I have been looking at some of the references used by the AAP in making  
their blanket pacifier use recommendation. Part of the problem is that these  
articles do not differentiate between whether it is the absence of the  pacifier 
(ie, babies who never use them) or whether it is being dependent  on a pacifier 
but then being denied it that puts the baby at risk. Not  having slept with 
the pacifier in the reference sleep is the criteria being used  to tell 4 
million parents in the US to use pacifiers. Babies who usually  used a pacifier and 
did not have it during the reference sleep were almost 6  times more at risk 
than regular users who did have it (McGarvey et al, Arch Dis  Child 2003; 
88:1058-1064. Arousal thresholds from sleep are different between  breastfed and 
bottle-fed babies. Breastfed babies are more easily aroused from  active sleep 
at 2-3 months of age than formula fed babies. This age coincides  with the 
peak incidence of SIDS. One theory about SIDS is that it arises from a  deficit 
in arousal responses to a life threatening situation. Using a pacifier  
increases arousability, something which is already present in a breastfed  infant. 
Infants dying of SIDS typically have less mature autonomic function  and delayed 
neuronal maturation that affects the arousal pathway in the  brain. 
Breastfeeding a baby during the critical risk period for SIDS (2-4  months) "covers" 
the period of time when reduced arousal capability impairs the  infant's ability 
to respond to life threatening situations. The studies do not  tell us if 
parents were using any of the sleep training programs (Ezzo, Ferber,  Baby 
Whisperer, etc) that deliberately train babies to sleep soundly through the  night, 
especially during the peak time of night when SIDS occurs.
 
The question becomes, should we artificially create a need for the use of a  
pacifier, i.e. hook babies on it so they are dependent on it to breathe while  
sleeping? Would this actually increase the risk for SIDS in more babies if 
AAP's  recommendations are followed? These studies are all retrospective. There 
is not  one piece of prospective evidence, randomizing babies into pacifier 
and  no-pacifier groups. Mostly what is shown is that pacifier-dependent babies 
are  at higher risk for SIDS when they are not put to sleep with their 
breathing  aid.
 
Also, Linda Smith has provided the information showing some of the  
partnerships between the authors of the AAP guidelines and SIDS organizations  that 
receive funding from pacifier and formula makers.
 
 
Fleming PJ, Blair PS, Pollard K, et al. Pacifier use and sudden infant  death 
syndrome: results from the CESDI/SUDI case control study. Arch Dis Child  
1999; 81:112-116
 
Horne RSC, Parslow PM, Ferens D, et al. Comparison of evoked arousability  in 
breast and formula fed infants. Arch Dis Child 2004; 89:22-25
 
L'Hoir MP, Engelberts AC, van Well GTJ, et al. Dummy use, thumb sucking,  
mouth breathing and cot death. Eur J Pediatr 1999; 158:896-901
 
Vennemann MMT, Findeisen M, Butterfab-Bahloul T, et al. Modifiable risk  
factors for SIDS in Germany: results of GeSID. Acta Paediatr 2005;  94:655-660
 
Marsha Walker, RN, IBCLC
Weston, MA



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