Victora C G, Behague D P, Barros F C, Olinto M T, Weiderpass E
Departamento de Medicina Social, Universidade Federal de Pelotas, Brazil.
Pediatrics. 1997 Mar;99(3):445-53. doi: 10.1542/peds.99.3.445.
Pacifiers are related to a shorter duration of breastfeeding. However, it is unclear whether this association is causal, because confounding, reverse causality, and self-selection of mothers may play a role. These issues were investigated through a combination of epidemiologic and ethnographic research in southern Brazil.
A population-based cohort of 650 mothers and infants were visited shortly after delivery and at 1, 3, and 6 months. The rate of complete follow-up was 96.8%. A subsample of 80 mothers and infants was selected for the ethnographic study, which included in-depth interviews and participant observations in the age range of 2 to 6 months with a mean of 4.5 visits.
The epidemiologic study showed that pacifier use was common with 85% of users at 1 month. However, this was a dynamic process, with many infants starting or abandoning the pacifiers in any age range. Children who stopped breastfeeding in a given period were likely to take up the pacifier during that period. Further analyses excluded all infants not breastfed at 1 month of age and those who reportedly had breastfeeding problems, leaving 450 infants with full data. Intense pacifier users at 1 month (children who used the pacifiers during most of the day and at least until falling asleep) were four times more likely to stop breastfeeding by 6 months of age than nonusers. Users also had fewer daily breastfeedings than nonusers. After adjustment for several confounding variables, logistic regression showed that pacifier use was still associated with an odds ratio of 2.5 (95% confidence interval, 1.40 to 4.01) for stopping breastfeeding. The ethnographic analysis showed that pacifier use was widely regarded as a positive behavior and that mothers often strongly stimulated the infants to accept it. Although few mothers openly admitted that pacifiers might shorten breastfeeding, a considerable group effectively used pacifiers to get their infants off the breast or to increase the interval between feedings. The latter also had rigid breastfeeding styles that increased maternal-infant distance, had important concerns about objective aspects of infant growth and development, and were highly sensitive to infant crying. These behaviors were linked to intense comparison between themselves and other mothers and to a lack of self-confidence. Nonwhite mothers, those who delivered vaginally, and mothers of infant girls seemed to be more confident and less affected by these difficulties. The epidemiologic analysis confirmed that pacifier use was more closely associated with breastfeeding duration among nonwhite mothers and for normally delivered infants.
Pacifiers may be an effective weaning mechanism used by mothers who have explicit or implicit difficulties in breastfeeding, but they are much less likely to affect infants whose mothers are confident about nursing. Breastfeeding promotion campaigns aimed specifically at reducing pacifier use will fail unless they also help women face the challenges of nursing and address their anxieties. The combination of epidemiologic and ethnographic methods was essential for understanding the complex relations between pacifier use and breastfeeding.
安抚奶嘴与母乳喂养时间较短有关。然而，这种关联是否具有因果关系尚不清楚，因为混杂因素、反向因果关系以及母亲的自我选择可能起了作用。通过在巴西南部进行的流行病学和人种学研究相结合的方式对这些问题进行了调查。
以人群为基础的650对母婴队列在产后不久以及1、3和6个月时接受了访视。完全随访率为96.8%。选取了80对母婴的子样本进行人种学研究，其中包括在2至6个月龄期间进行的深入访谈和参与观察，平均访视4.5次。
流行病学研究表明，安抚奶嘴的使用很普遍，1个月时85%的婴儿使用。然而，这是一个动态过程，许多婴儿在任何年龄段都开始或停止使用安抚奶嘴。在特定时期停止母乳喂养的儿童在该时期可能会开始使用安抚奶嘴。进一步分析排除了所有1个月龄时未进行母乳喂养的婴儿以及那些据报道有母乳喂养问题的婴儿，剩下450名有完整数据的婴儿。1个月时频繁使用安抚奶嘴的婴儿（一天中大部分时间使用安抚奶嘴且至少直到入睡的儿童）在6个月龄时停止母乳喂养的可能性是非使用者的四倍。使用者每天的母乳喂养次数也比非使用者少。在对几个混杂变量进行调整后，逻辑回归显示，使用安抚奶嘴与停止母乳喂养的比值比仍为2.5（95%置信区间，1.40至4.01）。人种学分析表明，使用安抚奶嘴被广泛视为一种积极行为，母亲们经常强烈刺激婴儿接受它。尽管很少有母亲公开承认安抚奶嘴可能会缩短母乳喂养时间，但有相当一部分母亲有效地使用安抚奶嘴让婴儿停止母乳喂养或增加喂奶间隔。后者的母乳喂养方式也很刻板，增加了母婴之间的距离，对婴儿生长发育的客观方面有重要担忧，并且对婴儿哭闹高度敏感。这些行为与她们自身与其他母亲之间的激烈比较以及缺乏自信有关。非白人母亲、经阴道分娩的母亲以及女婴的母亲似乎更自信，受这些困难的影响较小。流行病学分析证实，在非白人母亲和顺产婴儿中，使用安抚奶嘴与母乳喂养持续时间的关联更为密切。
安抚奶嘴可能是那些在母乳喂养方面有明显或潜在困难的母亲使用的一种有效的断奶机制，但对那些对哺乳有信心的母亲所生的婴儿影响要小得多。除非专门旨在减少安抚奶嘴使用的母乳喂养促进活动也能帮助女性面对哺乳挑战并解决她们的焦虑，否则这些活动将会失败。流行病学和人种学方法的结合对于理解使用安抚奶嘴与母乳喂养之间的复杂关系至关重要。
