of marketing of breast-milk substitutes. Geneva: World Health Organization. Retrieved from http://www.who.int

World Health Organisation. (2011). Exclusive breastfeeding statement. Retrieved from http://www.who.int

Young, J., Watson, K., Ellis, L., & Raven, L. (2012). Responding to evidence: breastfeed baby if you can-the sixth public health recommendation to reduce the risk of sudden and unexpected death in infancy. Breastfeeding Review, 20, 7-15.

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