Nutritive and non-nutritive sucking patterns associated with pacifier use and bottle-feeding in full-term infants
Introduction
Breastfeeding (BF) is considered the gold standard for infant feeding. In addition to its nutritional and immunological roles, BF is involved in the growth and development of the infant's orofacial structures [1]. BF increases infant survival, improves childhood health and development, saves maternal lives, and contributes to human capital. No other human behavior can generate as much benefit for the mother-child dyad as BF [2,3].
For BF to occur in an ideal manner, the infant must have extensive oral capacities for sucking functions. An infant demonstrates these capacities through two distinct patterns: non-nutritive sucking (NNS), which occurs in the absence of food supply, when the infant sucks a finger or a pacifier, and nutritive sucking (NS), which occurs when the infant uses a baby bottle or during BF. Both NS and NNS patterns are fundamental for ensuring infant stability, nutrition, and survival [4].
The use of artificial nipples may alter the patterns considered necessary for BF, generating nipple confusion, a hypothesis that states that baby bottles and pacifiers can affect the oral capacities of infants in NS and NNS, reducing the exclusive BF (EBF) time or even the presence of any BF [5,6]. The use of artificial nipples has been implicated as one of the causes of early weaning [7].
Neifert, Lawrence, and Seacat [8] introduced the term nipple confusion; since then, controversies over the topic remain [8]. The classic concept defines nipple confusion as an infant's difficulty in establishing the correct oral configuration for latching after exposure to an artificial nipple. However, the literature does not indicate which infant sucking configuration patterns are responsible for BF failure or which specific nipple can cause changes in sucking that disrupt normal latching [9].
Currently, there is uncertainty regarding the impact of artificial nipples on EBF and its duration. Literature reviews involving randomized clinical trials (RCTs) point to a lack of association between pacifier use and early cessation of BF [10,11]. One review that included RCTs and other observational studies showed that pacifiers disrupt the natural BF process, thus affecting the sucking aspects required for the optimal establishment of BF [12]. Early introduction of fluids via bottle feeding before six months of age also has negative effects on the duration of BF [13].
In the “Ten Steps to Successful Breastfeeding” recommended by the World Health Organization and the United Nations Children's Fund (UNICEF), step 9 states that artificial nipples, such as pacifiers and baby bottles, should not be given to breastfed babies. The aim is to optimize BF, which should be exclusive up to the 6th month of life and then be supplemented for up to two years or more, without any artifact interfering with the NS and NNS patterns [[14], [15], [16]].
This study aimed to investigate the association between the use of artificial nipples, specifically baby bottles and pacifiers, and the NNS and NS patterns of full-term infants, testing the hypothesis of the occurrence of nipple confusion. We also sought to determine the association of perinatal factors with the use of artificial nipples.
Section snippets
Design study
This cross-sectional study employed clinical and observational approaches. Full-term infants and their respective mothers were recruited from February to October 2016 at the University Hospital of the Federal University of Maranhão in the city of São Luís, northeast of Brazil. The hospital has a highly complex unit specialized in maternal and child care in high-risk pregnancy and delivery. The mothers of the potentially eligible infants were invited to participate in the study during routine
Results
A total of 429 infants up to 4 months old were evaluated in this cross-sectional study. The age of the mothers ranged from 13 to 47 years, with a mean of 26.9 ± 6.8 years. The infants had a mean age of 33.2 ± 13.1 days. It was observed that 32.9% of the sample used artificial nipples, 14.9% used baby bottles, and 18.9% used pacifiers.
Table 2 shows the association analyses between the perinatal variables and artificial nipple use. The unadjusted analysis showed risk associations with artificial
Discussion
The main findings of this study, which investigated the factors associated with NS and NNS patterns, suggest that the variables infant age <28 days, income greater than five times the minimum wage, primiparity, and delivery in a private health unit are risk factors for the use of artificial nipples. Receipt of information regarding BF in the pre and postnatal periods and the postnatal period were protective factors. In addition, there were higher frequencies of changes in the NNS and NS
Conclusion
In full-term infants assessed in this research, the use of pacifiers and/or baby bottles presented aspects of NS and NNS pattern changes that had no correspondence with the usual breastfeeding aspects described in the literature, which confirms the hypothesis of nipple confusion. The infants most likely to use artificial nipples are those who are firstborn, those born in private health units, and those whose mothers have higher family incomes, whereas, receiving BF information in the postnatal
Contributor statement
CLCB participated in all phases of the study and drafting the manuscript. VPR compiled the results, statistical analysis and revised the article critically. VSR and MSSBN participated in the data collection, supervised the project and writing the text. All the authors read and approved the final manuscript.
Declarations of interest
None.
Acknowledgments
The authors thank the mothers who voluntarily participated in this study and the staff of the University Hospital of the Federal University of Maranhão.
Funding
This work was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES) and Research Support Foundation of Maranhão State (FAPEMA), Brazil.
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