[Promotion of breastfeeding: the importance of pediatricians with specific training]. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Cohort studies: marching towards outcomes Breastfeeding Patterns in Relation to Thumb Sucking and Pacifier Use The effects of early pacifier use on breastfeeding duration. Advising mothers about breastfeeding and weaning reduced pacifier use in the first year of life: a randomized trial. Prevalence of exclusive breastfeeding and its determiners in the first 3 months of life in the South of Brazil. Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level? Does the recommendation to use a pacifier influence the prevalence of breastfeeding? Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Feeding practices of infants through the first year of life in Italy Evidence-based public health: moving beyond randomized trials. Factors associated with initiation and duration of breastfeeding in Italy The impact of pacifier use on breastfeeding: a prospective cohort study. Use of a pacifier and behavioural features in 2–4‐month‐old infants Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. How are effective breastfeeding technique and pacifier use related to breastfeeding problems and breastfeeding duration? Breastfeeding in Bristol: teaching good positioning, and support from fathers and families. Why we need observational studies to evaluate the effectiveness of health care Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial.
OBJECTIVE To study the factors involved in the maintenance of exclusive breastfeeding  in healthy infants during the first 4 months of life , with emphasis on the role of pediatricians . MATERIAL AND METHODS A longitudinal study was carried out with 101 healthy term babies at a pediatrics outpatient clinic in Uberaba , state of Minas Gerais , Brazil . The babies were divided at r and om into three groups : G1 , receiving advice from a multiprofessional breastfeeding team ; G2 , receiving advice from a pediatrician trained in breastfeeding ; and G3 , receiving advice from a pediatrician with no breastfeeding training . Group r and omization was confirmed by analysis of variance . The factors involved in the type of feeding at 4 months were analyzed by the chi-square test , by analysis of variance and by multiple variable analysis . RESULTS At the end of follow-up , Groups 1 and 2 showed similar percentages with respect to exclusive breastfeeding . In addition , the percentage of exclusively breastfed babies in Groups 1 and 2 was significantly higher than in Group 3 ( p = 0.002 ) . The use of a pacifier was negatively correlated with exclusive breastfeeding ( p = 0.003 ) . More maternal schooling increased the chance of exclusive breastfeeding at 4 months ( p = 0.041 ) . CONCLUSIONS In this study , a pediatrician who was prepared and motivated to encourage breastfeeding performed similarly to a multiprofessional breastfeeding team in terms of promoting exclusive breastfeeding until 4 months OBJECTIVE To enhance breastfeeding practice s , the World Health Organization discourages pacifiers and bottle-feeding . However , the effect of artificial nipples on breastfeeding duration is poorly defined . The effects of 2 types of artificial nipple exposure on breastfeeding duration were evaluated : 1 ) cupfeeding versus bottle-feeding for the provision of in-hospital supplements and 2 ) early ( 2 - 5 days ) versus late ( > 4 weeks ) pacifier introduction . METHODS A total of 700 breastfed newborns ( 36 - 42 weeks , birth weight > or=2200 g ) were r and omly assigned to 1 of 4 intervention groups : bottle/early pacifier ( n = 169 ) , bottle/late pacifier ( n = 167 ) , cup/early pacifier ( n = 185 ) , or cup/late pacifier ( n = 179 ) . The cup/bottle intervention was invoked for infants who received supplemental feedings : cup ( n = 251 ) , bottle ( n = 230 ) . Data were collected at delivery and at 2 , 5 , 10 , 16 , 24 , 38 , and 52 weeks ' postpartum . Intervention effects on breastfeeding duration were evaluated with logistic regression and survival analyses . RESULTS Supplemental feedings , regardless of method ( cup or bottle ) , had a detrimental effect on breastfeeding duration . There were no differences in cup versus bottle groups for breastfeeding duration . Effects were modified by the number of supplements ; exclusive and full breastfeeding duration were prolonged in cup-fed infants given > 2 supplements . Among infants delivered by cesarean , cupfeeding significantly prolonged exclusive , full , and overall breastfeeding duration . Exclusive breastfeeding at 4 weeks was less likely among infants exposed to pacifiers ( early pacifier group ; odds ratio : 1.5 ; 95 % confidence interval : 1.0 - 2.0 ) . Early , as compared with late , pacifier use shortened overall duration ( adjusted hazard ratio : 1.22 ; 95 % confidence interval : 1.03 - 1.44 ) but did not affect exclusive or full duration . CONCLUSIONS There was no advantage to cupfeeding for providing supplements to the general population of healthy breastfed infants , but it may have benefitted mother-infant dyads who required multiple supplements or were delivered by cesarean . Pacifier use in the neonatal period was detrimental to exclusive and overall breastfeeding . These findings support recommendations to avoid exposing breastfed infants to artificial nipples in the neonatal period A cohort study tracks two or more groups forward from exposure to outcome . This type of study can be done by going ahead in time from the present ( prospect i ve cohort study ) or , alternatively , by going back in time to comprise the cohorts and following them up to the present ( retrospective cohort study ) . A cohort study is the best way to identify incidence and natural history of a disease , and can be used to examine multiple outcomes after a single exposure . However , this type of study is less useful for examination of rare events or those that take a long time to develop . A cohort study should provide specific definitions of exposures and outcomes : determination of both should be as objective as possible . The control group ( unexposed ) should be similar in all important respects to the exposed , with the exception of not having the exposure . Observational studies , however , rarely achieve such a degree of similarity , so investigators need to measure and control for confounding factors . Reduction of loss to follow-up over time is a challenge , since differential losses to follow-up introduce bias . Variations on the cohort theme include the before-after study and nested case-control study ( within a cohort study ) . Strengths of a cohort study include the ability to calculate incidence rates , relative risks , and 95 % CIs . This format is the preferred way of presenting study results , rather that with p values Objectives . To analyze the influence of thumb sucking and pacifier use on breastfeeding patterns in exclusively breastfed infants , on the duration of exclusive breastfeeding , and on the total breastfeeding duration . Study Design . Descriptive , longitudinal , prospect i ve study . Setting . The subjects were recruited from a population of 15 189 infants born in the maternity ward at the University Hospital , Uppsala , Sweden between May 1989 and December 1992 . Study Population . 506 mother – infant pairs . Methods . Daily recordings by the mothers on infant feeding from the first week after delivery through the duration of the study . Fortnightly home visits with structured interviews by a research assistant . Results . Pacifier use was associated with fewer feeds and shorter suckling duration per 24 hours , shorter duration of exclusive breastfeeding , and shorter total breastfeeding duration compared with no pacifier use . These associations were not found for thumb sucking . The possible negative effects of pacifiers on breastfeeding seemed to be related to the frequency of their use . Maternal age and education only slightly modified the association between pacifier use and breastfeeding duration . Conclusions . More frequent use of a pacifier was associated with shorter breastfeeding duration , even among a group of mothers who were highly motivated to breastfeed . breastfeeding duration , breastfeeding pattern , exclusive breastfeeding , pacifier use , thumb sucking OBJECTIVE To evaluate the effects of pacifier use and the timing of pacifier introduction on  breastfeeding duration , problems , and frequency . METHODS A cohort of 265 breastfeeding mother-infant dyads was followed prospect ively . Maternal interviews were conducted at delivery , 2 , 6 , 12 , and 24 weeks , and thereafter every 90 days until breastfeeding ended . Information was obtained regarding pacifier use , infant feeding , use of supplemental foods and breastfeeding frequency , duration , and problems . The effect of pacifier introduction by 6 weeks of age on breastfeeding duration was evaluated with Kaplan-Meier and Cox proportional hazards models . The effect of the timing of pacifier introduction ( < /=2 weeks and < /=6 weeks ) on breastfeeding duration at 2 and 3 months was evaluated using logistic regression modeling . RESULTS A total of 181 mothers ( 68 % ) introduced a pacifier before 6 weeks . In adjusted analyses , pacifier introduction by 6 weeks was associated with a significantly increased risk for shortened duration of full ( hazard ratio , 1.53 ; 95 % confidence interval : 1.15 , 2.05 ) and overall ( hazard ratio , 1.61 ; 95 % confidence interval : 1.19,2.19 ) breastfeeding . Women who introduced pacifiers tended to breastfeed their infants fewer times per day , with significant differences noted at 2 ( 8.1 + /- 2.6 vs 9.0 + /- 2.3 ) and 12 weeks ' ( 6.3 + /- 2.0 vs 7.4 + /- 1.6 ) postpartum . At 12 weeks postpartum , women who introduced pacifiers also were more likely to report that breastfeeding was inconvenient and that they had insufficient milk supplies . Pacifier use begun either before 2 weeks or before 6 weeks ' postpartum was not significantly associated with breastfeeding duration at 2 and 3 months . CONCLUSIONS Pacifier use was independently associated with significant declines in the duration of full and overall breastfeeding . Breastfeeding duration in the first 3 months ' postpartum , however , was unaffected by pacifier use . Women who introduced pacifiers tended to breastfeed their infants less frequently and experienced breastfeeding problems consistent with infrequent feeding . Findings from this study suggest that the decreases in breastfeeding duration associated with pacifier use may be a consequence of less frequent breastfeeding among women who introduce pacifiers to their infants OBJECTIVE To assess the effectiveness of home visits for advising mothers about breastfeeding and weaning on pacifier use in the first year of life . METHOD A r and omized field trial was conducted on mothers who gave birth within the public health system in the Brazilian city of Sao Leopoldo ( intervention group = 200 ; controls = 300 ) . The intervention group received the advice 10 days after the child 's birth , monthly up to 6 months , at 8 , 10 , and 12 months , based on the ' Ten Steps for Healthy Feeding ' , a Brazilian national health policy for primary care , which follows WHO guidelines . Relative risk ( RR ) was used to estimate the effects of the intervention on the risk of using a pacifier . RESULTS 55.4 % of the children in the intervention group and 66.1 % of the controls used a pacifier  in the first year of life . The risk of using a pacifier  was 16 % lower for the intervention group ( RR = 0.84 ; 95 % CI , 0.71 - 0.99 ) . A multivariable Poisson regression model showed higher adjusted risk of using a pacifier  for children who had breastfeeding interrupted in the first month of life ( RR = 1.43 ; 95 % CI , 1.21 - 1.69 ) and whose mothers presented higher level of depression ( RR = 1.40 ; 95 % CI , 1.17 - 1.66 ) . CONCLUSIONS  Pacifier use is highly prevalent in the population studied . The home visits for dietary advice appear to help in reducing  pacifier use in infants . These findings suggest the need for public health strategies that address early advice on pacifier use to promote child oral and general health OBJECTIVE To determine the prevalence of exclusive breastfeeding during the first 3 months of life and its determinant factors in a city in the South region of Brazil . METHODS Prospect i ve study of a cohort of babies born between September 2002 and May 2003 in the city of Pelotas , RS . Data were obtained in interviews , at maternity units and during home visits , with mothers of babies aged between 1 and 3 months . Factors related to the cessation of breastfeeding were subjected to univariate , bivariate and multivariate analysis . RESULTS Nine hundred and forty mothers of children aged 3 months or less were interviewed , 39 % of whom were still exclusively breastfeeding and around 1/3 of whom no longer breastfed . Multivariate analysis by logistic regression demonstrated a significant association between interruption of exclusive breastfeeding before 3 months and maternal employment , use of a pacifier , low family income ( between one and three times the minimum wage ) , and less than 5 years ' paternal education . CONCLUSIONS Exclusive breastfeeding throughout the first 3 months of life is an uncommon practice among the population of Pelotas , RS , in particular when the mother works away from home , the father has little education and the child is given a pacifier , which reinforces the need to continue stimulating exclusive breastfeeding during the first months of life Objectives . In Switzerl and , the Baby-Friendly Hospital Initiative ( BFHI ) proposed by the United Nations Children 's Fund ( UNICEF ) was introduced in 1993 to promote breastfeeding nationwide . This study reports results of a national study of the prevalence and duration of breastfeeding in 2003 throughout Switzerl and and analyzes the influence of compliance with UNICEF guidelines of the hospital where delivery took place on breastfeeding duration . Methods . Between April and September 2003 , a r and om sample of mothers who had given birth in the past 9 months in Switzerl and received a question naire on breastfeeding and complementary feeding . Seventy-four percent of the contacted mothers ( n = 3032 ) participated ; they completed a 24-hour dietary recall question naire and reported the age at first introduction of various foods and drinks . After excluding question naires with missing information relevant for the analyses , we analyzed data for 2861 infants 0 to 11 months of age , born in 145 different health facilities . Because it was known whether each child was born in a design ated baby-friendly hospital ( 45 hospitals ) or in a health facility in the process of being evaluated for BFHI inclusion ( 31 facilities ) , we were able to assess a possible influence of the BFHI on breastfeeding success . For this purpose , we merged individual data with hospital data on compliance with the UNICEF guidelines , from a data source collected on an annual basis for quality monitoring of design ated baby-friendly hospitals and health facilities in the evaluation process . Information on actual compliance with the guidelines allowed us to investigate the relationship between breastfeeding outcomes and compliance with UNICEF guidelines . We were also able to compare the breastfeeding results with those for non – baby-friendly health facilities . The comparison was based on median duration s of exclusive , full , and any breastfeeding calculated for each group . To allow for other known influencing factors , we calculated adjusted hazard ratios by using Cox regression ; we also conducted logistic regression analyses with the 24-hour dietary recall data , to calculate adjusted odds ratios for validation of results from the retrospectively collected data . Results . In 2003 , the median duration of any breastfeeding was 31 weeks at the national level , compared with 22 weeks in 1994 , and the median duration of full breastfeeding was 17 weeks , compared with 15 weeks in 1994 . The proportion of exclusively breastfed infants 0 to 5 months of age was 42 % for infants born in baby-friendly hospitals , compared with 34 % for infants born elsewhere . Breastfeeding duration for infants born in baby-friendly hospitals , compared with infants born in other hospitals , was longer if the hospital showed good compliance with the UNICEF guidelines ( 35 weeks vs 29 weeks for any breastfeeding , 20 weeks vs 17 weeks for full breastfeeding , and 12 weeks vs 6 weeks for exclusive breastfeeding ) . To control for differences in the study population between the different types of health facilities , hazard and odds ratios were calculated as described above , taking into account socioeconomic and medical factors . Although the analysis of the retrospective data showed clearly that the duration of exclusive and full breastfeeding was significantly longer if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines , whereas this effect was less prominent in other baby-friendly health facilities , this difference was less obvious in the 24-hour recall data . Only for the duration of any breastfeeding could a positive effect be seen if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines . Known factors involved in the evaluation of baby-friendly hospitals showed the expected influence , on the individual level , on duration of exclusive , full , and any breastfeeding . If a child had been exclusively breastfed in the hospital , the median duration of exclusive , full , and any breastfeeding was considerably longer than the mean for the entire population or for those who had received water-based liquids or supplements in the hospital . A positive effect on breastfeeding duration could be shown for full rooming in , first suckling within 1 hour , breastfeeding on dem and , and also the much-debated practice of pacifier use . After controlling for medical problems before , during , and after delivery , type of delivery , well-being of the mother , maternal smoking , maternal BMI , nationality , education , work , and income , all of the factors were still significantly associated with the duration of full , exclusive , or any breastfeeding . Conclusions . Our results support the hypothesis that the general increase in breastfeeding in Switzerl and since 1994 can be interpreted in part as a consequence of an increasing number of baby-friendly health facilities , whose clients breastfeed longer . Nevertheless , several alternative explanations for the longer breastfeeding duration for deliveries that occurred in baby-friendly hospitals can be discussed . In Switzerl and , baby-friendly hospitals actively use their certification by UNICEF as a promotional asset . It is thus possible that differences in breastfeeding duration are attributable to the fact that mothers who intend to breastfeed longer would choose to give birth in a baby-friendly hospital and these mothers would be more willing to comply with the recommendations of the UNICEF guidelines . Even if this were the case , however , this selection bias would not explain the differences in breastfeeding duration between design ated baby-friendly health facilities with higher compliance with the UNICEF guidelines and those with lower compliance . Especially this last point strongly supports a beneficial effect of the BFHI , because mothers do not know how well hospitals comply with the UNICEF program . The fact that breastfeeding rates have generally improved even in non – baby-friendly health facilities may be indirectly influenced by the BFHI ; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding , and the number of professional lactation counselors has increased continuously . Breastfeeding prevalence and duration in Switzerl and have improved in the past 10 years . Children born in a baby-friendly health facility are more likely to be breastfed for a longer time , particularly if the hospital shows high compliance with UNICEF guidelines . Therefore , the BFHI should be continued but should be extended to include monitoring for compliance , to promote the full effect of the BFHI OBJECTIVE To evaluate whether the recommendation to offer a pacifier once lactation is well established reduces the prevalence or duration of breastfeeding . STUDY DESIGN A multicenter , r and omized , non-inferiority , controlled trial comprising 1021 mothers highly motivated to breastfeed whose newborns regained birth weight by 15 days . They were assigned to offer versus not to offer pacifiers . Primary outcome was prevalence of exclusive breastfeeding at 3 months . Main secondary outcomes were the prevalence of exclusive and any breastfeeding at different ages and duration of any breastfeeding . RESULTS At 3 months , 85.8 % infants in the offer pacifier group and 86.2 % in the not offer pacifier group were exclusively breastfeeding ( risk difference , 0.4 % ; 95 % CI , -4.9%-4.1 % ) , satisfying the pre-specified non-inferiority requirement of -7 % . Furthermore , the recommendation to offer a pacifier did not produce a significant decrease in the frequency of exclusive and any breastfeeding at different ages or in the duration of lactation . CONCLUSIONS The recommendation to offer a pacifier at 15 days does not modify the prevalence and duration of breastfeeding . Because pacifier use is associated with reduced incidence of sudden infant death syndrome , the recommendation to offer a pacifier appears safe and appropriate in similar population BACKGROUND The identification of factors that are associated with early cessation of exclusive breastfeeding  is important for defining strategies for the promotion of exclusive breastfeeding . The objective of this study was to identify the determinants of exclusive breastfeeding  cessation before 6 months , including variables that generally receive little attention , such as the influence of gr and mothers , breastfeeding technique , and sore nipples . METHODS This prospect i ve study follows a cohort of 220 healthy mother-baby pairs from birth to 6 months , living in Porto Alegre , Brazil . Data were collected at the maternity unit , during a home visit at 30 days , and by telephone interview at 60 , 120 , and 180 days .  Breastfeeding technique  was assessed and breasts examined at the maternity unit and during home visits . Cox regression was employed to estimate the degree of association between the variables and the outcome . RESULTS The following factors were associated with cessation of exclusive breastfeeding before 6 months : adolescent mother ( hazard ratio [ HR ] = 1.48 , 95 % CI 1.01 - 2.17 ) , fewer than six prenatal visits ( HR = 1.60 , 95 % CI 1.10 - 2.33 ) , use of a pacifier within the first month ( HR = 1.53 , 95 % CI 1.12 - 2.11 ) , and poor latch-on ( HR = 1.29 , 95 % CI 1.06 - 1.58 for each unfavorable parameter ) . CONCLUSIONS Activities to promote exclusive breastfeeding should be intensified for adolescent mothers and for those whose prenatal care was less than ideal . These activities should reinforce the ill effects of pacifiers and should also include appropriate instruction for these mothers in correct breastfeeding technique Aim : To investigate infant feeding practice s through the first year of life in Italy , and to identify factors associated with the duration of breastfeeding and early introduction of solid foods . Methods : Structured phone interviews on feeding practice s were conducted with 2450 Italian‐speaking mothers r and omly selected among women who delivered a healthy‐term singleton infant in November 1999 in Italy . Interviews were performed 30 d after delivery and when the infants were aged 3 , 6 , 9 and 12 mo . Type of breastfeeding was classified according to the WHO criteria . Results : Breastfeeding started in 91.1 % of infants . At the age of 6 and 12mo , respectively , 46.8 % and 11.8 % of the infants was still breastfed , 68.4 % and 27.7 % received formula , and 18.3 % and 65.2 % were given cow 's milk . Solids were introduced at the mean age of 4.3 mo ( range 1.6–6.5 mo ) . Introduction of solids occurred before age 3 and 4 mo in 5.6 % and 34.2 % of infants , respectively . The first solids introduced were fruit ( 73.1 % ) and cereals ( 63.9 % ) . The main factors ( negatively ) associated with the duration of breastfeeding were pacifier use ( p > 0.0001 ) , early introduction of formula  ( p > 0.0001 ) , lower mother 's age ( p > 0.01 ) and early introduction of solids  ( p= 0.05 ) . Factors ( negatively ) associated with the introduction of solids foods before the age of 3 mo were mother not having breastfed ( p > 0.01 ) , early introduction of formula  ( p > 0.01 ) , lower infant bodyweight at the age of 1 mo ( p= 0.05 ) and mother smoking ( p= 0.05 ) R and omized controlled trials ( RCTs ) are essential for evaluating the efficacy of clinical interventions , where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other setting s. However , causal chains in public health interventions are complex , making RCT results subject to effect modification in different population s. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility design s. For evaluating large-scale interventions , studies with plausibility design s are often the only feasible option and may provide valid evidence of impact . There is an urgent need to develop evaluation st and ards and protocol s for use in circumstances where RCTs are not appropriate To evaluate factors associated with initiation and duration of breastfeeding  in Italy , 1601 ( 73 % ) respondents among 2192 r and omly selected mothers were interviewed within 1 mo of delivery . Mothers who started breastfeeding ( 85 % ) were followed‐up for 12 mo . A compliance rate of 100 % was obtained . At multiple logistic regression analysis , mother having been breastfed herself ( p<0.01 ) , nursing guidance in the maternity ward ( p= 0.01 ) and higher social class ( p= 0.03 ) were positively associated with initiation of breastfeeding . We found that 42 % , 19 % , 10 % and 4 % mothers were still breastfeeding at 3 , 6 , 9 and 12 mo after delivery , respectively . Cox multiple regression analysis showed a negative association between duration of breastfeeding and pacifier use ( p<0.01 ) , and a positive association with a higher level of maternal education ( p= 0.04 ) . Formula supplementation in the maternity ward ( given to 30 % of infants ) was associated with a shorter duration of exclusive breastfeeding ( p = 0.03 ) . Mothers need support with breastfeeding , particularly those from lower social background s and with lower levels of education . Early use of the pacifier should be discouraged OBJECTIVES To determine the predictors of pacifier use during the first year of life and to assess the influence of pacifier use on the duration of breastfeeding . METHODOLOGY A prospect i ve cohort study was conducted . Three hundred and fifty mother-infant pairs were followed to 1 year of age to determine the impact of the use of a pacifier on the duration of breastfeeding . RESULTS A cohort of 441 mothers were enrolled and 79 % participated . Ninety four per cent were followed up to 1 year . Daily pacifier use was associated with early cessation of breastfeeding ( risk ratio ( RR ) 1.71 ; 95 % confidence interval ( 95%CI ) 1.29 , 2.28 ) and a reduced duration of full breastfeeding ( adjusted ( adj . ) RR 1.35 ; 95%CI 1.05 , 1.74 ) . Finger sucking was not associated with a reduced duration of breastfeeding ( RR 1.05 ; 95%CI 0.81 , 1.37 ) . Pacifier use less than daily was not associated with a change in duration of breastfeeding ( RR 1.02 ; 95%CI 0.75 , 1.39 ) . Most mothers commenced the use of a pacifier within the first month . Multiple logistic regression analysis found that the use of a pacifier was associated with male gender ( adj . RR 1.97 ; 95%CI 1.23 , 3.13 ) , maternal smoking in pregnancy ( adj . RR 2.23 ; 95%CI 1.01 , 4.95 ) , and low maternal confidence with breastfeeding ( adj . RR 2.70 ; 95%CI 1.48 , 4.93 ) . CONCLUSIONS Daily pacifier use is associated with a reduced duration of breastfeeding . Less frequent pacifier use does not reduce the duration of breastfeeding This study aim ed to analyse a possible association between the use of a pacifier and particular behavioural features in 2‐4‐month‐old infants as estimated by the means of the Early Infancy Temperament Question naire ( EITQ ) . It comprised 192 r and omly selected clinical ly healthy infants born in St Petersburg in 1997‐1998 . The mothers were asked to complete the question naires addressing infant , maternal and major demographic characteristics , and childcare practice s , with particular emphasis on the use of a pacifier , as well as to fill in the EITQ . The EITQ scores nine different aspects of infant temperament : activity , rhythmicity , approach , adaptability , intensity , mood , persistence , distractibility and threshold . A total of 117 of 192 infants ( 60.9 % ) used pacifiers , and they appeared to have more rhythmic behaviour than non‐users . This effect remained after adjustment was made for major potential confounding and /or modifying factors , including gender , parity , details from perinatal history and familial social background , feeding pattern , bed sharing and room sharing . With the exception of rhythmicity , no significant association was found between the use of a pacifier and any other particular feature of infant temperament . Use of a pacifier may be associated with higher rhythmicity in 2–4‐month‐old infants BACKGROUND The Cochrane Collaboration is strongly encouraging the use of a newly developed tool , the Cochrane Collaboration Risk of Bias Tool ( CCRBT ) , for all review groups . However , the psychometric properties of this tool to date have yet to be described . Thus , the objective of this study was to add information about psychometric properties of the CCRBT including inter-rater reliability and concurrent validity , in comparison with the Effective Public Health Practice Project Quality Assessment Tool ( EPHPP ) . METHODS Both tools were used to assess the method ological quality of 20 r and omized controlled trials included in our systematic review of the effectiveness of knowledge translation interventions  to improve the management of cancer pain . Each study assessment was completed independently by two review ers using each tool . We analysed the inter-rater reliability of each tool 's individual domains , as well as final grade assigned to each study . RESULTS The EPHPP had fair inter-rater agreement for individual domains and excellent agreement for the final grade . In contrast , the CCRBT had slight inter-rater agreement for individual domains and fair inter-rater agreement for final grade . Of interest , no agreement between the two tools was evident in their final grade assigned to each study . Although both tools were developed to assess ' quality of the evidence ' , they appear to measure different constructs . CONCLUSIONS Both tools performed quite differently when evaluating the risk of bias or method ological quality of studies in knowledge translation interventions for cancer pain . The newly introduced CCRBT assigned these studies a higher risk of bias . Its psychometric properties need to be more thoroughly vali date d , in a range of research fields , to underst and fully how to interpret results from its application BACKGROUND Inconsistent findings leave uncertainty about the impact of pacifier use on effective breastfeeding technique . The purpose of this study was to investigate how breastfeeding technique and pacifier use were related to  breastfeeding problems  and  duration of breastfeeding .  METHODS Data were collected from the intervention group of a r and omized trial in which health visitors followed up with mothers for 6 months after childbirth . The health visitors classified the breastfeeding technique at approximately 1 week after birth and repeated the observation if a correction was necessary . Effective technique included positioning , latch , sucking , and milk transfer . Data on breastfeeding problems and pacifier use were obtained from self-reported question naires . The study population included 570 mother-baby pairs with complete information on breastfeeding technique and pacifier use . The primary outcome was duration of exclusive breastfeeding . RESULTS One-half of the mothers showed ineffective breastfeeding technique at the first\ observation , most frequently ineffective position ( 61 % ) and latch ( 52 % ) . In the unadjusted analysis , only sucking and milk transfer were associated with breastfeeding duration . In the adjusted analysis , ineffective technique was significantly associated with mothers reporting early breastfeeding problems , which thereby influenced the breastfeeding duration . Pacifier use had an independent negative impact on duration of breastfeeding . A single correction of the breastfeeding technique was not associated with duration or occurrence of problems . CONCLUSIONS Observation of breastfeeding technique may help mothers in the stage of when they are establishing breastfeeding to avoid early and later problems , but breastfeeding technique is less useful in predicting breastfeeding duration . Use of a pacifier should be avoided in the first weeks after birth OBJECTIVES to determine whether a specific ' h and s-off ' breastfeeding technique , based on the physiology of suckling and clinical experience , if taught to mothers in the immediate postnatal period , improves their chances of breastfeeding successfully and reduces the incidence of problems . To investigate the factors associated with breastfeeding at two and six weeks postpartum using logistic regression analysis . DESIGN a non-r and omised prospect i ve cohort phased intervention study . SETTING subjects recruited from one postnatal ward in St. Michael 's Hospital , Bristol from October 1996 to November 1998 . PARTICIPANTS 1400 South Bristol mothers who were breastfeeding on discharge from hospital . Three hundred and ninety-five of these mothers were scored for  efficiency  of using the breastfeeding technique . INTERVENTION a ' h and s-off ' breastfeeding technique was taught to midwives in hospital who subsequently taught mothers in their care . MEASUREMENTS frequencies of exclusive and ' any breastfeeding ' at two and six weeks from question naires sent to mothers at home , and incidence of breastfeeding problems . FINDINGS significant increases were observed in the proportion of mothers exclusively breastfeeding at two weeks ( P < 0.001 ) and six weeks ( P=0.02 ) and in ' any breastfeeding ' rates ( P=0.005 ) at two weeks after the technique intervention . The incidence of mothers feeling that they did ' not have enough milk ' ( perceived milk insufficiency ) decreased significantly after the breastfeeding technique had been taught ( P=0.02 ) . Logistic regression analysis produced a model which showed that mothers with high scores for the ' h and s-off ' technique were significantly more likely to be breastfeeding at six weeks compared with those who did not use all the elements of the technique ( OR 2.4 ; CI 1.3 , 4.3 ) . Factors associated with continuing to breastfeed at two and six weeks postpartum were also investigated using logistic regression . At two weeks , the significant factors associated with breastfeeding included mothers feeling that they had a ' plentiful milk supply ' ( OR 3.3 ; CI 2.1 , 5.3 ) , not using a dummy ( OR 2.6 ; CI 1.6 , 4.0 ) , not giving the baby any other fluid in hospital ( OR 2.4 ; CI 1.5 , 3.8 ) and receiving enough support for breastfeeding from hospital staff ( OR 2.1 ; CI 1.3 , 3.5 ) . By six weeks , in addition to these factors , the encouragement from a supportive partner , other family members and health professionals in enabling women to continue to breastfeed was found to show the largest associations with the maintenance of breastfeeding [ ( OR 37.2 ; CI 17.3 , 80.2 ) for all three encouraging ( 327/817 ; 40 % of breastfeeders ) compared with no encouragement ( 67/817 ; 8 % of breastfeeders ) ] . CONCLUSIONS in the immediate postnatal period , if mothers are taught good breastfeeding technique by midwives in a ' h and s-off ' style , which enables mothers to position and attach their babies for themselves , and which is based on a physiological approach , breastfeeding rates are increased and the incidence of perceived milk insufficiency decreases . Successful breastfeeding in the early weeks was associated both with practice s and support in hospital and with factors at home including not using dummies and having a supportive partner , family and health professionals who are encouraging breastfeeding . IMPLICATION S FOR PRACTICE teaching mothers how to breastfeed in a ' h and s-off ' way is important in empowering mothers to ' do it for themselves ' and in improving breastfeeding rates . Widespread adoption of consistent good practice is achievable following a brief workshop teaching session . Using the  ' breastfeeding score checklist '  may help midwives to assess a breastfeed more accurately and determine which aspects need improving . Health professionals should aim to educate all key family members , whenever an opportunity arises both during pregnancy and postnatally , in the benefits of breast milk for babies in the first few months of life and how to encourage and support a mother in the early weeks of breastfeeding The view is widely held that experimental methods ( r and omised controlled trials ) are the " gold st and ard " for evaluation and that observational methods ( cohort and case control studies ) have little or no value . This ignores the limitations of r and omised trials , which may prove unnecessary , inappropriate , impossible , or inadequate . Many of the problems of conducting r and omised trials could often , in theory , be overcome , but the practical implication s for research ers and funding bodies mean that this is often not possible . The false conflict between those who advocate r and omised trials in all situations and those who believe observational data provide sufficient evidence needs to be replaced with mutual recognition of the complementary roles of the two approaches . Research ers should be united in their quest for scientific rigour in evaluation , regardless of the method used CONTEXT The World Health Organization and the United Nations Children 's Fund strongly discourage use of pacifiers because of their perceived interference with breastfeeding . Observational studies have reported a strong association between pacifier use and early weaning , but such studies are unable to determine whether the association is causal . OBJECTIVES To test whether regular pacifier use is causally related to weaning by 3 months postpartum and to examine differences in results according to r and omized intervention allocation vs observational use or nonuse of pacifiers . DESIGN Double-blind , r and omized controlled trial conducted from January 1998 to August 1999 . SETTING Postpartum unit of a university teaching hospital in Montreal , Quebec . PARTICIPANTS A total of 281 healthy , breastfeeding women and their healthy , term singleton infants . INTERVENTIONS Participants were r and omly allocated to 1 of 2 counseling interventions provided by a research nurse trained in location counseling . The experimental intervention ( n = 140 ) differed from the control ( n = 141 ) by recommending avoidance of pacifier use and suggesting alternative ways to comfort a crying or fussing infant . MAIN OUTCOME MEASURES Early weaning , defined as weaning within the first 3 months , compared between groups ; 24-hour infant behavior logs detailing frequency and duration of crying , fussing , and pacifier use at 4 , 6 , and 9 weeks . RESULTS A total of 258 mother-infant pairs ( 91.8 % ) completed follow-up . The experimental intervention increased total avoidance of pacifier use ( 38.6 % vs 16.0 % in the control group ) , reduced daily use ( 40.8 % vs 55.7 % ) , and decreased the mean number of pacifier insertions per day ( 0.8 vs 2.4 at 4 weeks [ P<.001 ] ; 0.8 vs 3.0 at 6 weeks [ P<.001 ] ; and 1.3 vs 3.0 at 9 weeks [ P = .004 ] ) . In the analysis based on r and omized intervention allocation , the experimental intervention had no discernible effect on weaning at 3 months ( 18.9 % vs 18.3 % in the experimental vs control group ; relative risk [ RR ] , 1.0 ; 95 % confidence interval [ CI ] , 0.6 - 1.7 ) , and no effect was observed on cry/fuss behavior ( in the experimental vs control groups , respectively , total daily duration , 143 vs 151 minutes at 4 weeks [ P = .49 ] ; 128 vs 131 minutes at 6 weeks [ P = .81 ] ; and 110 vs 104 minutes at 9 weeks [ P = .58 ] ) . When r and omized allocation was ignored , however , we observed a strong observational association between exposure to daily pacifier use and weaning by 3 months ( 25.0 % vs 12.9 % of the exposed vs unexposed groups ; RR , 1.9 ; 95 % CI , 1.1 - 3.3 ) . CONCLUSIONS We found a strong observational association between pacifier use and early weaning . No such association was observed , however , when our data were analyzed by r and omized allocation , strongly suggesting that pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed , rather than a true cause of early weaning
Identifying modifiable risk factor for  exclusive breastfeeding ( EBF ) interruption is key for improving child health globally .
There is no consensus about the effect of pacifier use on EBF interruption .
Thus , the aim of this systematic review was to investigate the association between pacifier use and EBF interruption during the first six month .