Pacifiers and SIDS?

I want to know what you think. And we have some fresh evidence to consider. In October 2005, the American Academy of Pediatrics (AAP) updated its position on preventing SIDS, boldly including the use of pacifiers in an attempt to save many more lives. But first, I’ll tell you about a Kaiser Permanente study that appeared online in the British Medical Journal on December 9, 2005, then let’s consider the AAP recommendations, and then I’d like to hear what you think.

The new evidence comes from interviews of parents in California whose children had died from SIDS and from carefully matched random parents with the same characteristics. All were asked exclusively about their baby’s last sleep. The statistical analysis was meticulous. The authors found that babies who had sucked their thumb had a 57 percent decreased chance of SIDS (not reported in any news stories I’ve seen, by the way). But those who used a pacifier had a 92 percent decreased chance of SIDS. Only 4 percent of the babies who died of SIDS had been using a pacifier, while 24 percent of babies in matched homes who had slept safely had been using a pacifier. The pacifier was associated with decreased SIDS rates in every group: those who used soft bedding and those who did not; those who slept with smoking parents and those who did not; those who were breastfeeding and those who were not; those who had been sick recently and those who had not; those who sucked their thumbs and those who did not; and in every cultural, age, education, and income group. The association was dramatic in all groups, and all the more so in the higher risk groups.

Clearly, there is a link between pacifier use and decreased SIDS – but an important question remains – which causes which? Perhaps the effect is only that babies who are fussier are more vigorous and more likely to have used a pacifier. This might address why pacifier use was so much lower than the neighborhood average in SIDS homes – these babies were calmer. Or perhaps the pacifiers are actually preventing SIDS. Pacifiers often have a bulky handles, which might create a tenting effect, preventing the baby’s nose from being blocked by soft bedding or by covers. Or maybe the sucking action encourages growth of important neural pathways or changes the threshold of what wakes a baby up. We just don’t know.

Currently, there is no strong evidence that pacifiers prevent SIDS, or if they do – how they work. But that there is a connection between the two has now been soundly proven, and it may be that pacifiers are one of the most important preventive health measures ever devised. Or not.

Similarly, there is now considerable evidence that pacifier use is associated with decreased breastfeeding. But again, which causes which? Perhaps pacifiers discourage breastfeeding. Perhaps babies who are weaning are fussier and more likely to be given a pacifier. Neither has been proven.

In the new official guidelines, the AAP has taken bets on both issues. They recommend pacifier use to prevent SIDS (even though it is just a proven association, not a cause), because it is a life-and death issue. Meanwhile, they dismiss breastfeeding concerns because the pacifier link is just a proven association, not a proven cause.

The 2005 official recommendation (italics and bold are mine):

“Consider offering a pacifier at nap time and bedtime: Although the mechanism is not known, the reduced risk of SIDS associated with pacifier use during sleep is compelling, and the evidence that pacifier use inhibits breastfeeding or causes later dental complications is not. Until evidence dictates otherwise, the task force recommends use of a pacifier throughout the first year of life according to the following procedures:

• The pacifier should be used when placing the infant down for sleep and not reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it.
• Pacifiers should not be coated in any sweet solution.
• Pacifiers should be cleaned often and replaced regularly.
• For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.”

With respect to the above AAP recommendations, it’s important to point out that SIDS is very rare before 1 month old. The peak age is between 2 and 4 months, and drops off rapidly after 6 months.

Now, I’ll put the question to you. So what do you think? And more importantly, what would you do?