Clinical Question

Does unrestricted pacifier use in healthy, full-term, exclusively breastfed infants decrease the duration of breastfeeding?

Evidence-Based Answer

In healthy, full-term, breastfeeding infants, there is moderate evidence that unrestricted pacifier use, started at birth or after lactation has been established, does not decrease the likelihood of continued exclusive or partial breastfeeding through four months of age.¹ (Strength of Recommendation: A, based on two quality randomized controlled trials [RCTs] leading to Cochrane opinion.)

Practice Pointers

The United States has seen a rise in infant breastfeeding rates over the past two decades, likely because of the growing body of evidence that supports improved health outcomes for both mother and baby. The percentage of infants who have ever breastfed increased from 71% in 2002 to 83% in 2014.² To encourage successful breastfeeding, many hospital systems ascribe to baby-friendly behavior practices based on the World Health Organization's (WHO's) Ten Steps to Successful Breastfeeding.³

One behavior postulated to interfere with the establishment of successful breastfeeding is pacifier use during the first few weeks of life. Step 9 of the WHO's 10 steps instructs parents to refrain from giving pacifiers or artificial nipples to breastfeeding infants; this is based on four observational studies published before 1998.³ One recent systematic review identified 46 relevant studies (two clinical trials, 20 longitudinal studies, and 24 cross-sectional studies).⁴ Meta-analysis of the largely observational data found a consistent association between pacifier use and risk of exclusive breastfeeding disruption. This Cochrane review sought to evaluate whether pacifier use in healthy breastfeeding infants affects multiple breastfeeding outcomes, including the duration (i.e., total months) of breastfeeding.¹

Two RCTs with 1,302 infants found no apparent difference between the pacifier and control groups in the proportion of infants who were exclusively or partially breastfeeding at three and four months of age.^5,6 The included studies did not report outcomes for total duration of breastfeeding. Additionally, this review did not assess secondary outcomes of breastfeeding difficulties (pain, mastitis, cracked nipples, breast engorgement), infant health, or maternal satisfaction or confidence in parenting.¹

Breastfeeding is endorsed by many professional societies, including the American Academy of Family Physicians (AAFP), as the preferred method of feeding infants during the first six to 12 months of life.⁷ Even more specifically, the AAFP breastfeeding position paper states that physicians should “Educate mothers about the risks of unnecessary supplementation and pacifier use.” The AAFP recommendation is based on the observational studies body of literature, and it falls contrary to the findings and recommendation in this Cochrane review. Further research could influence confidence about the effect of pacifier use and help inform decisions for infants beyond four months of age. Health care professionals should support breastfeeding mothers in making decisions regarding pacifier use based on infant needs and maternal preference.