Association between Pacifier Use, Bottle-Feeding, and Pre-Postnatal Variables: A Cohort Study

ABSTRACT

Objective:

To determine the prevalence and analyze the variables associated with the use of pacifiers and/or bottles by infants up to 6 months of age.

Material and Methods:

Data on sociodemographic characteristics, intention to offer pacifier and bottle-feeding, pregnancy and breastfeeding (BF) variables were collected at baseline by interviews and a self-administered questionnaire among pregnant women in the 3^rd trimester. After delivery, mother-baby binomials were followed by phone calls at the 1^st, 3^rd, and 6^th months of the baby's life (n=467) to gather information on the type of delivery, baby’s gender, BF in the first hour of the newborn’s life, baby’s weight, mother’s return to work, and oral habits. Association analyses were performed using logistic regression models with a 5% significance level with the pacifier/bottle-feeding use as the outcome.

Results:

Most mothers (52.5%) reported their babies used bottle-feeding, 48.2% used pacifiers and 33.4% used both of them throughout the 6 months. Intention to offer pacifier and bottle-feeding was reported by 45.0% and 54.8% of the mothers at the 3^rd trimester of the pregnancy, respectively. Not living in one’s own residence (OR=1.53; 95%CI: 1.05-2.24) and having the prenatal intention of offering a pacifier (OR=2.50; 95%CI: 1.63-3.83) to the baby were significantly associated with pacifier use. Variables significantly associated with bottle-feeding were mother’s return to work (OR=2.48; 95%CI: 1.54-3.97), baby’s lower birth weight (OR=1.58; IC95%: 1.07-2.33), and prenatal intention to offer bottle-feeding (OR=2.51; 95%CI 1.56-4.04).

Conclusion:

About half of the babies used pacifiers or were bottle-fed, which were associated with the mother’s prenatal intention to offer them to their babies and socioeconomic factors.

Keywords:
Pacifiers; Bottle Feeding; Intention; Pregnancy

Introduction

Breast milk is the ideal food for infants because of its nutritional properties and because it helps babies to develop optimally [¹]. Breastfeeding (BF) contributes to the adequate growth of the child's orofacial structures and brings several health benefits for mothers and babies [²].

Breast milk has immunological and anti-inflammatory properties that protect the infant from various infections and diseases [³]. It can prevent infant death [⁴,⁵,⁶], diarrhea, respiratory infections, especially in children of lower socioeconomic status [⁵], reduce the likelihood of developing chronic diseases and obesity throughout life, as well as promote better nutrition and adequate cognitive and oral cavity development [⁵,⁷].

On the contrary, deleterious oral habits modify the adequate development of the stomatognathic system [⁸] and compromise the duration of exclusive breastfeeding (EBF) [⁹]. Therefore, the World Health Organization (WHO) [¹⁰], the Brazilian Ministry of Health [¹¹], and researchers advise parents/guardians not to offer pacifiers or bottle-feed infants for the first six months of the baby’s life [¹²].

Bottle feeding is a very significant infant feeding modality to offer breast milk or formula, but for its optimal use, the baby, the parents/guardians, and the equipment used must contribute to the process [¹³]. Also, the mothers may consider it as a way to control the times and amounts of food offered to the child [¹⁴].

As a disadvantage, the high frequency of bottle-feeding has been considered a risk factor for the development of caries in early childhood [¹⁵], and may also contribute to overfeeding, leading to rapid weight gain in childhood and, subsequently, to obesity [¹⁶]. The use of bottle feeding may also cause alterations to the chewing, sucking, and swallowing functions, leading to dental malocclusion [⁸].

Pacifier use can negatively interfere with EBF duration [¹²,¹⁷] and is associated with otitis media and other infections [⁵,¹⁸]. The prevalence rates of pacifier use were found to be high in Brazil and Italy [¹²], and such non-nutritive habit is associated with malocclusion, even in BF children [¹⁹].

Some variables are usually associated with the use of pacifiers and bottles, such as primiparity, absence of the golden hour, consumption of other fluids on the first day at home, low birth weight [²⁰], maternal work outside the home [²⁰,²¹] and lower maternal level of schooling [²¹]. Despite this information, most studies are cross-sectional studies [¹⁴,²⁰-23]. There is a scarcity of cohort studies assessing the establishment of such habits and the pre- and postnatal associated variables.

This study aimed to determine the prevalence and analyze the factors associated with the use of pacifiers and/or bottles in infants up to 6 months of age.

Material and Methods

Study Design and Ethical Aspects

This was a prospective cohort study with a non-random sample obtained at a referral center for pregnant women in the third trimester of pregnancy who were followed after delivery until the baby was six months of age.

Participation in the study was considered after the pregnant woman signed the free and informed consent form. The Research Ethics Committee of the Araraquara School of Dentistry, UNESP, Brazil, approved the study protocol under register (CAAE 96978518.6.0000.5416).

Study Sample

The baseline sample consisted of all pregnant women in the third trimester of pregnancy who attended a public maternity hospital under private administration located in a medium-sized city in the state of São Paulo, Brazil, during the data collection period (December 2018 to November 2019). The inclusion criteria comprised literate Brazilian women with no contraindications for BF practice.

Among all invited pregnant women (n=678), 655 agreed to participate in the study. Two of them were excluded due to incomplete data, totaling 653 pregnant women at baseline. After delivery, 467 mother-baby binomials were followed until the baby was six months of age or BF was stopped. Four participants were excluded due by death of mother or baby, 1 twin pregnancy, and 181 due to contact failure, despite repeated attempts.

The sample size of 467 mother-infant binomials provided a test power of 0.80 (β=0.20) with a significance level of 5% (α=0.05) for a minimum detectable odds ratio of 2.0. This sample size also follows the minimum number of events per variable required in the logistic regression analyses [²⁴]. Calculations were performed using the Epi Info software for the main dependent variables "intention to offer pacifier" and "intention to offer bottle", considering the prevalence of pacifier and bottle use found in a previous study [²⁰].

Data Collection

At baseline, data collection was performed through interviews and a self-administered questionnaire. The following variables were collected: sociodemographic characteristics, parity, type of delivery, baby’s characteristics, maternal intention to exclusively BF, BF (previous BF experience, prior help on BF practice, golden hour) and intention to offer pacifier and use bottle-feeding. The questionnaire included the Infant Feeding Intentions Scale [²⁵] translated and adapted into Brazilian Portuguese [²⁶], to assess the intention to initiate and continue EBF during the baby's first six months of life, as well as questions of interest, according to a previous study [²⁷].

After delivery, mother-infant binomials were followed through telephone calls in the first, third and sixth months of the baby's life, to gather information on the type of delivery, baby's sex, BF in the golden hour, baby's birth weight, mother’s return to work, and oral habits (pacifier and bottle-feeding use).

Statistical Analysis

Descriptive data analysis was carried out. Association analyses were carried out for each independent variable individually and the outcomes (pacifier use, bottle feeding, pacifier+bottle feeding) using simple logistic regression models, estimating crude odds ratios and the 95% confidence intervals. All variables with p<0.20 in the individual analyses were included in the multiple logistic regression analyses. The variable entry sequence in the multiple models followed the conceptual model of Bucinni et al. [²⁰]. The blocks of variables were entered into the model from the most distal to the most proximal ones, and the variables with significant association with the outcomes were maintained in each step, until the final adjustment of the model. Based on the final model, adjusted odds ratios were estimated, with their respective 95% confidence intervals. Model fits were evaluated using Akaike's Information Criterion (AIC). All analyses were performed using the R software, with a significance level set at 5%.

Results

Table 1 shows the descriptive analysis of the sociodemographic variables. At baseline, the mothers' mean age was 27.2 years, the mean income was R$2,159.00, 36.8% were primiparous, 66.8% reported no help to BF before baseline data collection, 45.0% intended to offer a pacifier, and 54.8% intended to offer a bottle. After delivery, 55.0% reported they had a caesarean delivery, 48.2% offered a pacifier, 52.5% offered a bottle, and 33.4% offered a pacifier and bottle-feeding at some point during the baby's first six months.

Table 1
Descriptive analysis of the sample

Variables	Categories	N (%)
Type of residence1	Own, paid off	88 (18.8)
	Own, financed	126 (27.0)
	Rented	179 (38.3)
	Given by parents	64 (13.7)
	Ceded by employer	4 (0.9)
	Given up for having nowhere to live	1 (0.2)
	Others	4 (0.9)
	Not informed	1 (0.2)
Color/Race1	Black	57 (12.2)
	White	209 (44.8)
	Yellow	6 (1.3)
	Brown	193 (41.3)
	Indigenous	2 (0.4)
Maternal education1	Incomplete Elementary School	46 (9.8)
	Complete Elementary School	42 (9.0)
	Incomplete High School	77 (16.5)
	Complete High School	225 (48.2)
	Incomplete Higher Education	25 (5.4)
	Complete Higher Education	51 (10.9)
Maternal marital status1	Single	148 (31.7)
	Married	195 (41.8)
	Common-law marriage	115 (24.6)
	Separated/Divorced	9 (1.9)
Parity1	Primiparous	172 (36.8)
	Multiparous	295 (63.2)
Previous breastfeeding experience1	Yes	262 (56.1)
	No	205 (43.9)
Type of delivery2	Vaginal	210 (45.0)
	Caesarean section	257 (55.0)
Health Care Services1	Health insurance	2 (0.4)
	Private	1 (0.2)
	SUS	423 (90.6)
	Health Insurance + SUS	25 (5.4)
	Private + SUS	16 (3.4)
Golden hour breastfeeding practice2	Yes	172 (36.8)
	No	290 (62.1)
	Not informed	5 (1.1)
Baby’s sex2	Female	232 (49.7)
	Male	235 (50.3)
Mother received help to breastfeed1	Yes	154 (33.0)
	No	312 (66.8)
	Not informed	1 (0.2)
Intention to offer pacifier1	Yes	210 (45.0)
	No	164 (35.1)
	Doesn't know	93 (19.9)
Intention to offer bottle-feeding1	Yes	256 (54.8)
	No	114 (24.4)
	Doesn't know	97 (20.8)
A pacifier was offered during the first 6 months2	Yes	225 (48.2)
	No	235 (50.3)
	Not informed	7 (1.5)
Bottle feeding was offered for the first 6 months2	Yes	245 (52.5)
	No	212 (45.4)
	Not informed	10 (2.1)
Pacifiers and bottles were offered during the first 6 months2	Yes	156 (33.4)
	No	299 (64.0%)
	Not informed	12 (2.6%)
Returned to work before 6 months of the baby’s life2	Yes	110 (23.6%)
	No	350 (74.9%)
	Not informed	7 (1.5%)
Variables	Mean (SD)	Median (Min. and Max.)
Maternal Age (years)1	27.2 (6.4)	27.0 (15.0-44.0)
Family income (Brazilian Reais)1	2159.0 (1138.1)	2000.0 (190.0-7000.0)
Baby weight at birth (Kg)2	3.29 (0.51)	3.28 (1.67-6.30)
Infant Feeding Intention (IFI) Scale score1	14.4 (2.6)	16.0 (1.0-16.0)

• ¹
  Information collected at baseline; ²Information collected after delivery; SD: Standard Deviation; Min.: Minimum; Max.: Maximum.

Babies whose mothers did not own their own residence or those whose mothers intended to offer a pacifier were 1.53 (95%CI: 1.05-2.24) and 2.50-fold (95%CI: 1.63-3.83) more likely to use a pacifier during the baby’s first six months of life, respectively (p<0.05), as shown in Table 2.

Table 2
Analyses (crude and adjusted) of associations with pacifier use at some point during the first 6 months of the baby’s life (n=460).

Variables	Categories	N (%)	Pacifier Use During the First 6 Months		Crude OR (95%CI)	p-value	OR Final Model (95%CI)	p-value
			*Yes N (%)	No N (%)
Distal Level
Family income (Reais)1	≤ 2000	244 (53.0)	132 (54.1)	112 (45.9)	1.60 (1.07-2.40)	0.0224
	> 2000	158 (34.4)	67 (42.4)	91 (57.6)	Ref
	Not informed	58 (12.6)	26 (44.8)	32 (55.2)
Type of residence1	Own	211 (45.9)	89 (42.2)	122 (57.8)	Ref		Ref
	Not own	248 (53.9)	135 (54.4)	113 (45.6)	1.64 (1.13-2.27)	0.0090	1.53 (1.05-2.24)	0.0276
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-		-
Skin Color / Ethnicity1	White	205 (44.6)	98 (47.8)	107 (52.2)	Ref
	Not White	255 (55.4)	127 (49.8)	128 (50.2)	1.08 (0.75-1.56)	0.6700
Maternal Age (years)1	≤ 27	248 (53.9)	129 (52.0)	119 (48.0)	1.31 (0.91-1.89)	0.1502
	> 27	212 (46.1)	96 (45.3)	116 (54.7)	Ref
Maternal level of schooling1	Elementary school (complete and incomplete)	86 (18.7)	45 (52.3)	41 (47.7)	1.18 (0.74-1.88)	0.4966
	Other	373 (81.1)	180 (48.3)	193 (51.7)	Ref
	Not informed	1 (0.2)	0 (0.0)	1 (100.0)	-
Return to work within 6 months2	Yes	109 (23.7)	50 (45.9)	59 (54.1)	0.86 (0.56-1.32)	0.4849
	No	348 (75.6)	173 (49.7)	175 (50.3)	Ref
	Not informed	3 (0.6)	2 (66.7)	1 (33.3)	-
Parity1	Primiparous	171 (37.2)	85 (49.7)	86 (50.3)	1.05 (0.72-1.54)	0.7931
	Multiparous	289 (62.8)	140 (48.4)	149 (51.6)	Ref
Maternal marital status1	Single or Separated	156 (33.9)	76 (48.7)	80 (51.3)	0.99 (0.67-1.45)	0.9522
	Married or common-law marriage	304 (66.1)	149 (49.0)	155 (51.0)	Ref
Distal Intermediate Level
Baby’s sex2	Female	227 (49.4)	120 (52.9)	107 (47.1)	1.40 (0.95-1.97)	0.0947
	Male	233 (50.6)	105 (45.1)	128 (54.9)	Ref
Baby’s birth weight (Kg)2	≤ 3.28	228 (49.6)	116 (50.9)	112 (49.1)	1.17 (0.81-1.70)	0.3973
	> 3.28	226 (49.1)	106 (46.9)	120 (53.1)	Ref
	Not informed	6 (1.3)	3 (50.0)	3 (50.0)	-
Type of delivery2	Vaginal	205 (44.6)	93 (45.4)	112 (54.6)	Ref
	Caesarean section	255 (55.4)	132 (51.8)	123 (48.2)	1.29 (0.89-1.87)	0.1727
Proximal Intermediate Level
Prenatal care1	SUS, exclusively	417 (90.6)	205 (49.2)	212 (50.8)	1.11 (0.59-2.09)	0.7412
	Others	43 (9.4)	20 (46.5)	23 (53.5)	Ref
Mother received help to breastfeed1	Yes	152 (33.0)	80 (52.6)	72 (47.4)	Ref
	No	307 (66.7)	144 (46.9)	163 (53.1)	0,80 (0.54-1.17)	0.2487
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-
EBF intention (IFI Scale score)1	< 16	224 (48.7)	119 (53.1)	105 (46.9)	1.39 (0.96-2.01)	0.0786
	16	236 (51.3)	106 (44.9)	130 (55.1)	Ref
Had previously breastfed1	Yes	256 (55.6)	122 (47.7)	134 (52.3)	Ref
	No	204 (44.4)	103 (50.5)	101 (49.5)	1.12 (0.78-1.62)	0.5459
Golden hour breastfeeding1	Yes	169 (36.7)	75 (44.4)	94 (55.6)	Ref
	No	288 (62.6)	148 (51.4)	140 (48.6)	1.32 (0.90-1.94)	0.1482
	Not informed	3 (0.6)	2 (66.7)	1 (33.3)	-
Proximal Level
Intention to offer pacifier1	Yes	209 (45.4)	127 (60.8)	82 (39.2)	2.61 (1.71-3.98)	<0.0001	2.50 (1.63-3.83)	<0.0001
	No	161 (35.0)	60 (37.3)	101 (62.7)	Ref		Ref
	Doesn't know	90 (19.6)	38 (42.2)	52 (57.8)	1.23 (0.73-2.08)	0.4406	1.23 (0.72-2.08)	0.4470

• ^*
  Outcome event. Ref: Reference category for independent variables. OR: Odds Ratio. CI: Confidence Interval. AIC (empty model) = 638.04. AIC (final model) = 617.31. IFI: Infant Feeding Intention ¹ Information collected at baseline. ² Information collected after delivery.

Table 3 shows that babies whose mothers returned to work within 6 months after delivery were 2.48fold (95%CI: 1.54-3.97) more likely to use bottle-feeding during the first six months, with p<0.05. Lower birth weight infants were 1.58-fold (95% CI: 1.07-2.33) more likely to receive bottle-feeding during the six months, with p<0.05. Moreover, babies whose mothers previously intended to offer bottle-feeding at the end of the pregnancy were 2.51-fold (95% CI: 1.56-4.04) more likely to use bottle-feeding during the first six months, with p<0.05.

Table 3
Analyses (crude and adjusted) of associations with bottle feeding at some point during the first 6 months of life.

Variables	Categories	N (%)	Bottle-feeding up to 6 months		Crude OR (95%CI)	p-value	OR Final Model (95%CI)	p-value
			*Yes N (%)	No N (%)
Distal Level
Family income (Reais)1	≤ 2000	244 (53.4)	143 (58.6)	101 (41.4)	1.33 (0.88-1.99)	0.1707	-	-
	> 2000	155 (33.9)	80 (51.6)	75 (48.4)	Ref
	Not informed	58 (12.7)	22 (37.9)	36 (62.1)	-
Type of residence1	Own	211 (46.2)	113 (53.6)	98 (46.4)	Ref		-	-
	Not own	245 (53.6)	131 (53.5)	114 (46.5)	1.00 (0.69-1.44)	0.9855
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-
Skin Color / Ethnicity1	White	202 (44.2)	111 (55.0)	91 (45.0)	Ref		-	-
	Not White	255 (55.8)	134 (52.6)	121 (47.4)	0.91 (0.63-1.32)	0.6094
Maternal Age (years)1	≤ 27	246 (53.8)	128 (52.0)	118 (48.0)	0.87 (0.60-1.26)	0.4652	-	-
	> 27	211 (46.2)	117 (55.4)	94 (44.6)	Ref
Maternal level of schooling1	Elementary school (complete and incomplete)	86 (18.7)	53 (61.6)	33 (38.4)	1.49 (0.92-2.41)	0.1041	-	-
	Other	373 (81.1)	192 (51.9)	178 (48.1)	Ref
	Not informed	1 (0.2)	0 (0.0)	1 (100.0)	-
Return to work within 6 months2	Yes	110 (24.1)	76 (69.1)	34 (30.9)	2.35 (1.49-3.72)	0.0002	2.48 (1.54-3.97)	0.0002
	No	345 (75.5)	168 (48.7)	177 (51.3)	Ref		Ref
	Not informed	2 (0.4)	1 (50.0)	1 (50.0)	-		-
Parity1	Primiparous	169 (37.0)	92 (54.4)	77 (45.6)	1.05 (0.72-1.54)	0.7860	-	-
	Multiparous	288 (63.0)	153 (53.1)	135 (46.9)	Ref
Maternal marital status1	Single or Separated	156 (34.1)	84 (53.8)	72 (46.2)	1.01 (0.69-1.50)	0.9420	-	-
	Married or common-law marriage	301 (65.9)	161 (53.5)	140 (46.5)	Ref
Distal Intermediate Level
Baby’s sex2	Female	226 (49.4)	117 (51.8)	109 (48.2)	Ref		-	-
	Male	231 (50.6)	128 (55.4)	103 (44.6)	1.16 (0.80-1.67)	0.4352
Baby’s birth weight(Kg)2	≤ 3.28	227 (49.7)	135 (59.5)	92 (40.5%)	1.60 (1.10-2.33)	0.0129	1.58 (1.07-2.33)	0.0207
	> 3.28	224 (49.0)	107 (47.8)	117 (52.2)	Ref		Ref
	Not informed	6 (1.3)	3 (50.0)	3 (50.0)	-		-
Type of delivery2	Vaginal	201 (44.0)	100 (49.8)	101 (50.2)	Ref		-	-
	Caesarean section	256 (56.0)	145 (56.6)	111 (43.4)	1.32 (0.91-1.91)	0.1430
Proximal Intermediate Level
Prenatal care1	SUS, exclusively	414 (90.6)	222 (53.6)	192 (46.4)	1.00 (0.54-1.89)	0.9865	-	-
	Others	43 (9.4)	23 (53.5)	20 (46.5)	Ref
Mother received help to breastfeed1	Yes	151 (33.0)	82 (54.3)	69 (45.7)	Ref		-	-
	No	305 (66.7)	162 (53.1)	143 (46.9)	0.95 (0.64-1.41)	0.8106
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-
EBF intention (IFI Scale score)1	< 16	221 (48.4)	132 (59.7)	89 (40.3)	1.61 (1.11-2.34)	0.0114	-	-
	16	236 (51.6)	113 (47.9)	123 (52.1)	Ref
Had previously breastfed1	Yes	255 (55.8)	129 (50.6)	126 (49.4)	Ref		-	-
	No	202 (44.2)	116 (57.4)	86 (42.6)	1.32 (0.91-1.91)	0.1458
Golden hour breastfeeding1	Yes	165 (36.1)	81 (49.4)	84 (50.9)	Ref		-	-
	No	289 (63.2)	163 (56.4)	126 (43.6)	1.34 (0.91-1.97)	0.1334
	Not informed	3 (0.7)	1 (33.3)	2 (66.7)
Proximal Level
Intention to offer bottle-feeding1	Yes	250 (54.7)	155 (62.0)	95 (38.0)	2,58 (1.63-4.08)	<0.0001	2.51 (1.56-4.04)	0.0002
	No	111 (24.3)	43 (38.7)	68 (61.3)	Ref		Ref
	Not informed	96 (21.0)	47 (49.0)	49 (51.0)	1.52 (0.87-2.64)	0.1399	1.40 (0.79-2.48)	0.2541

• ^*
  Outcome event. Ref: Reference category for independent variables. OR: Odds Ratio. CI: Confidence Interval. AIC (empty model) = 622,02. AIC (final model) = 593.55. IFI: Infant Feeding Intention ¹ Information collected at baseline. ² Information collected after delivery (2nd phase of the study).

Table 4 shows the results for pacifier and bottle-feeding use at some point during the first six months of the baby's life. Babies whose mothers intended to offer a pacifier were 2.13-fold (95%CI: 1.36-3.33) more likely to use pacifier and bottle-feeding during the six months (p<0.05).

Table 4
Analyses (crude and adjusted) of associations with pacifier and bottle-feeding use at some point during the baby’s first 6 months of life (n=455).

Variables	Categories	N (%)	Pacifier and bottle-feeding up to 6 months of life		Crude OR (95%CI)	p-value	OR Final Model (95%CI)	p-value
			*Yes N (%)	No N (%)
Distal Level
Family income (Reais)1	≤ 2000	242 (53.2)	97 (40.1)	145 (59.9)	1.69 (1.09-2.60)	0.0180	-	-
	> 2000	155 (34.1)	44 (28.4)	111 (71.6)	Ref
	Not informed	58 (12.8)	15 (25.9)	43 (74.1)	-
Type of residence1	Own	211 (46.4)	63 (29.9)	148 (70.1)	Ref		-	-
	Not own	243 (53.4)	92 (37.9)	151 (62.1)	1.43 (0.97-2.12)	0.0734
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-
Skin Color / Ethnicity1	White	201 (44.2)	73 (36.3)	128 (63.7)	Ref		-	-
	Not White	254 (55.8)	83 (32.7)	171 (67.3)	0.85 (0.56-1.26)	0.4166
Maternal Age (years)1	≤ 27	246 (54.1)	86 (35.0)	160 (65.0)	1.07 (0.72-1.57)	0.7428	-	-
	> 27	209 (45.9)	70 (33.5)	139 (66.5)	Ref
Maternal level of schooling1	Elementary school (complete and incomplete)	86 (18.9)	40 (46.5)	46 (53.5)	1.89 (1.17-3.04)	0.0090	-	-
	Other	368 (80.9)	116 (31.5)	252 (68.5)	Ref
	Not informed	1 (0.2)	0 (0.0)	1 (100.0)	-
Return to work within 6 months2	Yes	109 (24.0)	42 (38.5)	67 (61.5)	1.28 (0.82-2.00)	0.2764	-	-
	No	344 (75.6)	113 (32,8)	231 (67.2)	Ref
	Not informed	2 (0.4)	1 (50.0)	1 (50.0)	-
Parity1	Primiparous	169 (37.1)	57 (33.7)	112 (66.3)	0.96 (0.64-1.44)	0.8474	-	-
	Multiparous	286 (62.9)	99 (34.6)	187 (65.4)	Ref
Maternal marital status1	Single or Separated	156 (34.3)	51 (32.7)	105 (673)	0.90 (0.60-1.35)	0.6051	-	-
	Married or common-law marriage	299 (65.7)	105 (35.1)	194 (64.9)	Ref
Distal Intermediate Level
Baby’s sex2	Female	224 (49.2)	79 (35.3)	145 (64.7)	Ref		-	-
	Male	231 (50.8)	77 (33.3)	154 (66.7)	0.92 (0.62-1.35)	0.6639
Baby’s birth weight (Kg)2	≤ 3.28	226 (49.7)	89 (39.4)	137 (60.6)	1.58 (1.07-2.34)	0.0228	-	-
	> 3.28	223 (49.0)	65 (29.2)	158 (70.8)	Ref
	Not informed	6 (1.3)	2 (33.3)	4 (66.7)	-
Type of delivery2	Vaginal	200 (44.0)	61 (30.5)	139 (69.5)	Ref		-	-
	Caesarean section	255 (56.0)	95 (37.2)	160 (62.8)	1.35 (0.91-2.01)	0.1324
Proximal Intermediate Level
Prenatal place1	SUS, exclusively	412 (90.6)	143 (34.7)	269 (65.3)	1.23 (0.62-2.43)	0.5568	-	-
	Others	43 (9.4)	13 (30.2)	30 (69.8)	Ref
Mother received help to breastfeed1	Yes	150 (33.0)	51 (34.0)	99 (66.0)	Ref		-	-
	No	304 (66.8)	104 (34.2)	200 (65.8)	1.00 (0.67-1.52)	0.9645
	Not informed	1 (0.2)	1 (100.0)	0 (0.0)	-
EBF intention (IFI Scale score)1	< 16	221 (48.6)	87 (39.4)	134 (60.6)	1.55 (1.05-2.29)	0.0269	-	-
	16	234 (51.4)	69 (29.5)	165 (70.5)	Ref
Have previously breastfed1	Yes	253 (55.6)	82 (32.4)	171 (65.6)	Ref		-	-
	No	202 (44.4)	74 (36.6)	128 (63.4)	1.21 (0.82-1.78)	0.3460
Golden hour breastfeeding practice1	Yes	164 (36.0)	49 (29.9)	115 (70.1)	Ref		-	-
	No	288 (63.3)	106 (36.8)	182 (63.2)	1.37 (0.91-2.06)	0.1364
	Not informed	3 (0.7)	1 (33.3)	2 (66.7)
Proximal Level
Intention to offer pacifier1	Yes	208 (45.7)	91 (43.8)	117 (56.2)	2.13 (1.36-3.33)	0.0009	2.13 (1.36-3.33)	0.0009
	No	157 (34.5)	42 (26.8)	115 (73.2)	Ref		Ref
	Don't know	90 (19.8)	23 (25.6)	67 (74.4)	0.94 (0.52-1.70)	0.8375	0.94 (0.52-1.70)	0.8375
Intention to offer bottle-feeding1	Yes	250 (55.0)	101 (40.4)	149 (59.6)	2.33 (1.40-3.89)	0.0012	-	-
	No	111 (24.4)	25 (22.5)	86 (77.5)	Ref
	Not informed	94 (20.7)	30 (31.9)	64 (68.1)	1.61 (0.87-3.00)	0.1399

• ^*
  Outcome event. Ref: Reference category for independent variables. OR: Odds Ratio. CI: Confidence Interval. AIC (empty model) = 587,05. AIC (final model) = 575,76. IFI: Infant Feeding Intention ¹ Information collected in the baseline. ² Information collected after delivery.

Discussion

This cohort study assessed the influence of pre- and postnatal factors on the prevalence of pacifier and bottle use over the first six months of a baby's life. Prevalence rates of 48.2%, 52.5%, and 33.4% were found for pacifier, bottle, and pacifier+bottle use, respectively. These rates are much higher than those found in the II Brazilian National Breastfeeding Prevalence Survey of 2008 [²⁰], which found that 24.8% of babies aged up to one year were exclusively bottle-fed and 9.1% used a pacifier.

The prevalence rates of pacifier and bottle-feeding use over the first six months of a baby´s life was very close to those found among pregnant women who reported intending to offer bottle-feeding (54.8%) and pacifier (45.0%). Therefore, we recommend effective strategies for improving the knowledge and empowering future lactating women about the consequences of deleterious oral habits to BF and the baby's health.

The pregnant women’s intention to bottle-feed was associated with the baby´s being offered bottle-feeding during the first six months. Similarly, the mother's return to work was associated with bottle-feeding use, corroborating data from cross-sectional studies [²⁰,²¹]. It has been pointed out that puerperal women who were unable to be close to their babies chose to bottle-feed [²⁸]. One can suggest measures for encouraging BF after the mothers return to work, such as manual milking and storage of breast milk that would be offered using alternative containers that do not promote nipple confusion (such as American, 360° cup and spoon-feeding).

The newborn's weight was also associated with bottle-feeding use. Those with lower birth weight (≤ 3.28 kg) were more likely to be bottle-fed. Considering that some practices associated with bottle-feeding can contribute to fast weight gain, it is possible that many parents choose to use infant formula [²⁹].

Concerning pacifier use, babies whose mothers who lived in residences that were not owned by them were more likely to use a pacifier. Although we cannot assume that people living in their own homes are more socioeconomically favored than their counterparts, babies living in lower socioeconomic households tend to use pacifiers [³⁰].

Babies whose mothers reported intending to offer a pacifier at the end of the pregnancy were more prone to offer it to their babies. It is important to consider that mothers who do not plan to BF, are undecided, or plan to BF for a short period, may choose to use a pacifier instead of the breast to comfort the baby and assist with weaning [¹⁸]. Additionally, there is a cultural issue in Brazil related to the offering of pacifiers to babies as early as in the first month of life, aiming to soothe them [³¹].

The pregnant women’s intention to offer a pacifier was also associated with the use of pacifier+ bottle, even though the participants showed a strong intention to EBF, as demonstrated in a study conducted in a Brazilian urban center that showed an association between the use of bottle in the first month of the baby’s life and the use of pacifier [²³]. However, according to Jaafar et al. [³²], mothers who are well motivated to breastfeed should be encouraged to make a decision about pacifier use based on their personal preferences. Thus, we recommend providing advice about the consequences of using artificial nipples on BF and the baby's health during pregnancy and after childbirth.

Considering the harmful effects of pacifiers and bottles for EBF practice and the health institutions recommendations, the health professional must also recognize the influence of culture and media exposure on the use of artificial nipples to guide future mothers since the gestational period. In case the family chooses to use them, the decision must be welcomed and respected since offering pacifiers and bottle-feeding provides emotional security for mother and baby, especially when the mother is not available. The findings of this study highlight the relevance of prenatal public policy measures aimed at improving the knowledge and empowering pregnant women about the deleterious effects of pacifier use and bottle-feeding on the baby's health and BF.

The limitations of this study include the failure to contact some of the participants at baseline due to telephone number changes. The strengths of this study are the design, quality of data, and statistical analysis.

Conclusion

About 50% of the babies used pacifier or were offered bottle-feeding, which were associated with the mothers’ prenatal intention to offer them to their babies and socioeconomic factors. It is necessary to advise pregnant women about the consequences of pacifier and bottle-feeding use for the baby's health and breastfeeding.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

Acknowledgments

The authors would like to thank the maternity hospital and its employees for welcoming us, and the pregnant women for their participation in the study, to Dr. Cintia Regina Tornisiello Katz for contribution to the article writing, Dr. Laurie Nommsen-Rivers, for authorizing the use and Dr. Fernanda Góes for translating the Infant Feeding Intentions scale.

• Financial Support
  This study was supported by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001.

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Edited by

Academic Editor: Alessandro Leite Cavalcanti

Publication Dates

• Publication in this collection
  04 Dec 2023
• Date of issue
  2023

History

• Received
  03 Nov 2022
• Accepted
  17 Mar 2023