PACIFIER USE AND SHORT BREAST-FEEDING DURATION - CAUSE, CONSEQUENCE, OR COINCIDENCE

Objectives. Pacifiers are related to shorter duration of breastfeeding . However, it is unclear whether this association is causal, because c onfounding,. reverse causality, and self-selection of mothers may play a role. These issues were investigated through a combination of epide miologic and ethnographic research in southern Brazil. Methodology. A population-based cohort of 650 mothers and infants were visited shortl y after delivery and at 1, 3, and 6 months. The rate of complete follo w-up was 96.8%. A subsample of 80 mothers and infants was selected for the ethnographic study, which included in-depth interviews and partic ipant observations in the age range of 2 to 6 months with a mean of 4. 5 visits. Results. The epidemiologic study showed that pacifier use wa s common with 85% of users at 1 month. However, this was a dynamic pro cess, with many infants starting or abandoning the pacifiers in any ag e range. Children who stopped breastfeeding in a given period were lik ely to take up the pacifier during that period. Further analyses exclu ded all infants not breastfed at 1 month of age and those who reported ly had breastfeeding problems, leaving 450 infants with full data. Int ense pacifier users at 1 month (children who used the pacifiers during most of the day and at least until falling asleep) were four times mo re likely to stop breastfeeding by 6 months of age than nonusers. User s also had fewer daily breastfeedings than nonusers. After adjustment for several confounding variables, logistic regression showed that pac ifier use was still associated with an odds ratio of 2.5 (95% confiden ce interval, 1.40 to 4.01) for stopping breastfeeding. The ethnographi c analysis showed that pacifier use was widely regarded as a positive behavior and that mothers often strongly stimulated the infants to acc ept it. Although few mothers openly admitted that pacifiers might shor ten breastfeeding, a considerable group effectively used pacifiers to get their infants off the breast or to increase the interval between f eedings. The latter also had rigid breastfeeding styles that increased maternal-infant distance, had important concerns about objective aspe cts of infant growth and development, and were highly sensitive to inf ant crying. These behaviors were linked to intense comparison between themselves and other mothers and to a lack of self-confidence. Nonwhit e mothers, those who delivered vaginally, and mothers of infant girls seemed to be more confident and less affected by these difficulties. T he epidemiologic analysis confirmed that pacifier use was more closely associated with breastfeeding duration among nonwhite mothers and for normally delivered infants. Conclusions. Pacifiers may be an effectiv e weaning mechanism used by mothers who have explicit or implicit diff iculties in breastfeeding, but they are much less likely to affect inf ants whose mothers are confident about nursing. Breastfeeding promotio n campaigns aimed specifically at reducing pacifier use will fail unle ss they also help women face the challenges of nursing and address the ir anxieties. The combination of epidemiologic and ethnographic method s was essential for understanding the complex relations between pacifi er use and breastfeeding.