Pictured: Confusion

Pictured: Confusion

My first “real world” employment after completing residency was as a full-time newborn hospitalist in Houston. After spending three years in Space City, often rounding on as many as 30 newborn infants in the Level 1 and Level 2 units each day at the county hospital, I feel as if I’ve probably about seen it all when it comes to the nursery. I then left the babies behind while working as a pediatric hospitalist in Baton Rouge for four years, but now I’m back in the newborn business up here in Boston. While there have certainly been a few changes since 2009, many things remain exactly the same.

I help take care of a very vulnerable population in my current position: parents. Parents, in particular the young and first time variety, often approach parenting with a blank slate. Sure there is frequently a grandparent or four there for assistance, but the healthcare professionals working in the nursery are looked to for vital knowledge about how to care for the new arrival. Even some of the more experienced parents will still have questions, and most respect and follow the advice given during those first few days while at the hospital. These questions most commonly focus on topics such as feeding, vaccinations and vitamin supplementation, but I am regularly asked about a variety of routine parenting skills such as swaddling, and even baby “gear” like Angel monitors.

Parents love their children and want what is best for them, and they frequently express fear and anxiety over some of these topics. Love and fear are two powerful factors in the acceptance of pseudoscience and bad advice, which is why parents are set up to be fooled. Over the next few posts, I plan to cover some examples of newborn issues known to cause excessive parental anxiety and that sometimes lead to poor decisions, in large part because of bad information received from people who should know better.

First up is a concept that is well-known in the nursery, and strikes fear in the hearts of lactation consultants all over the world. I’m talking about nipple confusion. This is a concept that may seem silly to those unfamiliar with the world of parenting, but it is something that newborn doctors deal with daily and there is a great deal of controversy. Not “vaccines and autism” controversy unfortunately, but if after reading this post you find yourself feeling let down because I didn’t start with something sexier, take solace in the fact that winter is coming.

What is nipple confusion?

If you don’t know what nipple confusion is, don’t feel bad. Most people probably don’t. And many who think they understand the concept have fallen for what I believe is hype based on scant evidence. Beliefs regarding nipple confusion transfer from generation to generation propelled by misinformation and cultural momentum. And based on questionable recommendations from organizations like the WHO and the AAP, many healthcare professionals encourage these beliefs, which tend to be very firmly held. On many occasions I have witnessed intense arguments over the existence of nipple confusion and the degree of respect it deserves.

According to proponents, nipple confusion occurs when a breastfeeding newborn is given a bottle or pacifier. They believe that because the mechanics of sucking on bottle nipples and pacifiers are so different, it confuses the infant and causes them to pick up bad feeding habits. When they attempt to put these newly acquired skills to use on their mother’s breast it results in frustration, maternal pain, and premature cessation of breastfeeding.

La Leche League International, a group which (to put it nicely) strongly supports breastfeeding, has the following to say about nipple confusion:

Pacifier use in the early weeks may affect milk supply and lead to slow weight gain. It is important that nursing sessions are not delayed and that all sucking is done at the breast in order to establish a good milk supply.

Using a pacifier may also result in latch-on and sucking problems for the baby. This is because the shape of the pacifier is different from your soft breast and the baby may get confused as to how to suck. This may result in sore nipples for mom. In addition to sore nipples, introducing a “dummy” may lead to mastitis because baby is not sucking as much at the breast. Also, you may find your fertility returns more quickly if you use a pacifier as your hormonal balance is affected by less sucking at the breast.

There may also be an increased risk of ear infections for a baby if regularly sucking on a pacifier. Thrush can also be a problem, as it thrives on moist surfaces at room temperature. Not only can it cause thrush infection, but unless pacifiers are boiled each day for five minutes and replaced each week during an outbreak of thrush, the pacifier can cause reinfection, too.

Regular pacifier use has also been shown to affect the growth of teeth and the shape of the mouth, increasing the need for braces later on. Also, it can increase the levels of bacteria in the mouth that cause dental caries. Regular pacifier use is also associated with early weaning.

There is almost too much misinformation in that quote to deal with in one post, but I will do my best. Moving on.

The Sears family, a group of pediatricians who (to put it nicely) are easily confused by scientific evidence and prone to things like alternative vaccine schedules, bad advice about SIDS prevention and poorly produced daytime talk shows, agrees with the LLLI:

There are some basic mechanical differences between how a baby gets milk from a bottle and how a baby gets milk out of the breast. Giving bottles or pacifiers to young, breastfeeding babies often leads to nipple confusion. Baby tries to use the bottle-feeding technique on the breast and has difficulty latching-on and sucking. Baby gets very frustrated, and so does mother. Nipple confusion can even lead to baby refusing the breast.

Though not a new concern, the real fuss over nipple confusion started when the World Health Organization’s Division of Child Health and Development and UNICEF issued a joint statement on breastfeeding in 1989. The statement included the now famous (infamous perhaps depending on whether or not you work for Ross or Mead-Johnson) Ten Steps to Successful Breastfeeding. The following year WHO/UNICEF policymakers released the Innocenti Declaration, which called upon the governments of the world to adopt the Ten Steps in all hospitals providing maternity services. We now live in a society where the hospital’s pacifiers are sometimes locked in cabinets that require a special code, fingerprint analysis and retinal scan to open. Okay, maybe not the retinal scan.

What are the Ten Steps to Successful Breastfeeding?

The Steps are pretty straightforward and reasonable with the exception of number 9, which is the source of the nipple confusion controversy.

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in — allow mothers and infants to remain together — 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The American Academy of Pediatrics, in its 1997 policy statement on breastfeeding, did not mention the Ten Steps but made recommendations equivalent to number 6 and 9. In their reaffirmation of the policy in 2005, again there was no specific mention of the Steps. There was, thankfully, a somewhat more nuanced discussion of the use of pacifiers:

Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established. 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. This recommendation does not contraindicate pacifier use for non-nutritive sucking and oral training of premature infants and other special care infants.

This change allowed some interpretation. A pediatric resident at the time, I felt that I could counsel families that pacifier use was okay if breastfeeding was going very well, even in the nursery. There was also a lot more data available at the time that questioned the concept of nipple confusion as an entity that should even be on our radar. Also that year, emerging evidence on the benefit of pacifier use for reduction of the risk of SIDS led to the AAP recommendation that they be used in all infants less than one year of age during sleep initiation.

The AAP officially endorsed the WHO/UNICEF statement and their Ten Steps in 2009, and reaffirmed their endorsement in 2011. Of note, the AAP does not fully accept the ninth step, as is made clear in the most current policy statement on breastfeeding:

The AAP does not support a categorical ban on pacifiers because of their role in SIDS risk reduction and their analgesic benefit during painful procedures when breastfeeding cannot provide the analgesia. Pacifier use in the hospital in the neonatal period should be limited to specific medical indications such as pain reduction and calming in a drug-exposed infant, for example. Mothers of healthy term breastfed infants should be instructed to delay pacifier use until breastfeeding is well-established, usually about 3 to 4 weeks after birth.

All of this has led to the current predicament when caring for newborn infants being exclusively breastfed. How do pediatricians and family doctors appropriately discuss the use of pacifiers with their parents? What does “well-established” even mean exactly? Can we support breastfeeding while also reducing the risk of SIDS? More to the point of this post, is the ninth step or even the more nuanced AAP stance even reasonable?

But before I delve into whether or not pacifiers actually impact breastfeeding success, first a quick discussion about why this discussion even matters. Breastfeeding is, hands down, one of the most beneficial actions a mother can take in raising a healthy child. If proponents of Step 9 are correct, and pacifier use can impair the ability of a young infant to establish breastfeeding, then this issue should be taken very seriously.

Why breastfeeding matters?

Infants fed human milk, and the mothers that feed them benefit from a wide variety of well-established health outcomes, even in developed countries. In many areas, there is benefit even with partial breastfeeding. Here are a few of the improved outcomes seen in breastfed infants and their mothers:

1. Significant reductions in the risk of lower respiratory infections and hospitalizations for lower respiratory infections during the first year of life.

2. Significant reduction in the incidence of gastrointestinal tract infections while being breastfed and up to 2 months after breastfeeding is stopped.

3. Significant reduction in the risk of necrotizing enterocolitis (trust me, it’s as bad as it sounds) in premature infants. One surgery or death prevented for every 8 premies being fed exclusively with human milk. This is a big reason why human milk banks are being established in many areas.

4. Significant reduction in the risk of SIDS (#1 cause of death from 1 to 12 months of life in the US) and infant mortality around the world.

5. Reduced risk of asthma, eczema, celiac disease (the real kind) and inflammatory bowel disease.

6. Breastfed infants are less likely to become obese children and adults.

7. Reduction in the risk of type 1 diabetes, childhood leukemia and lymphoma.

8. Improved neurodevelopmental outcomes in premature infants (best supported) and likely even term infants (probably not significant enough to matter in most healthy kids) even when accounting for social variables.

9. Mothers who breastfeed have less postpartum bleeding, less risk of postpartum depression, are less likely to abuse their children even after accounting for social variables and have lower risk of breast and ovarian cancer.

10. Lactational amenorrhea helps to prevent subsequent pregnancy while still breastfeeding.

And I didn’t even get into the economic benefits. One possible benefit that is probably more fiction than reality, however, is improved postpartum weight loss. If there even is a difference, it probably doesn’t manifest until breastfeeding has lasted longer than 9 months and the effect is probably minimal.

While the benefits of breastfeeding are huge, please to not misinterpret my support of the practice. I love and encourage breastfeeding but I do not endorse tactics to coerce uninterested mothers into doing it. There are few medical contraindications to breastfeeding, but many personal ones, and I support those mothers just as much. Despite the long list above, formula fed infants do very well. The one possible exception for me is when it comes to extremely premature infants. I consider breast milk as vital to their health as I would an antibiotic in a patient with meningitis. Mothers should be strongly encouraged to provide breast milk to the best of their ability, and they should be made aware of the potentially lifesaving benefits in this population of newborns. And I strongly support the development of more human milk banks so that human milk is available for premature infants whose mothers are unable or unwilling to provide it.

Now back to pacifiers!

Is nipple confusion real?

From a plausibility standpoint, I don’t think that nipple confusion makes a whole lot of sense. Though I am often the first to point out that newborn babies are helpless (thanks evolution), and would not survive long without significant intervention from caregivers, I must admit that they are actually quite good at what they can do. They can’t see much of anything, control their movements, or communicate their specific needs very well but healthy babies know how to suck. It is, in fact, a reflex action that they do not control. Sucking is a natural means of soothing a crying baby.

Put anything in an infant’s mouth and it will suck on it. I use this to my advantage during every newborn exam, placing my gloved pinky finger in the oral cavity, not just to assess this normal reflex or to check for a cleft palate but also to quiet them down so that I might check their little hummingbird hearts for murmurs. Newborns suck on their hands, their feet, blanket edges, and essentially whatever they can get into their mouths. It is actually quite common to find self-inflicted suction blisters on various body parts that were acquired prenatally. Somehow this does not alter the mechanics of their suck and lead to early cessation of breastfeeding, but even intermittent use of a pacifier is felt to do so.

In addition to the argument that pacifier use alters feeding mechanics, the claim is often made that choosing the pacifier instead of putting the baby to the breast will cause a delay in milk let down and increase the likelihood of breastfeeding cessation. There is some truth to this. It is a definite issue when it comes to bottle feeding, again not because of altered mechanics but because formula feeding leads to satiety.

The more that a baby feeds from the breast, the faster the milk will come in, and a baby full of formula will feed less from the breast. A pacifier will not appreciably space out breastfeeding because hungry babies will rarely be soothed by one. If anything, lack of a pacifier would seem to be more likely to encourage turning to formula in the nursery because many babies spend much of their 2nd day of life crying. The 2nd day is often the hardest because it is the time between the sleepy 1st day of life and mom’s milk coming in. A pacifier can help between feeding attempts, but formula works much better. But to be clear, a pacifier should not be used as a substitute for feeding a hungry baby.

In my opinion, any strict ban of pacifiers is unreasonable and even cruel considering how effective pacifiers are, particularly when combined with sucrose, in alleviating pain during procedures such as heel sticks, venipuncture and circumcision. Furthermore, I do not accept that use of pacifiers interferes with breastfeeding at all. It probably hurts breastfeeding efforts. So what does the evidence reveal?

When WHO/UNICEF handed down their Ten Steps in 1989, the evidence for Step 9 was very poor. The available studies were small and did not account for a variety of variables that might affect breastfeeding other than pacifier use. And according to their own 1998 paper discussing the evidence in support of The Ten Steps, while the evidence suggested that pacifiers may be to blame for breastfeeding difficulties, “their use may be a marker of the desire to stop breastfeeding early rather than a cause of discontinuation.” So are mothers neglecting breastfeeding in favor of the pacifier, or grabbing the pacifier because breastfeeding is going poorly for some other reason?

The WHO paper also outlines a number of other reasons why pacifiers are evil, which were also in that earlier statement from the LLLI on nipple confusion. These included concerns of tooth decay, dental malocclusion (misalignment of teeth), ear infections, thrush, toxic chemicals and choking. Most of these concerns are overblown by nipple confusion proponents.

Tooth decay is primarily an issue of propping a formula-filled bottle in the crib, but pacifiers can contribute somewhat to the development of caries. This can easily be avoided by not dipping a pacifier in honey or other sugary liquid. Also parents should avoid “spit cleaning” pacifiers, which can allow for the transfer of cavity causing bacteria and lead to caries. According to the American Academy of Pediatric Dentistry, concerns of malocclusion should not scare parents away from using the pacifier as a SIDS risk reduction strategy, stating that “Dental effects are generally reversible and unlikely to cause any long-term problems if the habit is discontinued by the age of 5.”

Children who use a pacifier are more likely to develop ear infections, but not by much and not typically during the first six months of life when the risk of SIDS is highest. There appears to be about a 1-2 fold increased risk in older infants and children. Pacifier-using infants are also more likely to be colonized with the species of yeast that causes thrush, although many children who don’t use them are as well, and colonization does not equal infection. Many exclusively breast fed infants develop thrush. It is not uncommon for the nipples and areolae of breastfeeding mothers to become infected as well and, like pacifiers, serve as a source of reinfection. Pacifiers can be cleaned and mom’s nipples can be treated. This should not deter pacifier use.

But what about the impact on breastfeeding? There have been a number of larger and better controlled studies that have come out in recent years, and they have not supported the concerns of nipple confusion advocates. A Cochrane review of pacifier use in breastfeeding term infants looked at the three best available studies through 2012 and found no detrimental effect up to four months of age. There isn’t enough good data to make a conclusion about longer term problems, but I would be very surprised if there were any. This more recent 2013 paper in Pediatrics looked at over 2,000 newborns both before and after pacifiers were literally put under lock and key in a hospital nursery. It raises serious concerns that restricting pacifier availability in the newborn period may even increase the likelihood that breastfeeding mothers will reach for formula. It appears that, as the old saying goes, correlation does not equal causation in this case and pacifiers may even be protective.

Conclusion: Do no fear pacifiers

Newborns may lack orientation to person, place, time and situation but they do not become confused simply because of having a pacifier placed in their mouth. Pacifiers are an effective means of soothing a crying infant and treating their pain during brief procedures, and they protect against SIDS. The evidence to date does not support concerns that pacifier use will interfere with breastfeeding and they may even help exhausted mothers say no to formula. Additional health concerns blamed on pacifiers are overblown and should not serve as a reason to miss out on the benefits of their use.

There is a lot of bad information out there that unfortunately will not be going away anytime soon, so I expect to continue to have to reassure parents that the pacifier is perfectly appropriate. Breastfeeding is a wonderful endeavor with myriad benefits to both mother and child, and it should be encouraged, but not with the use of propaganda and misinformation. Hopefully the American Academy of Pediatrics will take this new evidence into account when the time to reaffirm their breastfeeding policy comes around again in a few years.




  • Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.