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1.  Pacifier use in the first month of life 
Canadian Family Physician  2013;59(5):499-500.
Question As a family physician who frequently attends deliveries and follows up with neonates, parents often ask me if they can provide their newborns with pacifiers in order to calm infants down, reduce crying, and improve sleep. Is pacifier use safe in the first month of life?
Answer While pacifiers are useful for soothing, there is concern that their use might cause early weaning of breastfeeding owing to “nipple confusion.” Several organizations, such as the World Health Organization and the United Nations Children’s Fund, recommend avoiding use of pacifiers in term infants who breastfeed. However, evidence suggests that it might not be pacifier use that causes premature cessation of breastfeeding, and that use of pacifiers might only be a sign of a maternal decision to stop breastfeeding.
PMCID: PMC3653652  PMID: 23673585
2.  Analgesic effect of breast feeding in term neonates: randomised controlled trial 
BMJ : British Medical Journal  2003;326(7379):13.
To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier.
Randomised controlled trial.
180 term newborn infants undergoing venepuncture; 45 in each group.
During venepuncture infants were either breast fed (group 1), held in their mother's arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study.
Main outcome measures
Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aiguë Nouveau-né scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18).
Median pain scores (interquartile range) for breast feeding, held in mother's arms, placebo, and 30% glucose plus pacifier groups were 1 (0-3), 10 (8.5-10), 10 (7.5-10), and 3 (0-5) with the Douleur Aiguë Nouveau-né scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9-13), and 4 (1-6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aiguë Nouveau-né scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16).
Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates.
What is already known on this topicCurrent pharmacological treatments are not appropriate for pain relief during minor procedures like venepuncture or heel prick in newborn infantsOral sweet solutions, non-nutritive sucking, and skin to skin contact reduce procedural pain in newborn infantsWhat this study addsBreast feeding during a painful procedure effectively reduces the response to pain in newborn infantsThe analgesic properties of breast feeding are at least as potent as the combination of sweet solutions and a pacifier
PMCID: PMC139493  PMID: 12511452
3.  A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department 
BMC Pediatrics  2007;7:27.
Although sucrose has been accepted as an effective analgesic agent for procedural pain in neonates, previous studies are largely in the NICU population using the procedure of heel lance. This is the first report of the effect of sucrose, pacifier or the combination thereof for the procedural pain of venipuncture in infants in the pediatric emergency department population.
The study design was a double (sucrose) and single blind (pacifier), placebo-controlled randomized trial – factorial design carried out in a pediatric emergency department. The study population was infants, aged 0 – 6 months. Eighty-four patients were randomly assigned to one of four groups: a) sucrose b) sucrose & pacifier c) control d) control & pacifier. Each child received 2 ml of either 44% sucrose or sterile water, by mouth. The primary outcome measure: FLACC pain scale score change from baseline. Secondary outcome measures: crying time and heart rate change from baseline.
Sucrose did not significantly reduce the FLACC score, crying time or heart rate. However sub-group analysis revealed that sucrose had a much greater effect in the younger groups. Pacifier use reduced FLACC score (not statistically significant), crying times (statistically significant) but not heart rate. Subgroup analysis revealed a mean crying time difference of 76.52 seconds (p < 0.0171) (0–1 month) and 123.9 seconds (p < 0.0029) (1–3 month). For subgroup age > 3 months pacifier did not have any significant effect on crying time. Age adjusted regression analysis revealed that both sucrose and pacifier had significant effects on crying time. Crying time increased with both increasing age and increasing gestational age.
Pacifiers are inexpensive, effective analgesics and are easy to use in the PED for venipuncture in infants aged 0–3 months. The benefits of sucrose alone as an analgesic require further investigation in the older infant, but sucrose does appear to provide additional benefit when used with a pacifier in this age group.
Trial registration
Current Controlled Trials ISRCTN15819627
PMCID: PMC1950500  PMID: 17640375
4.  Maternal Assessment of Physician Qualification to Give Advice on AAP-Recommended Infant Sleep Practices Related to SIDS 
Academic pediatrics  2010;10(6):383-388.
The American Academy of Pediatrics (AAP) strongly recommends the supine-only sleep position for infants and issued 2 more sudden infant death syndrome (SIDS) reduction recommendations: avoid bed sharing and use pacifiers during sleep. In this study, we investigated the following: 1) if mothers from at risk populations rate physicians as qualified to give advice about sleep practices and 2) if these ratings were associated with reports of recommended practice.
A cross-sectional survey of mothers (N = 2355) of infants aged <8 months was conducted at Women, Infants, and Children (WIC) Program centers in 6 cities from 2006 to 2008. The predictor measures were maternal rating of physician qualification to give advice about 3 recommended sleep practices and reported nature of physician advice. The dependent measures were maternal report of usage of recommended behavior: 1) “infant usually placed supine for sleep,” 2) “infant usually does not share a bed with an adult during sleep,” and 3) “infant usually uses a pacifier during sleep.”
Physician qualification ratings varied by topic: sleep position (80%), bed sharing (69%), and pacifier use (60%). High ratings of physician qualification were associated with maternal reports of recommended behavior: supine sleep (adjusted odds ratio [AOR] 2.1, 95% confidence interval [CI], 1.6–2.6); usually no bed sharing (AOR 1.5, 95% CI, 1.2–1.9), and usually use a pacifier during sleep (AOR 1.2, 95% CI, 1.0–1.5).
High maternal ratings of physician qualification to give advice on 2 of the 3 recommended sleep practices targeted to reduce the risk of SIDS were significantly associated with maternal report of using these behaviors. Lower ratings of physician qualification to give advice about these sleep practices may undermine physician effectiveness in promoting the recommended behavior.
PMCID: PMC3209617  PMID: 21075318
Back to Sleep campaign; infant mortality disparities; sleep position; sudden infant death syndrome
5.  Factors Associated with Exclusive Breastfeeding of Preterm Infants. Results from a Prospective National Cohort Study 
PLoS ONE  2014;9(2):e89077.
Background and Aim
Evidence-based knowledge of how to guide the mothers of preterm infants in breastfeeding establishment is contradictive or sparse. The aim was to investigate the associations between pre-specified clinical practices for facilitating breastfeeding, and exclusive breastfeeding at discharge as well as adequate duration thereof.
A prospective survey based on questionnaires was conducted with a Danish national cohort, comprised of 1,221 mothers and their 1,488 preterm infants with a gestational age of 24–36 weeks. Adjusted for covariates, the pre-specified clinical practices were analysed by multiple logistic regression analyses.
At discharge 68% of the preterm infants were exclusively breastfed and 17% partially. Test-weighing the infant, and minimizing the use of a pacifier, showed a protective effect to exclusive breastfeeding at discharge (OR 0.6 (95% CI 0.4–0.8) and 0.4 (95% CI 0.3–0.6), respectively). The use of nipple shields (OR 2.3 (95% CI 1.6–3.2)) and the initiation of breast milk expression later than 48 hours postpartum (OR 4.9 (95% CI 1.9–12.6)) were associated with failure of exclusive breastfeeding at discharge. The clinical practices associated with an inadequate breastfeeding duration were the initiation of breast milk expression at 12–24 hours (OR 1.6 (95% CI 1.0–2.4)) and 24–48 hours (OR 1.8 (95% CI 1.0–3.1)) vs. before six hours postpartum, and the use of nipple shields (OR 1.4 (95% CI 1.1–1.9)).
Early initiation of breast milk pumping before 12 hours postpartum may increase breastfeeding rates, and it seems that the use of nipple shields should be restricted. The use of test-weighing and minimizing the use of a pacifier may promote the establishment of exclusive breastfeeding, but more research is needed regarding adequate support to the mother when test-weighing is ceased, as more of these mothers ceased exclusive breastfeeding at an early stage after discharge.
PMCID: PMC3929624  PMID: 24586513
6.  Breastfeeding and sucking habits in children enrolled in a mother-child health program 
BMC Research Notes  2014;7:362.
Early weaning can cause changes in posture and strength of the phonoarticulatory organs, favoring the installation of undesirable oral habits. The objective of the research was to evaluate the relationship between the practice of exclusive breastfeeding and its influence on the development of deleterious oral habits in children. This was a cross sectional observational study with 252 children of both sexes, between 30 and 48 months of age, attending a program of dental care for mothers and newborns. As an instrument of data collection was a questionnaire semistructured mothers of children with questions about the form and duration of breastfeeding and non-nutritive oral habits in children.
In this sample, 48.4% of the children were exclusively breastfed for six months; 20.2% exhibited sucking habits involving the use of a pacifier, which was more frequent among the girls. As factors associated with the decreasing of the occurrence of non-nutritive sucking habits, are a longer exclusive breastfeeding, predominant breastfeeding and breastfeeding. Children who were breastfed for six months until twelve months in an exclusive way decreased by 69.0% chances of coming to have non-nutritive sucking habits when compared with those who were breastfed up to one month.
The longer the duration of breastfeeding, that is, exclusive, predominant or breastfeeding, the lower are the chances of children develop non-nutritive sucking habits.
PMCID: PMC4067086  PMID: 24927634
Breastfeeding; Habits; Stomatognathic system; Maternal-child health services
7.  Pacifier Stiffness Alters the Dynamics of the Suck Central Pattern Generator 
Variation in pacifier stiffness on non-nutritive suck (NNS) dynamics was examined among infants born prematurely with a history of respiratory distress syndrome. Three types of silicone pacifiers used in the NICU were tested for stiffness, revealing the Super Soothie™ nipple is 7 times stiffer than the Wee™ or Soothie™ pacifiers even though shape and displaced volume are identical. Suck dynamics among 20 preterm infants were subsequently sampled using the Soothie™ and Super Soothie™ pacifiers during follow-up at approximately 3 months of age. ANOVA revealed significant differences in NNS cycles/min, NNS amplitude, NNS cycles/burst, and NNS cycle periods as a function of pacifier stiffness. Infants modify the spatiotemporal output of their suck central pattern generator when presented with pacifiers with significantly different mechanical properties. Infants show a non-preference to suck due to high stiffness in the selected pacifier. Therefore, excessive pacifier stiffness may decrease ororhythmic patterning and impact feeding outcomes.
PMCID: PMC2597857  PMID: 19492006
Preterm birth; Non-nutritive suck; Respiratory distress syndrome
8.  Using a pacifier to decrease sudden infant death syndrome: an emergency department educational intervention 
PeerJ  2014;2:e309.
Background. Pacifier use decreases the risk of sudden infant death syndrome (SIDS). An emergency department (ED) visit may provide an opportunistic ‘teachable moment’ for parents.
Objectives. To test the hypotheses (1) that caregivers were less familiar with the role of pacifiers in sudden infant death (SIDS) prevention than other recommendations, and (2) that an ED educational intervention would increase pacifier use in infants younger than six months, and (3) that otitis media would not occur more frequently in pacifier users.
Methods. We did an intervention-group-only longitudinal study in a county hospital ED. We measured pacifier use infants and baseline knowledge of SIDs prevention recommendations in caregivers. We followed up three months later to determine pacifier use, and 12 months later to determine episodes of otitis media.
Results. We analyzed data for 780 infants. Parents knew of advice against co-sleeping in 469/780 (60%), smoking in 660/776 (85%), and prone sleeping in 613/780 (79%). Only 268/777 (35%) knew the recommendation to offer a pacifier at bedtime. At enrollment 449/780 (58%) did not use a pacifier. Of 210/338 infants aged less than 6 months followed up 41/112 (37%) non-users had started using a pacifier at bedtime (NNT 3). Over the same period, 37/98 (38%) users had discontinued their pacifier. Otitis media did not differ between users and non-users at 12 months.
Conclusion. Caregiver knowledge of the role of pacifiers in SIDS prevention was less than for other recommendations. Our educational intervention appeared to increase pacifier use. Pacifier use was not associated with increased otitis media.
PMCID: PMC3961164  PMID: 24688883
Pacifier; Sudden infant death syndrome; Infant; Emergency department; Education in the emergency department
9.  Oral sucrose and a pacifier for pain relief during simple procedures in preterm infants: a randomized controlled trial 
Annals of Saudi Medicine  2009;29(3):184-188.
Previous randomized trials of the analgesic effects of sucrose, glucose, and a pacifier in term neonates have shown that the pacifier resulted in lower pain scores than glucose or sucrose, but the pacifier with and without sucrose did not differ. The current study was designed to assess the analgesic effect of pharmacologic (sucrose, water) and a non-pharmacologic measures (pacifier) in preterm infants and to find whether there is any synergism between these intervention in relieving pain during painful procedures.
In this double-blind, randomized, controlled study, 36 preterm infants (mean 31 weeks gestational age, range 27 to 36 weeks) were randomly allocated to six different regimens (0.5 mL sterile water with pacifier, 0.5 mL sterile water without pacifier, 0.5 mL sucrose 24% with pacifier, 0.5 mL sucrose 24% without pacifier, pacifier alone and control group) during a stay in intensive care of up to 15 days. Pain scores were measured with the Premature Infant Pain Profile (PIPP), a validated behavioral acute pain scale.
Of all the regimens, the lowest pain scores occurred with the use of 24% sucrose solution combined with pacifier. The mean pain score for the combination of sucrose with pacifier was 0.7 as compared to 1.4 for the sterile water with pacifier group (P<.05).
The synergistic effect of the combination of sucrose and non-nutritive sucking was clinically effective and safe in relieving the pain of simple procedures such as venipuncture or heel stick in preterm and term infants, but further research is needed on these interventions alone and in combination with other behavioral interventions in neonates.
PMCID: PMC2813645  PMID: 19448377
10.  Do pacifiers increase the risk of nosocomial diarrhoea? A cohort study 
BMJ Open  2012;2(2):e000427.
Prospective cohort study.
Teaching paediatric hospital—Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Northeast Brazil.
378 of 536 infants admitted in paediatric wards from April to October 2009 were daily assessed during hospital stay until the first episode of nosocomial diarrhoea (ND), death or discharge. Infants with community-acquired diarrhoea, respiratory or haemodynamic instability and who stayed in hospital for <24 h were excluded.
Primary and secondary outcome measures
Incidence and risk factors for ND and rates of pacifier faecal contamination.
33 ND episodes occurred in 378 infants, with a cumulative incidence of 8.7% and density of 11.25/1000 patients-day. ND occurred in 8.2% (16/194) of pacifier users compared with 9.2% (17/184) in non-users (adjusted OR=0.88, 95% CI 0.43 to 1.80). In multivariate logistic regression analysis, duration of oxygen use (OR=1.61; 95% CI 1.18 to 2.20) and days of antimicrobial use (OR=1.62, 95% CI 1.34 to 1.94) were associated with higher risk of ND, whereas being breast fed (OR=0.40, 95% CI 0.17 to 0.93) and each day of hospital stay (OR=0.65, 95% CI 0.53 to 0.80) were protective factors. Faecal coliforms were isolated in 16% (27/169) of tested pacifiers, 77.8% of which had more than 100 000 CFU/ml. The probability of a child remaining free of an episode of diarrhoea up to the seventh day of hospitalisation in the ward was 91.2% (95% CI 87.7% to 94.9%). The log-rank test showed no statistical difference between pacifier users and non-users.
ND is a frequent healthcare-associated infection in paediatric wards, but the use of pacifiers during the stay in hospital does not seem to affect the incidence of ND in infants in many settings where the burden of diarrhoea is still high.
Article summary
Article focus
Healthcare-associated infections in paediatric hospital.
ND incidence.
Influence of pacifier use and ND in hospitalised children.
Key messages
Pacifier use is common in paediatric wards and ND is a frequent healthcare-associated infection in hospitalised infants.
The use of pacifiers during hospital stay does not seem to affect the incidence of ND in infants in a high diarrhoea burden setting. Breast feeding reduces the incidence of ND in infants in a high diarrhoea burden setting.
Strengths and limitations of this study
The study did not assess microbial aetiology of ND and, due to limited isolation facilities, infants admitted with community-acquired diarrhoea were not routinely segregated in this study setting.
To our knowledge, this is the first report of a hospital-based prospective cohort designed to investigate the association of pacifier use and the risk of ND in infants.
PMCID: PMC3332242  PMID: 22508955
11.  Breastfeeding Twins: A Qualitative Study 
The purpose of this qualitative research was to explore the needs and difficulties of mothers who had multiple babies at Sakarya County by focusing on their breastfeeding experience. Ten mothers who gave birth to multiple infants participated in the study voluntarily. The framework method of data analysis was applied systematically both within and across cases, with categories and themes identified by reading transcripts of interviews. Major themes generated from focus narrative interviews are described. These themes are: willingness of mothers to breastfeed and continue, management of breastfeeding, use of pacifier, daily life, ınstructions of healthcare personnel, and advices from practice of experienced mothers. This study showed that women were aware of the importance of mother's milk for their babies. They all, somehow, made intensive efforts to breastfeed their twins. Women who expect and/or have multiple babies need much more support and guidance, which may include advice for nutritional and daily care.
PMCID: PMC3905645  PMID: 24592592
Breastfeeding; Mothers’ experiences; Multiple babies; Qualitative study; Turkeyitative Study
12.  Attitudes of Saudi mothers towards prolonged non-nutritive sucking habits in children 
The Saudi Dental Journal  2010;22(2):77-82.
The purpose of the present study was to evaluate Saudi mothers’ attitude towards non-nutritive sucking habits by their children and report the methods they used to stop these habits.
Across-sectional study involved 181 mothers of preschool children currently engaged in non-nutritive sucking habits (digit and pacifier) were studied. The information was obtained from a self-administered questionnaire completed by the mothers.
The majority of mothers (69.1%) were from high socio-economic families, (77%) had university or higher education and more than half of them (58.6%) were employed. About 75% of the children were pacifier users, and 25% of them habitually sucked their digits. Nearly half of the mothers (43.5%) thought that the reason of acquiring the habit was because their children cried a lot at night. The majority of studied mothers (88.7%) considered sucking a harmful habit to their children’ teeth, and 69.1% never accepted the sucking habit. High percentage (80.8%) of mothers tried to intervene with these habits and 61.0% of them tried their intervention when children were one year old or less. Most proposed reasons for mothers’ intervention with sucking habits were their concerns that the habit might continue until the child become older (53.3%) followed by their concern that the habit might affect their children’s permanent teeth (45.3%). The methods used by mothers were mostly non-invasive procedures which included restricting the use of pacifier to specific times in the day (63.0%), followed by reinforcement of positive behaviors and using rewards (26.0%). None of the mothers sought advice from pediatrician while only one mother (0.6%) consulted a dentist about sucking habits.
This study shows that Saudi mothers are concerned about sucking habits and recognized the harmful effect on their children. These mothers, however, are in great need for education about ways of preventing the habits in the first place as well as professional advice and help in treatment cessation of already established habits.
PMCID: PMC3723077  PMID: 23960479
Attitudes; Non-nutritive sucking habits
13.  Pacifier use and sudden infant death syndrome: results from the CESDI/SUDI case control study 
Archives of Disease in Childhood  1999;81(2):112-116.
OBJECTIVES—To investigate the relation between pacifier use and sudden infant death syndrome (SIDS).
DESIGN—Three year population based, case control study with parental interviews for each death and four age matched controls.
SETTING—Five regions in England (population > 17 million).
SUBJECTS—325 infants who had died from SIDS and 1300 control infants.
RESULTS—Significantly fewer SIDS infants (40%) than controls (51%) used a pacifier for the last/reference sleep (univariate odds ratio (OR), 0.62; 95% confidence interval (CI), 0.46 to 0.83) and the difference increased when controlled for other factors (multivariate OR, 0.41; 95% CI, 0.22 to 0.77). However, the proportion of infants who had ever used a pacifier for day (66% SIDS v 66% controls) or night sleeps (61% SIDS v 61% controls) was identical. The association of a risk for SIDS infants who routinely used a pacifier but did not do so for the last sleep became non-significant when controlled for socioeconomic status (bivariate OR, 1.39 (0.93 to 2.07)).
CONCLUSIONS—Further epidemiological evidence and physiological studies are needed before pacifier use can be recommended as a measure to reduce the risk of SIDS.

PMCID: PMC1718026  PMID: 10490514
14.  Short-Term Effects of Pacifier Texture on NNS in Neurotypical Infants 
The dense representation of trigeminal mechanosensitive afferents in the lip vermilion, anterior tongue, intraoral mucosa, and temporomandibular joint allows the infant's orofacial system to encode a wide range of somatosensory experiences during the critical period associated with feed development. Our understanding of how this complex sensorium processes texture is very limited in adults, and the putative role of texture encoding in the infant is unknown. The purpose of this study was to examine the short-term effects of a novel textured pacifier experience in healthy term infants (N = 28). Nonnutritive suck (NNS) compression pressure waveforms were digitized in real time using a variety of custom-molded textured pacifiers varying in spatial array density of touch domes. MANCOVA, adjusted for postmenstrual age at test and sex, revealed that infants exhibited an increase in NNS burst attempts at the expense of a degraded suck burst structure with the textured pacifiers, suggesting that the suck central pattern generator (sCPG) is significantly disrupted and reorganized by this novel orocutaneous experience. The current findings provide new insight into oromotor control as a function of the oral somatosensory environment in neurotypically developing infants.
PMCID: PMC3657447  PMID: 23737804
15.  Language experienced in utero affects vowel perception after birth: a two-country study 
To test the hypothesis that exposure to ambient language in the womb alters phonetic perception shortly after birth. This two-country study aimed to see if neonates demonstrated prenatal learning by how they responded to vowels in a category from their native language and another nonnative language, regardless of how much postnatal experience the infants had.
A counterbalanced experiment was conducted in Sweden (n=40) and the USA (n=40) using Swedish and English vowel sounds. The neonates (mean postnatal age = 33 hrs) controlled audio presentation of either native or nonnative vowels by sucking on a pacifier, with the number of times they sucked their pacifier being used to demonstrate what vowel sounds attracted their attention. The vowels were either the English /i/ or Swedish /y/ in the form of a prototype plus 16 variants of the prototype.
The infants in the native and nonnative groups responded differently. As predicted, the infants responded to the unfamiliar nonnative language with higher mean sucks. They also sucked more to the nonnative prototype. Time since birth (range: 7–75 hours) did not affect the outcome.
The ambient language to which foetuses are exposed in the womb starts to affect their perception of their native language at a phonetic level. This can be measured shortly after birth by differences in responding to familiar vs. unfamiliar vowels.
PMCID: PMC3543479  PMID: 23173548
fetal; language; learning; neonatal; vowels
16.  The relationship of bottle feeding and other sucking behaviors with speech disorder in Patagonian preschoolers 
BMC Pediatrics  2009;9:66.
Previous studies have shown that children's nonnutritive sucking habits may lead to delayed development of their oral anatomy and functioning. However, these findings were inconsistent. We investigated associations between use of bottles, pacifiers, and other sucking behaviors with speech disorders in children attending three preschools in Punta Arenas (Patagonia), Chile.
Information on infant feeding and sucking behaviors, age starting and stopping breast- and bottle-feeding, pacifier use, and other sucking behaviors, was collected from self-administered questionnaires completed by parents. Evaluation of speech problems was conducted at preschools with subsequent scoring by a licensed speech pathologist using age-normative standards.
A total of 128 three- to five-year olds were assessed, 46% girls and 54% boys. Children were breastfed for an average of 25.2 (SD 9.6) months and used a bottle 24.4 (SD 15.2) months. Fifty-three children (41.7%) had or currently used a pacifier for an average of 11.4 (SD 17.3) months; 23 children (18.3%) were reported to have sucked their fingers. Delayed use of a bottle until after 9 months appeared to be protective for subsequent speech disorders. There was less than a one-third lower relative odds of subsequent speech disorders for children with a delayed use of a bottle compared to children without a delayed use of a bottle (OR: 0.32, 95% CI: 0.10-0.98). A three-fold increase in relative odds of speech disorder was found for finger-sucking behavior (OR: 2.99, 95% CI: 1.10-8.00) and for use of a pacifier for 3 or more years (OR: 3.42, 95% CI: 1.08-10.81).
The results suggest extended use of sucking outside of breastfeeding may have detrimental effects on speech development in young children.
PMCID: PMC2773774  PMID: 19845936
17.  Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population based case-control study 
BMJ : British Medical Journal  2006;332(7532):18-22.
Objectives To examine the association between use of a dummy (pacifier) during sleep and the risk of sudden infant death syndrome (SIDS) in relation to other risk factors.
Design Population based case-control study.
Setting Eleven counties in California.
Participants Mothers or carers of 185 infants whose deaths were attributed to SIDS and 312 randomly selected controls matched for race or ethnicity and age.
Main outcome measure Use of a dummy during sleep determined through interviews.
Results The adjusted odds ratio for SIDS associated with using a dummy during the last sleep was 0.08 (95% confidence interval 0.03 to 0.21). Use was associated with a reduction in risk in every category of sociodemographic characteristics and risk factors examined. The reduced risk associated with use seemed to be greater with adverse sleep conditions (such as sleeping prone or on side and sleeping with a mother who smoked), although the observed interactions were not significant. In addition, use of a dummy may reduce the impact of other risk factors for SIDS, especially those related to adverse sleep environment. For example, infants who did not use a dummy and slept prone or on their sides (v on their back) had an increased risk of SIDS (2.61, 1.56 to 4.38). In infants who used dummies, there was no increased risk associated with sleeping position (0.66, 0.12 to 3.59). While cosleeping with a mother who smoked was also associated with increased risk of SIDS among infants who did not use a dummy (4.5, 1.3 to 15.1), there was no such association among those who did (1.1, 0.1 to 13.4).
Conclusions Use of a dummy seems to reduce the risk of SIDS and possibly reduces the influence of known risk factors in the sleep environment.
PMCID: PMC1325127  PMID: 16339767
18.  Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates 
BMJ : British Medical Journal  1999;319(7222):1393-1397.
To assess and compare the analgesic effects of orally administered glucose and sucrose and pacifiers. To determine the synergistic analgesic effect of sucrose and pacifiers.
Randomised prospective study with validated behavioural acute pain rating scale.
Maternity ward.
150 term newborns undergoing venepuncture randomly assigned to one of six treatment groups: no treatment; placebo (2 ml sterile water); 2 ml 30% glucose; 2 ml 30% sucrose; a pacifier; and 2 ml 30% sucrose followed by a pacifier.
Median (interquartile) pain scores during venepuncture were 7 (5-10) for no treatment; 7 (6-10) for placebo (sterile water); 5 (3-7) for 30% glucose; 5 (2-8) for 30% sucrose; 2 (1-4) for pacifier; and 1 (1-2) for 30% sucrose plus pacifier. Mann-Whitney U test P values for comparisons of 30% glucose, 30% sucrose, pacifier, and 30% sucrose plus pacifier versus placebo (sterile water) were 0.005, 0.01, <0.0001, and <0.0001, respectively. Differences between group median pain scores for these comparisons were 2 (95% confidence interval 1 to 4), 2 (0 to 4), 5 (4 to 7), and 6 (5 to 8), respectively. P values for comparisons of 30% glucose, 30% sucrose, and 30% sucrose plus pacifier versus pacifier were 0.0001, 0.001, and 0.06, respectively. Differences between group medians for these comparisons were 3 (2 to 5), 3 (1 to 5), and 1 (0 to 2), respectively.
The analgesic effects of concentrated sucrose and glucose and pacifiers are clinically apparent in newborns, pacifiers being more effective than sweet solutions. The association of sucrose and pacifier showed a trend towards lower scores compared with pacifiers alone. These simple and safe interventions should be widely used for minor procedures in neonates.
Key messagesThe analgesic effects on newborn infants of sucrose, glucose, and pacifiers can be clearly detected by a behavioural pain rating scalePacifiers had a better analgesic effect than sweet solutionsA synergistic effect was found with a combination of sucrose and pacifiersSweet solutions and pacifiers constitute simple and safe interventions that can be used to provide analgesia in newborns during minor procedures
PMCID: PMC28282  PMID: 10574854
19.  The Effects of Vestibular Stimulation Rate and Magnitude of Acceleration on Central Pattern Generation for Chest Wall Kinematics in Preterm Infants 
To examine the role of vestibular inputs on respiratory and oromotor systems in healthy preterm infants.
Study Design
27 preterm infants were quasi-randomly assigned to either the VestibuGlide treatment or control groups. VestibuGlide infants were held in a developmentally supportive position, given a pacifier and received a series of vestibular stimuli, counterbalanced across rate and acceleration conditions, 15 minutes 3x/day for 10 days. The control infants were also held in a developmentally supportive position, given a pacifier for 15 minutes 3x/day for 10 days but did not receive the VestibuGlide stimulation.
A multi-level regression model revealed that treatment infants increased their respiratory rate in response to vestibular stimulus and that the highest level of vestibular acceleration delivered to the infants (0.51 m/s2) resulted in a significant increase in breaths per minute.
Vestibular stimulation delivered to preterm infants prior to scheduled feeds effectively modulates respiratory rate and resets the respiratory central pattern generator.
PMCID: PMC3725755  PMID: 22157627
respiration; non-nutritive suck
20.  Sucrose and non‐nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial 
Screening is necessary for infants at risk of retinopathy of prematurity. Despite local anaesthetic drops, infants find eye examinations distressing, displaying behavioural and physiological changes indicating acute pain. Oral sucrose and non‐nutritive sucking reduce pain responses associated with invasive procedures.
To evaluate the use of oral sucrose and/or pacifier for reducing pain responses during eye examinations.
Forty infants <32 weeks gestation or <1500 g birth weight, in two neonatal units, were randomised to one of four interventions administered two minutes before their first screening examination: 1 ml sterile water as placebo (group 1, n  =  10), 1 ml 33% sucrose solution (group 2, n  =  10), 1 ml sterile water with pacifier (group 3, n  =  9), or 1 ml 33% sucrose solution with pacifier (group 4, n  =  11). Examinations were videotaped. Two observers, blind to the intervention, assessed recordings. Pain responses were scored using the premature infant pain profile (PIPP).
The groups were similar in gestation, birth weight, and age at examination. Mean PIPP scores were 15.3, 14.3, 12.3, and 12.1 for groups 1, 2, 3, and 4 respectively. Analysis of variance showed a significant difference in PIPP score between groups (p  =  0.023). Infants randomised to pacifiers scored lower than those without pacifiers (p  =  0.003). There was no difference between groups receiving sucrose and those receiving water (p  =  0.321).
Non‐nutritive sucking reduced distress responses in infants undergoing screening for retinopathy of prematurity. The difference in response was large enough to be detected by a validated assessment tool. No synergistic effect of sucrose and pacifier was apparent in this group.
PMCID: PMC2672697  PMID: 16428355
premature; retinopathy of prematurity; pain; sucrose
The Journal of pediatrics  2012;161(6):1080-1084.e1.
To determine the accuracy of information on infant sleep safety on the internet using Google. We hypothesized that the majority of websites would accurately reflect the AAP recommendations for infant sleep safety.
Study design
We searched for advice using 13 key phrases and analyzed the first 100 websites for each. Websites were categorized by type and assessed for accuracy of information provided, based on AAP recommendations. The accuracy of information was classified as “accurate,” “inaccurate,” or “not relevant.”
Overall, 43.5% of the 1300 websites provided accurate information, 28.1% provided inaccurate information, and 28.4% were not relevant. The search terms “infant cigarette smoking,” “infant sleep position,” and “infant sleep surface” resulted in the highest percentage of websites with accurate information. “Pacifier infant,” “infant home monitors,” and “infant co-sleeping” resulted in the lowest percentage of websites with accurate information. Government websites had the highest rate of accuracy, and blogs had the lowest rate of accurate information.
The internet frequently contains information about infant sleep safety that is inconsistent with AAP recommendations. Health care providers should realize the extent to which parents may turn to the internet for information about infant sleep safety.
PMCID: PMC3504635  PMID: 22863258
accuracy; sleep position; bedsharing; parental decision; decision-making; SIDS
22.  Preterm Infants Show Reduced Stress Behaviors and Activity after 5 days of Massage Therapy 
Infant behavior & development  2007;30(4):557-561.
Preterm infants residing in an NICU were randomly assigned to a massage therapy or to a control group. The preterm infants in the massage therapy group received three 15 minute massages each day for 5 consecutive days, with the massages consisting of moderate pressure stroking to the head, shoulders, back, arms and legs and kinesthetic exercises consisting of flexion and extension of the limbs. Infant stress behaviors and activity were recorded on the first and last day of the study. Preterm infants receiving massage therapy showed fewer stress behaviors and less activity from the first to the last day of the study. The findings suggest that massage has pacifying or stress reducing effects on preterm infants, which is noteworthy given that they experience numerous stressors during their hospitalization.
PMCID: PMC2254497  PMID: 17548111
Preterm infants; massage; activity; stress behaviors
23.  Prevalence of Oral Habits in Children with Cleft Lip and Palate 
Plastic Surgery International  2013;2013:247908.
This study investigated the prevalence of oral habits in children with clefts aged three to six years, compared to a control group of children without clefts in the same age range, and compared the oral habits between children with clefts with and without palatal fistulae. The sample was composed of 110 children aged 3 to 6 years with complete unilateral cleft lip and palate and 110 children without alterations. The prevalence of oral habits and the correlation between habits and presence of fistulae (for children with clefts) were analyzed by questionnaires applied to the children caretakers. The cleft influenced the prevalence of oral habits, with lower prevalence of pacifier sucking for children with cleft lip and palate and higher prevalence for all other habits, with significant association (P < 0.05). There was no significant association between oral habits and presence of fistulae (P > 0.05). The lower prevalence of pacifier sucking and higher prevalence of other oral habits agreed with the postoperative counseling to remove the pacifier sucking habit when the child is submitted to palatoplasty, possibly representing a substitution of habits. There was no causal relationship between habits and presence of palatal fistulae.
PMCID: PMC3600175  PMID: 23533744
24.  Feasibility of aerosol drug delivery to sleeping infants: a prospective observational study 
BMJ Open  2014;4(3):e004124.
Delivery of inhaled medications to infants is usually very demanding and is often associated with crying and mask rejection. It has been suggested that aerosol administration during sleep may be an attractive alternative. Previous studies in sleeping children were disappointing as most of the children awoke and rejected the treatment. The SootherMask (SM) is a new, gentle and innovative approach for delivering inhaled medication to infants and toddlers. The present pilot study describes the feasibility of administering inhaled medications during sleep using the SM.
Prospective observational study.
Out patients.
13 sleeping infants with recurrent wheezing who regularly used pacifiers and were <12 months old.
Participants inhaled technetium99mDTPA-labelled normal saline aerosol delivered via a Respimat Soft Mist Inhaler (SMI) (Boehringer-Ingelheim, Germany) and SM + InspiraChamber (IC; InspiRx Inc, New Jersey, USA).
The two major outcomes were the acceptability of the treatment and the lung deposition (per cent of emitted dose).
All infants who fulfilled the inclusion criteria successfully received the SM treatment during sleep without difficulty. Mean lung deposition (±SD) averaged 1.6±0.5% in the right lung.
This study demonstrated that the combination of Respimat, IC and SM was able to administer aerosol therapy to all the sleeping infants who were regular pacifier users with good lung deposition. Administration of aerosols during sleep is advantageous since all the sleeping children accepted the mask and ensuing aerosol therapy under these conditions, in contrast to previous studies in which there was frequent mask rejection using currently available devices.
Clinical Trial Registry
PMCID: PMC3975762  PMID: 24670428
25.  Perceptions of Placebo Therapy Among Health Practitioners in Jazan Region of Saudi Arabia. 
Placebo therapy has always been a subject of controversy in the field of medicine. Some choose to admit it as “fake, irresponsible medicine” while others advocate its effectiveness in various clinical settings. With the advent of the recent concept of mind-body medicine, placebo has entered from fringe to mainstream therapeutics. Some clinicians use it for its actual positive outcomes while others use it merely to buy time until definitive diagnosis or even as a pacifier for patients.
The present study was carried out to observe the perceptions about placebo therapy among health practitioners in Jazan region of Saudi Arabia
Data was analyzed through statistical analysis of retrospective questionnaires addressing various issues on placebo therapy, including types of placebo used in various clinical settings, mechanism of placebo action, ethics of use and openness with patients etc.
The study elucidated that the perceptions regarding placebo therapy are subjective and variable within and between institutions ranging from firm belief in its positive effects and efficacy; to neutral attitudes among some, to strong opposition for it among still others.
More research is needed to ethically define the boundary between explicit fraudulence and marginalized evidence based therapeutic deception to effectively achieve the goal of positive health outcomes in patients.
PMCID: PMC3312768  PMID: 22489229
Placebo therapy; Saudi Arabia

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