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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