The New SIDS Recommendations: did they really say to use a pacifier?

This year, the AAP came out with new recommendations for SIDS prevention.  In addition to stressing the importance of tummy time, and thereby acknowledging a the huge unintended consequence of the previous policy statement of plagiocephaly, and torticollis, they made some recommendations that made me check to see that my computer screen wasn't blurry.

The AAP said that kids should use pacifiers. 

First things first.  SIDS is defined as "The sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including a performance of a complete autopsy, examination of the death scene, and review of the clinical history."   In this definition of SIDS is the crux of the problem: we don't know what causes it.  When we don't know what causes something in medicine, we make lists.  So here's the list:

The official recommendations for SIDS prevention:

• Back to Sleep
• Use a firm surface
• Keep soft objects and loose bedding out of the crib
• Do not smoke
• Separate but proximate sleeping environment
• Use a pacifier
• Avoid overheating
• Avoid commercial devices used to reduce SIDS (like sleep positioners)
• Do not use home monitors as a strategy for SIDS risk reduction
• Avoid development of positional plagiocephaly

There are some asterisks for the pacifier use-- breastfed kids shouldn't be offered one until they are one month old, but, indeed, it does say to use a pacifier.   I found the "close proximity" very interesting.  The AAP is very anti-co-sleeping, but they can't ignore the mounting evidence that kids with frequent parental contact at night are less likely to die of SIDS.  This might be as close to them saying that babies shouldn't sleep through the night.

Let's tackle the pacifier stuff first.  I'll save the safe sleep environment stuff for another page.

The gold standard for clinical research is a prospective double blind randomized controlled study, where you do one intervention in one group and don't do it in another and the people doing the evaluating don't know what group you belong to (which you really couldn't do with pacifiers). The two groups should be the same in terms of age, weight and any number of other factors so that you are comparing apples to apples.

The pacifier data tried to be a randomized controlled study, but then the babies did what babies will do, which is be babies.  And you can't always make babies do what you want them to-- some kids who were supposed to take pacifiers didn't, and some who weren't supposed to take pacifiers did.  That mucks up your data.  It's hard to make policy statements based on mucked up data.

Next, there was a big study (a meta-analysis) done which looked at all the data from the little studies and came up with the conclusion that there is a strong correlation between pacifier use and SIDS risk reduction.  That turned into the US recommendation for pacifier use.  That same data was available to other researchers (from Canada) who lessened their conclusion to there is no reason to discourage use.  They stopped short of saying that we should use pacifiers.  Plus, this is data that shows a correlation-- not a cause and effect.

So what does all this mean? I'm not sure.

Maybe, we are discovering that there is something special about kids who take pacifiers.

Maybe, we are teaching the kids something.  That could be good or bad, since it seems that once a kid starts taking a pacifier, they should stay using one.  The data seem to indicate that there is a risk to a child who is a regular pacifier user who doesn't get their pacifier at the time they go to bed.  If your child uses a pacifier, it seems to suggest, stay using one.  It may be risky not to take a pacifier if you are routinely using one.

Or maybe, kids who are regular pacifier users who then don't take their pacifier before they go to bed are sick or having some change in behavior that would indicate something was wrong before they went to bed.

So.  This is all a bit confusing.

Where we are:

The AAP statement says that  "the reduced risk of SIDS associated with pacifier use is compelling" so "until the evidence dictate otherwise" that children should be offered a pacifier unless they are breastfeeding, at which point the pacifier should be introduced at 1 month of age. 

If you choose to use a pacifier, use it regularly.  There seems to be a risk to children who regularly use a pacifier and then don't.

If you are nursing and want to use a pacifier before 1 month of age, that can be a sign of breastfeeding difficulties and I want to hear about those.

We need more research.  The stuff we have doesn't really paint a clear picture either for or against pacifier use.  Even though the AAP says "yes" to pacifiers, there are certainly lots of organizations that have disagreed.