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Revista de Saúde Pública logoLink to Revista de Saúde Pública
. 2014 Aug;48(4):571–582. doi: 10.1590/S0034-8910.2014048005128

Determinants of using pacifier and bottle feeding

Determinantes do uso de chupeta e mamadeira

Gabriela dos Santos Buccini I, Maria Helena D’Aquino Benício I, Sonia Isoyama Venancio II
PMCID: PMC4181101  PMID: 25210816

Abstract

OBJECTIVE

To analyze the factors associated with the use of pacifiers and/or bottle feeding in infants aged under one year.

METHODS

This is a cross-sectional study with 34,366 children and using data from the database of the 2nd Nationwide Survey of Breastfeeding Prevalence performed in the Brazilian capitals and Federal District in 2008. Cluster sampling was used. The questionnaire included questions about the use of artificial nipples in the last 24 hours. The analysis considered three outcomes: exclusive use of pacifier, exclusive use of bottle feeding, and use of artificial nipples (pacifier and bottle feeding). Prevalence ratios were obtained using Poisson regression with robust variance following a hierarchical model.

RESULTS

The following factors were associated with exclusive use of the pacifier: mother working outside the home, primiparity, child was not breastfed within the first hour, and child had consumed tea on the first day at home. The following factors were associated with exclusive use of bottle feeding: mother working outside the home, primiparity, low birth weight, child not breastfed within the first hour, and child had consumed milk formula and tea on the first day at home. The following factors were associated with use of artificial nipples (pacifier and bottle feeding): mother working outside the home, primiparity, cesarean delivery, the male gender, low birth weight, born in a hospital not accredited as “baby friendly”, required health baby monitoring in the Primary Health Care Unit (PR = 0.91), and child had consumed milk formula, water, or tea on the first day at home.

CONCLUSIONS

This study identified profiles of exclusive users of pacifiers, bottle feeding, and both. The provided information can guide preventive practices for child health.

Keywords: Bottle Feeding; Pacifiers, utilization; Maternal and Child Health; Cross-Sectional Studies

INTRODUCTION

It is estimated that two-thirds of newborns will receive bottle feeding and pacifiers during the first year of life. 24 However, the use of these tools can affect breastfeeding 14 and induce alteration in the children’s health. 9 , 19 , 23 In the history of mankind, the use of artificial nipples has assumed different roles and sociocultural representations. 12 , 16 , 23

Among the pacifier users, those who use it more frequently include firstborn children, 19 , 24 males, 18 , 23 , 24 children with low birth weight, 23 children aged under 6 months, 19 children not breastfed in the maternity ward, 23 and children breastfed at prearranged times. 22 In addition, mothers who were younger, 1 , 6 , 23 were primiparous, 6 , 23 had a low socioeconomic status, 9 had a smoking history, 9 , 24 and were less educated 1 , 9 , 18 were more likely to resort to the use of pacifiers. Qualitative studies have indicated that the use of pacifiers is correlated with cultural issues, maternal uncertainty about her ability to breastfeed, and crying and behavior of baby. 3 , 16 , 23 , 24 Previous studies have indicated that infant-related factors that favor the use of bottle feeding include decreased weight gain, excessive crying, 12 the use of pacifiers, 6 and the consumption of processed milk, tea, and water. 6 Maternal-related factors that favor the use of bottle feeding include teenage mothers, 6 maternal uncertainty about her ability to breastfeed and difficulty in breastfeeding, 6 , 12 , 23 nervousness and impatience, 12 convenience, 12 working outside the home, 12 , 13 and coexistence with the maternal grandmother. 6 In addition, parents and health professionals indicate that the use of bottle feeding facilitates feeding and brings confidence during infant feeding.

However, these results cannot be generalized because the aforementioned studies were conducted in distinct periods, with distinct methodologies and population groups. Till date, no study has investigated the determinants of the use of artificial nipples using a representative sample of children in Brazil. Therefore, the present study aimed to identify the factors associated with the use of pacifiers and/or bottle feeding in children aged under one year.

METHODS

This cross-sectional study analyzed data from the Second National Survey on the Prevalence of Breastfeeding (II NSPB), conducted in Brazil in 2008. a

The II NSPB is a national survey on the status of breastfeeding and complementary feeding involving children aged ≤ 12 months who participated in the second phase of the national campaign of multivaccination. 21

The survey was conducted with cluster samples, lots were cast in two stages, and the probabilities were proportional to the cluster size. In the first stage, lots were cast on the vaccination sites, and in the second stage, lots were cast on the children vaccinated at each site. The sample size considered the prevalence of exclusive breastfeeding in 1999, in the 26 state capitals and in the Federal District (FD), with an added rate of 2.0%-10.0% to account for the increase in prevalence. To compensate for the potential loss of precision, the design effect was added to the sample by multiplying the initial estimate by 1.5 and incorporating a nonresponse rate, which ranged between 5.0% and 10.0%. The sample size required to estimate the prevalence of breastfeeding in children aged < 6 months was multiplied by two. Therefore, the minimum sample size varied between each capital but was reached in all capitals, ensuring sample representativeness. In total, 34,366 children aged under one year, who participated in the second phase of the multivaccination campaign conducted in all Brazilian capitals and FD in 2008, were analyzed. Detailed data of each sample population by capital have been reported previously. 21 , 22

For proper implementation of the process of casting lots on the children participating in the vaccination program, the interviewers were provided instructions with regard to the importance of randomness in data collection and systematic random sampling. 21

The data collection instrument was also applied to the child’s parents or guardians. The questionnaire included closed questions related to the children and mother profile, infant feeding, health care services used by families, and use of pacifiers and bottle feeding in the last 24 hours.

Three outcomes were defined: the exclusive use of pacifiers (i.e., nonusers of bottle feeding), exclusive use of bottle feeding (i.e., nonusers of pacifiers), and use of artificial nipples (users of both pacifiers and bottle feeding). Each of the three outcomes were classified on the basis of the affirmative responses to the outcome in relation to the lack of use of artificial nipples during the study period, similar to the methodology used in studies on disease-associated factors (sick versus healthy patients). The three children subsamples with a positive outcome were compared with the subsample comprising the nonusers of artificial nipples. We chose this analysis strategy to attenuate potential confounders.

Data entry was performed by team members in each state capital using a web application specially developed for the typing of this information. 21 The II NSPB database was exported to Stata software version 9.2 for data analysis. Sample complexity in all the study phases was considered.

After descriptive analysis, age-adjusted Poisson regression analysis with robust variance 4 was used to estimate the prevalence ratio (PR) and confidence intervals (95%CI). A linear trend test was used for the variables having a theoretical assumption of a dose-response relation. To estimate the individual influence of the outcome-associated variables, we used a multiple hierarchical model. For this purpose, the variables were grouped into blocks and ordered according to the influence that they would have on each outcome. The theoretical model that guided the analysis and the variables are presented in Figure. Notably, the variables related to infant feeding during the first day after hospital discharge were only collected for children aged under four months (subsample) to any avoid possible memory bias.

Figure. Hierarchical theoretical model to determine the factors associated with use of artificial nipples. State capitals and Federal District, Brazil, 2008.

Figure

Considering that this study has three different outcomes, the steps for data analysis were separately reproduced for each outcome. Initially, PR was calculated for each variable and outcome (step 1). Variables with p < 0.20 were entered into multiple internal analysis of each block (step 2). Following this, variables with p < 0.20 in internal analysis of each block were used as control variables in step 3 as follows.

The variables of the more distal block (1), “Socioeconomic profile and maternal lifestyle”, were the first variables to be included in the model and served as adjustment factors for the hierarchically inferior variables. Similarly, the variables of the intermediate blocks (2 and 3), “Characteristics related to birth conditions and the health care services used”, which met the inclusion criteria of the multivariate model after adjusting for the distal block, became the control variables of the subsequent block. An analogous procedure was adopted for analyzing the proximal blocks (4A and 4B), “Characteristics of infant feeding within the first hour after birth and on the first day after hospital discharge”. The selected variables were maintained in the model despite having lost statistical significance after including the inferior blocks. After adjusting for the factors of the same block and superior blocks, the correlation between variables and outcomes was considered significant by adopting a significance level of 5%.

The research protocol was approved by the Research Ethics Committee of the Faculdade de Saúde Pública of the Universidade de São Paulo (Protocol 2,192, from 3/18/2011).

RESULTS

The study included 34,366 children aged ≤ 12 months. We observed a predominance of children aged under six months (54.5%) and of the male gender. Low birth weight was observed in 9.0% of the children. Most mothers were aged between 20 and 35 years (72.2%), had < 12 years of education (85.6%), and did not work outside the home (66.2%). Approximately 50.0% of the mothers were primiparous, and approximately 50.0% deliveries were cesarean. One-third of the deliveries occurred in a Baby-Friendly Hospital initiative (BFH), and 58.7% of the children had routine follow-up in public health care units (basic health care units or family health strategy (FHS) units). Approximately 70.0% of the children were breastfed within the first hour after birth. With regard to the outcomes, information on the use of pacifiers and/or bottle feeding was available for 33,776 children (98.3%). Of these, 2,901 (9.1%) exclusively used pacifiers, 8,757 (24.8%) exclusively used bottle feeding, and 10,451 (33.5%) used artificial nipples. Approximately one-third (n = 11,667, 32.6%) of the children used no artificial nipples.

In the subsample of children aged under four months (n = 12,704), 95.9% were breastfed on the first day after hospital discharge. In contrast, processed milk, tea, and water were consumed on the first day after birth by 12.0%, 8.4%, and 5.0% of the children, respectively. To determine the similarity between the subsample of children aged under four months and the rest of the population, these two groups were compared in relation to maternal education (considered in this study as a proxy for the socioeconomic status), infant gender, birth weight, and type of delivery. No significant differences were found among these groups.

The sample strata used for analysis of the exclusive use of pacifiers comprised exclusive users of pacifiers (n = 2,901) and nonusers of artificial nipples (n = 11,667). The frequency of use of pacifiers gradually decreased as infant age increased, indicating a strong inverse correlation (p < 0.001) (data not shown).

Table 1 shows the prevalence of children who used exclusively pacifiers among those born from primiparous women, those born by cesarean delivery, and male infants. The use of pacifiers gradually increased among children born from mothers who worked outside the home. It was observed that the consumption of tea on the first day after hospital discharge and the inability to breastfeed within the first hour after birth were associated with the increased use of pacifiers.

Table 1. Poisson analysis of the exclusive use of pacifiers in children aged under one year and age-adjusted prevalence ratio. State capitals and Federal District, Brazil, 2008.

Variable Total Na Exclusive use of pacifier (%) PRadjusted 95%CI p
Distal block (1)          
 Maternal age (years)         0.122b
  20 to 35 9,017 21.3 1    
  < 20 3,044 23.0 1.09 0.97;1.24 0.119
  > 35 1,372 21.9 1.03 0.88;1.21 0.685
 Maternal education (years)         0.161b
  > 12 1,795 24.8 1    
  9 to 12 6,363 21.7 0.90 0.77;1.03 0.139
  0 to 8 5,189 20.9 0.90 0.76;1.02 0.093
 Maternal work         0.016b
  Not working outside the home 9,025 20.6 1    
  On maternity leave 1,964 26.9 1.13 0.99;1.29 0.076
  Working outside the home 1,678 23.1 1.16 1.00;1.35 0.045
 Primiparity          
  No 7,079 19.3 1    
  Yes 6,114 24.8 1.28 1.16;1.41 < 0.001

Intermediate block (2 to 3)
 Type of delivery          
  Normal/Forceps 7,582 20.7 1    
  Cesarean 6,862 23.0 1.10 1.00;1.21 0.049
 Infant gender          
  Female 7,395 20.8 1    
  Male 7,173 22.8 1.10 1.00;1.21 0.041
 Low birth weight ( < 2,500 g)          
  No 13,182 22.1 1    
  Yes 1,069 20.4 0.90 0.74;1.10 0.297
 Born in Baby-Friendly Hospital          
  Yes 5,092 21.5 1    
  No 8,385 22.1 1.02 0.92;1.13 0.611
 Routine health care services          
  Family Health Strategy 3,715 23.4 1    
  Basic health care unit 4,514 20.7 0.89 0.79;1.01 0.088
  Private health care services 4,747 23.4 1.00 0.89;1.13 0.923

Proximal block (4A)
 Breastfed within first hour of birth          
  Yes 9,976 20.3 1    
  No 3,886 24.8 1.19 1.08;1.32 0.001

Proximal block (4B)
 Breastfed on the first day after hospital discharge      
  Yes 7,310 25.6 1    
  No 168 23.8 0.94 0.66;1.33 0.744
 Consumed processed milk on the first day after hospital discharge
  No 7,021 25.3 1    
  Yes 384 28.9 1.16 0.91;1.48 0.219
 Consumed water on the first day after hospital discharge
  No 7,219 25.6 1    
  Yes 186 23.3 0.96 0.62;1.48 0.873
 Consumed tea on the first day after hospital discharge
  No 7,052 25.2 1    
  Yes 337 32.0 1.30 1.01;1.67 0.040

a This analysis included exclusively users of pacifiers and nonusers of artificial nipples.

b Linear trend test.

Table 2 shows that the factors associated with the exclusive use of pacifiers in multivariate analysis were primiparity, mother working outside the home, inability to breastfeed within the first hour after birth, and consumption of tea on the first day after hospital discharge.

Table 2. Multiple hierarchical model to identify the factors associated with the exclusive use of pacifiers in children aged under one year. State capitals and Federal District, Brazil, 2008.

Variable PRadjusted 95%CI p
Model 1a
 Maternal work     0.017d
  Not working outside the home 1    
  On maternity leave 1.11 0.96;1.27 0.139
  Working outside the home 1.18 1.01;1.37 0.034
 Primiparity      
  No 1    
  Yes 1.28 1.15;1.42 < 0.001

Model 3b
 Breastfed within the first hour after birth
  Yes 1    
  No 1.15 1.03;1.29 0.014

Model 4c
 Ingested tea on the first day after birth
  No 1    
  Yes 1.37 1.05;1.79 0.020

a Model 1: work, primiparity, and infant age.

Model 2: Model 1 + infant gender and type of delivery.

b Model 3: Model 2 + breastfeeding within the first hour.

c Model 4: Model 3 + consumption of tea on the first day after hospital discharge.

d Linear trend test.

The sample strata used for analysis of the exclusive use of bottle feeding comprised exclusive users of bottle feeding (n = 8,757) and nonusers of artificial nipples (n = 11,667).

It was observed that as the children age progressed, the exclusive use of bottle feeding increased. Trend analysis indicated the existence of a dose-response relationship (p < 0.001) (data not shown).

Table 3 shows that the frequency of use of bottle feeding gradually increased among working mothers; however, no significant difference was observed between mothers on maternity leave and those who did not work outside the home. Low birth weight and inability to breastfeed within the first hour after birth were associated with the increased use of bottle feeding. As expected, the consumption of commercial milk, tea, or water on the first day after hospital discharge stimulated the exclusive use of bottle feeding.

Table 3. Poisson analysis of the exclusive use of bottle feeding in children aged under one year and age-adjusted prevalence ratio. State capitals and Federal District, Brazil, 2008.

Variable Total Na Exclusive use of baby bottles (%) PRadjusted 95%CI p
Distal block (1)
 Maternal age (years)         0.274b
  20 to 35 12,127 40.6 1    
  < 20 4,243 42.0 1.02 0.96;1.08 0.433
  > 35 1,897 44.5 1.07 0.98;1.15 0.090
 Maternal education (years)         0.008b
  > 12 2,419 44.7 1    
  9 to 12 8,725 41.4 0.93 0.87;1.00 0.073
  0 to 8 7,036 40.3 0.90 0.83;0.96 0.006
 Maternal work         < 0.001b
  Not working outside the home 12,171 39.0 1    
  On maternity leave 1,985 26.6 0.99 0.88;1.12 0.953
  Working outside the home 3,089 60.3 1.40 1.33;1.48 < 0.001
 Primiparity          
  No 9,424 38.7 1    
  Yes 8,501 44.3 1.13 1.07;1.19 < 0.001

Intermediate block (2 to 3)
 Type of delivery          
  Normal/Forceps 10,526 41.6 1    
  Cesarean 9,698 45.0 1.08 1.03;1.13 0.001
 Child gender          
  Female 10,287 42.3 1    
  Male 10,137 44.2 1.01 0.97;1.06 0.488
 Low birth weight (< 2,500 g)          
  No 18,188 42.4 1    
  Yes 1,711 49.6 1.18 1.09;1.27 < 0.001
 Born in Baby-Friendly Hospital          
  Yes 6,993 41.9 1    
  No 11,881 44.2 1.05 1.00;1.10 0.050
 Routine health care services          
  Family Health Strategy 5,129 42.1 1    
  Basic health care unit 6,371 41.6 0.96 0.90;1.02 0.252
  Private health care services 6,854 47.3 1.08 1.02;1.14 0.008

Proximal block (4A)
 Breastfed within the first hour after birth
  Yes 13,793 24.9 1    
  No 5,485 38.7 1.55 1.15;2.09 0.003

Proximal block (4B)
 Breastfed on the first day after hospital discharge      
  Yes 7,467 24.9 1    
  No 197 38.7 1.50 1.12;2.03 0.007
 Consumed processed milk on the first day after hospital discharge
  No 7,007 22.8 1    
  Yes 580 51.4 2.20 1.91;2.52 < 0.001
 Consumed water on the first day after hospital discharge
  No 7,318 24.6 1    
  Yes 266 41.3 1.54 1.21;1.94 < 0.001
 Consumed tea on the first day after hospital discharge
  No 7,079 23.3 1    
  Yes 493 52.2 2.15 1.86;2.49 < 0.001

a This analysis included exclusively users of baby bottles and nonusers of artificial nipples.

b Linear trend test.

Table 4 indicates that the factors associated with the exclusive use of bottle feeding in multivariate analysis were primiparity, mother working outside the home, low birth weight, inability to breastfeed within the first hour after birth, and the consumption of processed milk or tea on the first day after hospital discharge.

Table 4. Multiple hierarchical model to identify the factors associated with the exclusive use of bottles in children aged under one year. State capitals and Federal District, Brazil, 2008.

Variable PRadjusted 95%CI p
Model 1a      
 Maternal work     < 0.001e
  Not working outside the home 1    
  On maternity leave 0.97 0.86;1.10 0.708
  Working outside the home 1.39 1.32;1.47 < 0.001
 Primiparity      
  No 1    
  Yes   1.06;1.17 < 0.001

Model 2b
 Low birth weight      
  No 1    
  Yes 1.21 1.11;1.31 < 0.001

Model 3c
 Breastfed within the first hour after birth
  Yes 1    
  No 1.08 1.02;1.15 0.004

Model 4d
 Consumed processed milk on the first day after hospital discharge
  No 1    
  Yes 1.82 1.52;2.19 < 0.001
 Consumed tea on the first day after hospital discharge
  No 1    
  Yes 1.96 1.63;2.36 < 0.001

a Model 1: maternal work, primiparity, infant age.

b Model 2: Model 1 + low birth weight.

c Model 3: Model 2 + breastfeeding within the first hour.

d Model 4: Model 3 + intake of processed milk or tea on the first day.

e Linear trend test.

The sample strata used for analysis of the use of artificial nipples comprised users of artificial nipples (pacifiers and bottle feeding) (n = 10,451) and nonusers of artificial nipples (n = 11,667).

Advancing child age was associated with the increased use of artificial nipples. Trend analysis indicated a significant correlation (p < 0.001), suggesting the existence of a dose-response relationship (data not shown).

Table 5 shows that younger women offered artificial nipples to their children more frequently than older women. Moreover, primiparous women offered artificial nipples to their children more frequently than nonprimiparous women. Cesarean delivery, low birth weight, and the male gender were factors associated with the increased use of artificial nipples. As expected, mothers who worked outside the home resorted to artificial nipples more frequently than those who did not work outside the home. However, births in BFH and breastfeeding within the first hour after birth favored the decreased use of artificial nipples. Children routinely attending basic health care units tended to use artificial nipples less frequently, whereas those attending private health care facilities tended to use artificial nipples more frequently.

Table 5. Poisson analysis of the use of artificial nipples in children aged under one year and age-adjusted prevalence ratio. State capitals and Federal District, Brazil, 2008.

Variable Total Na Use of artificial nipples (%) PRadjusted 95%CI p
Distal block (1)          
 Maternal age (years)         0.004b
  20 to 35 12,809 46.8 1    
  < 20 4,584 50.1 1.07 1.02;1.13 0.008
  > 35 2,018 50.6 1.06 0.99;1.14 0.072
 Maternal education (years)         < 0.001b
  > 12 2,783 55.7 1    
  9 to 12 9,056 47.1 0.86 0.81;0.91 < 0.001
  0 to 8 7,479 46.6 0.84 0.79;0.89 < 0.001
 Maternal work         < 0.001b
  Not working outside the home 12,550 43.8 1    
  On maternity leave 2,148 34.1 0.97 0.88;1.08 0.644
  Working outside the home 3,562 69.1 1.45 1.39;1.52 < 0.001
 Primiparity          
  No 9,680 43.2 1    
  Yes 9,349 52.9 1.21 1.16;1.26 < 0.001

Intermediate block (2 to 3)
 Type of delivery          
  Normal/Forceps 11,132 48.4 1    
  Cesarean 10,718 52.7 1.09 1.04;1.13 < 0.001
 Child gender          
  Female 11,021 49.4 1    
  Male 11,097 52.1 1.04 1.00;1.08 0.016
 Low birth weight (< 2,500 g)          
  No 19,657 49.9 1    
  Yes 1,866 55.2 1.11 1.05;1.19 < 0.001
 Born in Baby-Friendly Hospital          
  Yes 7,496 45.5 1    
  No 12,812 53.0 1.15 1.10;1.20 < 0.001
 Routine health care services          
  Family Health Strategy 5,521 49.6 1    
  Basic health care unit 6,528 46.7 0.93 0.88;0.98 0.011
  Private Health Care Service 7,723 56.5 1.09 1.05;1.15 < 0.001

Proximal block (4A)
 Breastfed within the first hour after birth
  Yes 14,669 49.0 1    
  No 6,129 52.5 1.09 1.05;1.14 < 0.001

Proximal block (4B)
 Breastfed on the first day after hospital discharge
  Yes 8,082 33.5 1    
  No 399 72.4 2.11 1.91;2.33 < 0.001
 Consumed processed milk on the first day after hospital discharge
  No 7,493 30.6 1    
  Yes 910 70.5 2.25 2.08;2.44 < 0.001
 Consumed water on the first day after hospital discharge
  No 7,952 33.6 1    
  Yes 438 66.2 1.87 1.67;2.08 < 0.001
 Consumed tea on the first day after hospital discharge
  No 7,746 33.1 1    
  Yes 639 64.0 1.87 1.70;2.06 < 0.001

a This analysis included exclusive user of artificial nipples (pacifiers and bottle feeding) and nonusers of artificial nipples.

b Linear trend test.

Table 6 presents the factors associated with the use of artificial nipples after adjusting for other variables: mother working outside the home, primiparity, cesarean delivery, the male gender, low birth weight, deliveries in hospitals not accredited by the BFH system, type of health care service (private/health insurance), inability to breastfeed within the first hour after birth, and consumption of processed milk, tea, or water on the first day after hospital discharge. Performing routine follow-up in primary health care units was a protective factor against the use of artificial nipples.

Table 6. Multiple hierarchical model to identify the factors associated with the use of artificial nipples in children aged under one year. State capitals and Federal District, Brazil, 2008.

Variable PRadjusted 95%CI p
Model 1a
 Maternal work     < 0.001f
  Not working outside the home 1    
  On maternity leave 0.95 0.86;1.07 0.447
  Working outside the home 1.43 1.37;1.51 < 0.001
 Primiparity      
  No 1    
  Yes 1.21 1.15;1.27 < 0.001

Model 2b
 Type of delivery      
  Normal/Forceps 1    
  Cesarean 1.06 1.01;1.12 0.008
 Child gender      
  Female 1    
  Male 1.07 1.02;1.12 0.003
 Low birth weight      
  No 1    
  Yes 1.11 1.03;1.19 0.005

Model 3c
 Born in Baby-Friendly Hospital
  Yes 1    
  No 1.12 1.06;1.18 < 0.001
 Routine health care services
  Family Health Strategy 1    
  Basic Health Care Unit 0.91 0.86;0.97 0.005
  Private health care services 1.02 0.96;1.09 0.397

Model 4d
 Breastfed within the first hour after birth
  Yes 1    
  No 1.06 1.00;1.11 0.030

Model 5e
 Consumed processed milk on the first day after hospital discharge
  No 1    
  Yes 2.06 1.83;2.31 < 0.001
 Consumed water on the first day after hospital discharge
  No 1    
  Yes 1.18 1.01;1.37 < 0.001
 Consumed tea on the first day after hospital discharge
  No 1    
  Yes 1.38 1.21;1.59 < 0.001

a Model 1: maternal age, education and work, primiparity, and infant age.

b Model 2: Model 1 + child gender, low birth weight, and type of delivery.

c Model 3: Model 2 + BFH and health care services.

d Model 4: Model 3 + breastfeeding within the first hour.

e Model 5: Model 4 + intake of processed milk, tea, or water on the first day.

f Linear trend test.

DISCUSSION

This study is the first to investigate the determinants of the use of artificial nipples in a representative sample of children living in state capitals in Brazil. Importantly, the study classified the use of nipples into three outcomes (use of pacifiers, bottle feeding, or both), which allowed us to understand the use of these equipment, which can negatively interfere with breastfeeding and child health.

Maternal-related factors, including mother working outside the home and primiparity, were significantly correlated with the three outcomes, whereas infant-related factors, including low birth weight, cesarean delivery, and the male gender, were significantly correlated with only two outcomes (exclusive use of bottle feeding and use of artificial nipples). Child feeding on the first day after hospital discharge (through the consumption of baby formula, tea, or water) influenced the three outcomes but not the same components of each outcome, which suggests the existence of different motivations for the adoption of each feeding equipment. Birth in BFH and child follow-up in basic health care units were factors significantly correlated with the decreased use of artificial nipples.

Child age was significantly correlated with all the three outcomes. Previous studies indicated that child age may influence the use of artificial nipples. 1 , 9 , 18 , 19 , 23 , 24 Victora et al 23 and Aarts et al 1 observed that the use of pacifiers begins in early childhood and is a dynamic process until the age of three and four months. However, with advancing age, the use of this feeding equipment decreases. 1 , 9 , 23 Other authors indicated that bottle use is associated with water and tea intake and with the intake of processed milk, which increases the use of bottle feeding as child age progresses. 6 , 23 Considering the potential influence of this variable on the outcomes studied, infant age was considered an adjustment variable.

The male gender was significantly correlated with the use of artificial nipples but not with the isolated use of the two equipment. Previous studies on the use of pacifiers identified a correlation between its increased use and the male gender. 9 , 18 , 23 , 24 Another study reported a higher probability of interruption of breastfeeding in male infants. 20 In this respect, the authors suggest that mothers believe that male infants have higher nutritional requirements than female infants and they are therefore provided food supplements first. 11 Scott et al 15 indicated that the cultural construction of gender can influence this decision and can lead to the increased use of bottle feeding by male infants. However, till date, no study has indicated child gender as a determinant of the use of bottle feeding. The higher tendency of male infants to use artificial nipples than female infants warrants an explanation and should be further explored in qualitative studies. 15 , 18

Low birth weight was associated with the exclusive use of bottle feeding and artificial nipples. Weight gain is associated with child survival and is a condition that raises concerns among family members and health professionals. 3 This condition stimulates the early indication of food supplements, which are usually provided in bottle feeding, 6 , 23 thereby increasing its use among children with low birth weight. The associated use of bottle feeding and pacifiers has not been reported in previous studies. However, it is plausible to assume that these equipment will be used more frequently, considering the stressful conditions that the mother and infant are exposed to in hospital settings and during family adaptation. 3

The consumption of processed milk, tea, and water within the first day after hospital discharge was significantly correlated with the three outcomes. Previous studies have indicated that these liquids are usually provided by bottle feeding. 6 , 23 França et al 6 found that 21.3% and 46.9% infants used bottle feeding seven days and 30 days after birth, respectively, and tea and processed milk were the main ingredients offered at both instances. Bottle feeding is used as a vehicle for fluid delivery, whereas pacifiers are used to calm the infants, 16 , 18 and the latter function is also attributed to tea. 6 The symbolic and sociocultural role of calming the infant 16 , 18 , 23 corroborates the results of the present study. Although previous studies have indicated that the use of pacifiers increases the likelihood of using bottle feeding, 6 a causal relationship could not be established.

Primiparity was significantly correlated with the three outcomes, and it has been reported as a risk factor for early weaning and consequently for the use of artificial nipples. 18 , 19 , 24 Silva 17 reported that since child birth, mothers go through a learning process to understand their child’s language. Previous studies have found that parents are poorly oriented on how to manage child crying and behavior, 3 , 8 and when oriented, they feel more confident in comforting the child without resorting to artificial nipples. 8 Therefore, one can assume that less experienced mothers become more anxious when managing infant crying and behavior 16 , 19 and therefore resort to artificial nipples more frequently.

The factor mother working outside the home was significantly correlated with the three outcomes studied. Maternal work was expressed in categories of increased frequency of the use of nipples. Therefore, maternity leave was considered an intermediate condition with respect to the others. 10 , 12 , 13 Rea & Cukier 12 observed that mother working outside the home has become a primary reason for bottle feeding and weaning. Previous studies have shown that reconciling the roles of a worker and mother is increasingly common and that employee benefits alone are not sufficient for mothers to continue breastfeeding and not resort to artificial nipples. 12 , 13 In Brazil, women working in the formal sector are entitled to 120 days of maternity leave. However, their return to work is filled with anxiety and uncertainty related to children feeding and comfort in times of maternal absence. 12 Therefore, maternal work outside the home and the return to work after maternity leave are situations of great vulnerability that favor the interruption of exclusive breastfeeding and the consequent introduction of pacifiers and bottle feeding. 10

A significant correlation was observed between cesarean delivery and the use of artificial nipples. Victora et al 23 found that women who had cesarean delivery breastfed for a shorter period and resorted to pacifiers more frequently. Other authors found that women having cesarean deliveries showed a significant delay in the initiation of breastfeeding, which could lead to decreased frequency of breastfeeding and increased use of artificial nipples. 2

Breastfeeding in the first hour after birth was a protective factor and was strongly correlated with the three outcomes. In this sense, no previous studies that correlated the use of artificial nipples with breastfeeding in the first hour were found. However, some studies have correlated breastfeeding in the first hour with the increased prevalence of breastfeeding and the establishment of stronger bonds between the mother and child, 2 which are important factors involved in the decision to use artificial nipples.

BFH follow the “Ten Steps to Successful Breast-feeding”. 5 , 18 , 22 Step 9 establishes the nonuse of pacifiers and bottle feeding in hospitals for breastfed children. 5 In this study, child birth in hospitals without BFH accreditation was associated with the increased use of artificial nipples. Corroborating these findings, Coutinho et al 5 observed that the use of pacifiers and bottle feeding decreased after an BFH training program in two maternity wards. Moreover, Venancio et al 22 found a correlation between birth in BFH and the decreased use of pacifiers. Therefore, these studies highlight the need for effective support and guidance interventions during child follow-up in health care units and in the community. 5 , 22

Child follow-up is performed through primary health care services in public health care facilities, which comprise basic health care units and FHS units. In basic health care units, follow-up is performed by a pediatrician, whereas in FHS units, it is performed by a multidisciplinary team. Follow-up in public health care facilities, particularly in basic health care units, was considered a protective factor against the use of artificial nipples. The noninfluence of FHS in the results can be attributed to its low application in the Brazilian capitals (53.1% of the Brazilian territory in 2011). b

With regard to the surveys conducted during the vaccination campaigns, Venancio et al 22 reported that they are widely used in Brazil and can collect data in a short period, at a low cost. The adopted sample design and the high sample coverage (> 80.0%) in the second stage of the vaccination campaign in 2008 ensured sample representativeness. Furthermore, maternal educational levels were similar to those reported in the Live Births Information System in the same year. 21

One limitation of the present study is the noninclusion of subjects living in rural areas, and this aspect deserves attention in relation to the generalization of results. The other limitation is that the cross-sectional design of the study did not allow an assessment of the temporality of facts. However, the present study helped to identify situations that may serve as “markers” of the analyzed outcomes and to generate hypotheses for the development of longitudinal studies. 7

This is the first study to identify the factors associated with the exclusive use of bottle feeding and pacifiers and the use of artificial nipples (bottle feeding and pacifiers) in children aged under one year, in a representative sample of children. These results can be generalized to populations living in middle-income urban areas in countries such as Brazil and contribute to the planning of preventive actions in maternal and child health.

Footnotes

a

Ministério da Saúde. Prevalência de aleitamento materno nas capitais brasileiras e no Distrito Federal. Brasília (DF); 2001.

b

Ministério da Saúde. Secretária de Atenção a Saúde. Departamento de Atenção Básica. Números da Saúde da Família. Brasília (DF); 2012 [cited 2014 Jun 12]. Available from: http://dab.saude.gov.br/abnumeros.php

Article based on the master’s dissertation of Buccini GS, titled: “Determinantes do uso de chupeta e mamadeira em crianças menores de um ano nas Capitais Brasileiras e Distrito Federal”, presented to the Programa de Pós-Graduação em Nutrição em Saúde Pública of the Faculdade de Saúde Pública of the Universidade de São Paulo, in 2012.

The authors declare no conflict of interest.

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