EXPANDED HOSPITAL POLICY #7:
Artificial nipples and pacifiers should be discouraged for healthy breastfeeding infants.
INTERVENTION / MANAGEMENT
7.1 Pacifiers should not be given to breastfeeding infants. Mothers should be encouraged to breastfeed frequently in response to hunger cues.
7.1 Breast stimulation is critical to milk production. When an infant needs to suck, in the first days of life, the breast should be offered. The use of pacifiers may shorten the duration of breastfeeding. 1,4,5,6,7,11,12,13
Introducing artificial nipples
- is associated with decreased duration of breastfeeding. 1,4,5,14
- may prevent establishing of milk supply.
- may prevent optimal tooth, jaw and speech development. 10
- may encourage the infant to suck incorrectly, since on an artificial nipple the baby will be rewarded even for a physiologically incorrect suck. This is sometimes referred to as “nipple preference.” 3,8
- is associated with increased risk of otitis media. 9,10
Permission forms may be used to educate mothers about the use of pacifiers.
What should i know about giving my breastfed baby a pacifier?
Primarily mothers need to be aware of the importance of breastfeeding to meet newborn’s sucking needs instead of delaying feedings with pacifiers.
Information and references on the use of pacifiers from the UK website, which addresses the use of “teats” (artificial nipples) and “dummies’ (pacifiers) as well as nipple shields.
Recent recommendations by the American Academy of Pediatrics to use pacifiers to avoid SIDS do not conflict with this policy. In its policy, the AAP recommends that: “For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.” [full policy]
In order to avoid artificial nipples, some agencies use alternative ways of feeding infants who require supplementation such as:
- Spoon feeding colostrum hand-expressed into a plastic spoon
- Dropper feeding colostrum hand-expressed into a spoon or cup
- Cup-feeding hand-expressed, pumped, or banked human milk
- Finger Feeding using a syringe of feeding device such as a Hazelbaker FingerFeeder system.
- Use of a feeding-tube device such as the Supplemental Nursing System, Lact-Aid one created by using an NG tube slipped into a bottle of expressed breast milk, banked human milk or formula (see “Using a Lactation Aid” by and video link by Dr. Jack Newman.
- When using bottles to supplement, utilizing the “paced bottle feeding technique” helps reduce the risk of infants’ refusing the breast due to establishing a pattern of immediate and continuous feeding from non-paced bottle feeding.*
(See Policy and Procedures for alternate feeding methods of Very Low Birth Weight Infants from the California Perinatal Quality Care Collaborative)
Pacifiers may be used in full-term babies during painful procedures such as circumcisions, however, they should not remain in the crib, which would give the parents the impression that it is a tool to be used to comfort the newborn, which may delay the next breastfeeding experience.
7.2 Mothers can be encouraged to hold and breastfeed their infants during routine painful procedures such as heel sticks and intra-muscular injections. If the mother chooses not to breastfeed during the painful procedure, a pacifier may be used and discarded after the procedure.
7.2 Infants breastfeeding during painful procedures demonstrate greatly diminished or zero response to pain.2
See Reference #2 below:
Policy #7 References:
1. Barros, F. C., Victoria, C. G., Semer, T. C., Filho, S. T., Tomasi, E., & Weiderpass, E. (1995). Use of pacifiers is associated with decreased breastfeeding duration. Pediatrics, 95(4), 497-499. [Abstract]
2. Gray, L., Miller, L. W., Philipp, B. L., & Blass, E. M. (2002). Breastfeeding is analgesic in healthy newborns. Pediatrics ,109(4), 590-593. [Abstract]
3. Hill, P. D., & Humenick, S. S. (1997). Does early supplementation affect long-term breastfeeding? Clinical Pediatrics, 36(6), 345-350. [Abstract]
4. Howard, C. R., Howard, F. M., Lanphear, B., deBlieck, E. A., Eberly, S., & Lawrence, R. A. (1999). The effects of early pacifier use on breastfeeding duration. Pediatrics, 103(3), 33-38. [Abstract (PDF)]
5. Howard, C. R., Howard, F. M., Lanphear, B., Eberly, S., deBlieck, E. A., Oakes, D., & Lawrence, R. (2003). Randomized clinical trial of pacifier use and bottle-feeding or cup feeding and their effect on breastfeeding. Pediatrics, 111(3), 511-518. [Abstract]
6. Kramer M. S., Barr, R. G., Dagenais, S., Yang, H., Jones, P., Ciofani, L. & Jane F. (2001). Pacifier use, early weaning, and cry/fuss behavior: A randomized controlled trial. Journal of the American Medical Association, 286(3), 322-326. [Abstract]
7. Lawrence, R. (1987). The management of lactation as a physiologic process. Clinics in Perinatology, 14(1), 1-10. [Abstract]
8. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical professional (6th ed.). St. Louis, MO: Mosby (pp. 223-224, 309-310).
9. Newman, J. (1990). Breastfeeding problems associated with the early introduction of bottles and pacifiers. Journal of Human Lactation, 6(2), 59-63. (Abstract).
10. Niemela, M. Uhar, M. & Hannuksela, A. (1994). Pacifiers and dental structure as risk factors for otitis media. International Journal of Pediatric Otorhinolaryngology, 29(2), 121-127. (Abstract)
11. Niemela, M., Uhari, M., & Mottonen, M. (1995). A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics, 96(5), 884-888. (Abstract)
12. Righard, L. & Alade, M. (1997). Breastfeeding and the use of pacifiers. Birth, 24(2), 116-120. (Abstract)
13. Victora, C. G., Behague, D. P., Barros, F. C., Olinto, M. T. A., & Weiderpass, E. (1997). Pacifier use and short breastfeeding duration: Cause, consequence, or coincidence? Pediatrics, 99(3), 445-453. (Abstract)
14. Victora, C. G., Tomasi, E., Olinto, M. T. A., & Barros, F. C. (1993). Use of pacifiers and breastfeeding duration. Lancet, 341, 404-406. (Abstract)
Merewood A., Mehta S, Chamberlain, LB, Philipp BL, and Bauchner H,; Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey, PEDIATRICS Vol. 116 No. 3 September 2005, pp. 628-634 (Abstract)
Binns CW, Scott JA. “Using pacifiers: what are breastfeeding mothers doing?” Breastfeed Rev. 2002 Jul;10(2):21-5. (Abstract)
Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, Lawrence RA., “Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding”. Pediatrics. 2003 Mar;111(3):511-8.
Mizuno K, Ueda A: Changes in Sucking Performance from Nonnutritive Sucking to Nutritive Sucking during Breast- and Bottle-Feeding; Pediatric Research 59:728-731 (2006) (Abstract)
Nelson EA, Yu LM, Williams S; International Child Care Practices Study Group Members. International Child Care Practices study: breastfeeding and pacifier use; J Hum Lact. 2005 Aug;21(3):289-95. (Abstract)
Soares ME, Giugliani ER, Braun ML, Salgado AC, de Oliveira AP, de Aguiar PR. “Pacifier use and its relationship with early weaning in infants born at a Child-Friendly Hospital; J Pediatr (Rio J). 2003 Jul-Aug;79(4):309-16. (Abstract) (PDF)
*Kassing,D; “Bottle-feeding as a tool to reinforce breastfeeding” J Hum Lact. 2002 Feb;18(1):56-60 Pacifiers may be used in full-term babies during painful procedures such as circumcisions, however, they should not remain in the crib, which would give the parents the impression that it is a tool to be used to comfort the newborn, which may delay the next breastfeeding experience.
Fern R. Hauck, MD, MS*,, Olanrewaju O. Omojokun, MD and Mir S. Siadaty, MD, MS; “Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis” REVIEW PEDIATRICS (doi:10.1542/peds.2004-2631)
CONCLUSIONS.: … In consideration of potential adverse effects, we recommend pacifier use for infants up to 1 year of age, which includes the peak ages for SIDS risk and the period in which the infant's need for sucking is highest. For breastfed infants, pacifiers should be introduced after breastfeeding has been well established.
Responses to the above article:
From the: POLICY STATEMENT by the Section on Breastfeeding of the American Academy of Pediatrics: “Breastfeeding and the Use of Human Milk” (PDF):
“5. Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established.166–168
- In some infants early pacifier use may interfere with establishment of good breastfeeding practices, whereas in others it may indicate the presence of a breastfeeding problem that requires intervention.169
- This recommendation does not contraindicate pacifier use for nonnutritive sucking and oral training of premature infants and other special care infants.”
166. Howard CR, Howard FM, Lamphear B, de Blieck EA, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics. 1999;103(3). [Full Article]
167. Howard CR, Howard FM, Lanphear B, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111:511–518 [Full Article]
168. Schubiger G, Schwarz U, Tonz O. UNICEF/WHO Baby-Friendly Hospital Initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group. Eur J Pediatr. 1997;156:874–877 [Abstract]
169. Kramer MS, Barr RG, Dagenais S, et al. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. JAMA. 2001;286: 322–326 [Abstract]