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How Are Effective Breastfeeding Technique and

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34 BIRTH 36:1 March 2009

How Are Effective Breastfeeding

Technique and Pacifier Use Related to
Breastfeeding Problems and
Breastfeeding Duration?
Hanne Kronborg, RN, MPH, PhD, and Michael Vth, PhD

Abstract: 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 randomized 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
questionnaires. 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. (BIRTH 36:1 March 2009)

Key words: breastfeeding, postpartum period, sucking behavior, nursing assessment, pacifier

The short- and long-term health benefits that breast-
feeding confers on the child are well documented (1).
Therefore, primary health promotion begins at the
breast. An effective sucking technique is considered
important to establish breastfeeding, to ensure milk
transfer, and to prevent breastfeeding problems (24).
The babys positioning, latch, and sucking behavior at
the mothers breast define this effective technique (5).
For 20 years, the mechanics of effective sucking
technique has primarily been explained as the baby

Hanne Kronborg is an Assistant Professor in the Department of Nursing
Science at the Institute of Public Health; and Michael Vth is a Pro-
fessor in the Department of Biostatistics at the Institute of Public
Health, University of Aarhus, Aarhus C, Denmark.
Funding for this study was provided by the Danish Health Insurance
Foundation, Copenhagen; the Lundbeck Foundation, Hellerup; and the
Counties of Ribe and Ringkjobing in Denmark.
Address correspondence to Hanne Kronborg, RN, MPH, PhD,
Department of Nursing Science, Institute of Public Health, University
of Aarhus, Hegh-Guldbergsgade 6A, 8000 Aarhus C, Denmark.
Accepted October 7, 2008
2009, Copyright the Authors
Journal compilation 2009 Blackwell Publishing, Inc.
BIRTH 36:1 March 2009
expels the affluent milk from the lactiferous sinuses
beneath the areola (6,7). However, recent studies
question the existence of the lactiferous sinuses and
point to the influence of the vacuum the baby estab-
lishes and milk ejection as important factors for the
babys milk consumption (810).
An intervention study published in 1992 found that
mothers whose ineffective breastfeeding technique
was identified and corrected had a longer duration
of breastfeeding (11). Recently, two randomized stud-
ies that investigated the impact of effective breastfeed-
ing technique education were unable to confirm any
effect on breastfeeding duration (12,13).
Two other publications reported that pacifier use
combined with superficial sucking technique led to
early breastfeeding cessation and breastfeeding prob-
lems (14,15). Observational studies have subsequently
found pacifier use associated with less frequent breast-
feeding and shorter breastfeeding duration (1619),
whereas a randomized study in which mothers in the
intervention group successfully avoided pacifier use
showed no effect on weaning (20).
The lack of scientific data and inconsistency of find-
ings among breastfeeding studies leave uncertainty
about the impact and associations of effective breast-
feeding technique and pacifier use on breastfeeding
duration. The present study is based on data from
mothers included in the intervention group of a cluster-
randomized trial, aimed at prolonging the breast-
feeding period (21). In this group, but not in the
comparison group, we collected data on breastfeed-
ing technique in connection with observing and guid-
ing breastfeeding mothers in effective breastfeeding
technique. The purpose of this study was to investi-
gate how breastfeeding technique and pacifier use
were related to breastfeeding problems and duration
of breastfeeding.
Methods
Setting and Participants
The trial took place in western Denmark, where
health visitors routinely visit families with newborns
shortly after discharge from the maternity ward.
Health visitors are registered nurses with 1 year of
supplementary training. In Denmark, nearly 98 per-
cent of all deliveries take place in hospitals. The five
hospitals serving the study area had adopted the
standards of the Baby Friendly hospital initiative
(22). Primiparas and mothers who had a cesarean sec-
tion usually stayed in the hospital for 4 days, whereas
multiparas without complications returned home
within 24 hours after the delivery.
35
Mothers were enrolled in a 6-month period from
February 2004, and followed up for 6 months (26
weeks) from time of delivery. All Danish mothers
who lived in the study region, who gave birth to a
single child with a gestational age of 37 or more
completed weeks, and who started breastfeeding were
invited to participate. Exclusion criteria included
mothers with an ethnic background other than
Danish, and mothers who had a preterm or twin
birth.
Procedures
Before the trial, all health visitors except one partici-
pated in an 18-hour training course that was devel-
oped for the trial, based on the World Health
Organizations Breastfeeding Counselling: A Training
Course (23). It included sessions about how to observe
effective breastfeeding technique and perform skills
training with the breastfeeding mother to achieve
effective breastfeeding technique (21).
At the first visit, which took place approximately 8
days after birth, the health visitor observed a breast-
feeding session and confirmed the mothers use of an
effective breastfeeding technique. Mothers who used
an ineffective breastfeeding technique were corrected
by means of guided practice and feedback, and then
observed in a second breastfeeding session.
Data Collection, Questionnaires
Data were collected from both the mothers and the
health visitors, who recruited mothers for the trial.
The health visitor filled out a registration form for
every mother who fulfilled the inclusion criteria, and
followed up with those who agreed to participate for 6
months. The observed breastfeeding technique was
registered by means of answers to standardized
questions. Data about weeks of exclusive breastfeed-
ing were obtained from regular contacts with the
mother.
The mothers answered two anonymous, self-
administered questionnaires, the first at the health
visitors first visit, which was on average returned
16 days after birth, and the second handed out or
sent to the mothers approximately 5 months after
the birth. The first questionnaire included sociode-
mographic questions, maternal questions about pre-
vious breastfeeding experience, current breastfeeding
concerns, and infant questions about growth and
pacifier use. The second questionnaire had questions
related to problems during the breastfeeding period
and the service received from the heath visitor. As
36 BIRTH 36:1 March 2009

part of the trial preparations, all questionnaires were
reviewed by four experts and subsequently tested for
content and face validity by 24 mothers.
Study Variables
The primary study variables were effective breastfeed-
ing technique and pacifier use. Mothers perceptions
of early problems related to breastfeeding were
included as a secondary study variable. Effective
breastfeeding technique included the following fac-
tors: positioning, latch, sucking, and milk transfer (5).
Position was measured by two questions: 1) Is the
baby positioned with its stomach close to the mothers
stomach? 2) Are the head and body in line? Latch was
measured by three questions: 3) Is the mouth wide
open? 4) Does the chin touch the breast? 5) Is the
under lip flanged out and placed with a good part
underneath the breast? Sucking and milk transfer
were measured by two questions: 6) When onset of
milk occurs, does the sucking rhythm change to deep
rhythmical sucks? 7) Is swallowing audible?
During the observation of a breastfeeding session,
the health visitors registered a yes or no to each
of these questions. An effective breastfeeding tech-
nique was defined as a yes response to all seven
questions.
Information on use of a pacifier and early breast-
feeding problems during the first 2 weeks was
obtained from the mothers first questionnaire, which
included the questions: Does the baby use a pacifier?
and Have you had problems breastfeeding? with
response categories of yes or no.

Table 1. Sociodemographic and Perinatal Characteristics of 579 Mother-Child Pairs and Their Associations with Effective
Breastfeeding Technique and Pacifier Use

Effective Breastfeeding Techniquea Pacifier Useb

Yes No Yes No
Characteristics (n = 302) (n = 277) pc (n = 372) (n = 207) pc
Sociodemographic
Age (yr)
1529 146 141 176 111
3046 156 135 0.51 195 96 0.15
Duration of schooling (yr)
710 82 83 108 57
> 10 218 189 0.40 261 146 0.76
Vocational training
Noneshort 160 168 221 107
Intermediatelong 139 103 0.04 147 95 0.10
Parity
Primiparous 109 123 127 105
Multiparous 193 154 0.04 245 102 0.00
Perinatal conditions
Participation in prenatal classes
Yes 157 153 183 127
No 144 118 0.30 186 76 0.00
Hospitalization
Birth at home 4 4 5 3
Handled on an outpatient basis 111 88 140 59
Hospitalizedrooming-in 24 hr 181 174 0.55 217 138 0.09
Formula supplement, within 5 days after birth
Babies not given formula 206 166 236 136
Babies given formula 91 100 0.08 125 66 0.64
Length of previous breastfeeding experience (wk)
05 20 25 38 7
617 61 73 98 36
> 17 112 56 0.00 109 59 0.03
Birthweight (g)
Minimum to 3,599 121 126 151 96
3,600 to maximum 177 150 0.22 219 108 0.15
a
Number of initial observations of effective breastfeeding technique from health visitors registration forms.
b
Number of answers from mothers questionnaire 1.
c
Pearson chi-squared, p value.
BIRTH 36:1 March 2009 37

Adjusted for Reported Adjusted for Confounding Adjusted for Confoundingc

Outcome Variables

and Risk Factorsd

1.09 (0.911.30)

1.42 (1.181.72)

1.31 (1.101.58)
The primary study outcome was the duration of

1.00 reference

1.00 reference

1.00 reference
exclusive breastfeeding in weeks. Exclusive breastfeed-
ing was defined as a child being fed only on mothers
milk (24).
The secondary outcome was the mothers perception
of problems related to the breastfeeding period. In the
Table 2. Cox Regression Analysis of Study Variables Associated with Exclusive Breastfeeding Cessation, Unadjusted and Adjusted Hazard Ratios

second questionnaire, mothers were asked if they had

encountered specific breastfeeding problems in the
period from week 3 until week 17 after delivery. The
1.15 (0.971.38)

1.45 (1.201.74)

1.35 (1.131.63)
specific problems were pain related to breastfeeding,
1.00 reference

1.00 reference

1.00 reference
poor attachment, damaged nipples, blocked ducts,
Factorsc

and mastitis. The response categories for each problem

were yes or no.
Hazard Ratioa (95% CI) for Breastfeeding

Statistical Methods
Cessation between 1 and 26 Weeks

Associations between maternal characteristics and

1.21 (1.021.44)

1.42 (1.181.69)
Early Problems

Cox regression analysis based on minimum 550 mothers followed up for 26 weeks with complete information on all six variables.
1.00 reference

1.00 reference

each of the study variables were assessed by chi-

square tests. A variable was considered as a potential
confounder if it was associated with one of the study
variables and with breastfeeding duration.
The duration of exclusive breastfeeding was
described by survival curves calculated by the
Adjusted for Pacifier Use

Kaplan-Meier method. Log-rank tests were used for

comparison of survival curves. Mothers who moved
1.26 (1.071.49)

1.32 (1.111.57)
1.00 reference

1.00 reference

out of the area were censored at the time of change of

Education, earlier breastfeeding experience, and formula supplement within 5 days after birth.

address. Cox regression analyses were used to evalu-

ate the influence of study variables on the duration of
exclusive breastfeeding. The effect was described by
a hazard ratio (HR) with a 95% confidence interval.
A logistic regression analysis with early breastfeed-
ing problems as the dependent variable was used to
Adjusted for Ineffective

further clarify if early breastfeeding problems medi-

Each of the study variables was adjusted for the other two risk factors.
1.41 (1.181.68)

1.30 (1.091.54)

ated the influence of the primary study variables on

1.00 reference

1.00 reference
b
Technique

breastfeeding duration. The effect of effective breast-

feeding technique was here stratified on pacifier use
and described by an odds ratio with a 95% confidence
Initial observation of effective breastfeeding technique.

interval.
Similar methods were used to evaluate the effect of
correction of breastfeeding technique on the duration
1.27 (1.081.51)

1.42 (1.191.69)

1.34 (1.131.59)

of breastfeeding and on the presence of breastfeeding

1.00 reference

1.00 reference

1.00 reference

problems. These analyses included only mothers who

Crude

had a second observation after correction. The level of

significance was chosen as 5 percent. Stata version 8
was used for all statistical analyses (25).
b
Effective technique
Study Variables

Early problems

Results
Pacifier use

In the intervention area, 1,066 mothers gave birth in

Yes

Yes

Yes
No

No

No

the recruitment period, 870 mothers fulfilled the in-

clusion criteria, and 780 of these mothers agreed to
a
b

d
c
38 BIRTH 36:1 March 2009

Effective technique participate. The 579 mothers who had complete infor-
1.00
mation on effective breastfeeding technique and paci-
Yes fier use formed the study population of this study.
No Breastfeeding information was available for an addi-
0.75
tional 201 mothers, who had no data on breastfeeding
observation (150) or pacifier use (70). No statistically
significant difference in breastfeeding duration was
Proportion

0.50 seen between these women and the women included

in the study.
Table 1 provides baseline information on maternal
0.25 sociodemographic and perinatal characteristics and
how these related to observed effective breastfeeding
technique and reported pacifier use. Forty percent of
0.00 the participating mothers were primiparous. The pre-
0 4 8 12 16 20 24 28 vious breastfeeding experiences of the multiparous
Weeks mothers were, on average, 16.8 weeks (SD = 8.5 wk).
Fifty-two percent of the mothers were initially identi-
Pacifier use fied to have an effective breastfeeding technique, 64
percent reported that their babies used a pacifier, and
1.00
No 40 percent had early problems in relation to breast-
Yes feeding. The use of a pacifier was not related to effective
0.75
breastfeeding technique (p = 0.99). Table 1 presents
associations between study variables and maternal
characteristics. These results identified education,
Proportion

0.50 parity, and previous breastfeeding experience as

potential confounding factors, because they are
known also to be associated with the duration of
0.25 breastfeeding.
In the crude analysis, we found that duration of
breastfeeding was longer for mothers with effective
0.00 breastfeeding technique at the first observation (p =
0 4 8 12 16 20 24 28
0.003) compared with mothers who were shown to
Weeks
have ineffective technique, for mothers who did not
use a pacifier (p < 0.001) compared with mothers
Reported problems who reported using a pacifier, and for mothers who
1.00
did not report early problems compared with mothers
No who reported early problems (p < 0.001) (Fig. 1;
Yes Table 2). The increased risks of cessation associated
0.75 with pacifier use and early problems were essentially
unchanged when evaluated simultaneously and
adjusted for confounding factors, but the risk associ-
Proportion

0.50 ated with ineffective breastfeeding was reduced con-

siderably and was no longer statistically significant in
the adjusted analysis. Further analysis showed that it
0.25 was the correction for early problems and confound-
ing factors, and not the correction for pacifier use,
that reduced the risk associated with ineffective
0.00 breastfeeding, whereas the risk associated with paci-
0 4 8 12 16 20 24 28 fier use was unchanged when correction was made for
Weeks the effect of early problems (Table 2).
The mediating role of early breastfeeding problems
Fig. 1. Proportion of exclusive breastfeeding in relation on the cessation of risk was further clarified by a logis-
to effective breastfeeding technique, pacifier use, and re- tic regression analysis with the presence of early
ported breastfeeding problems as a function of time since breastfeeding problems as the outcome (Table 3).
delivery. Text next to curves refers to categorization. Ineffective breastfeeding technique was associated
BIRTH 36:1 March 2009 39

with a statistically significant increase of the risk of
early problems. The increase associated with pacifier
use was somewhat smaller and not statistically signif-
icant. Further analysis showed that no interaction was
present between the effect of the two risk factors (p =
0.996), and assuming independent effects the adjusted
odds ratios associated with ineffective technique and
pacifier use were 2.33 (95% CI 1.603.38) and 1.41
(95% CI 0.962.10), respectively.
The presence of early breastfeeding problems was
strongly associated with perceived problems later in
the follow-up period. These problems included pain
when breastfeeding (OR 6.83, 95% CI 3.4813.40),
poor attachment (OR 10.31, 95% CI 3.4231.13),
and damaged nipples (OR 6.61, 95% CI 3.1214.00).
A total of 277 mothers were classified as having an
ineffective breastfeeding technique at the health visi-
tors first observation. In particular, ineffective posi-
tion was observed for 169 mothers, ineffective latch
for 144 mothers, ineffective sucking for 45 mothers,
and ineffective milk transfer for 41 mothers. All
these factors had a statistically significant impact
on the presence of early problems (p < 0.001), but
their consequences for the duration of breastfeeding
differed. Ineffective position and ineffective latch
had no influence (HR 1.03, 95% CI 0.861.25; HR
1.19, 95% CI 0.981.45), whereas ineffective sucking
and ineffective milk transfer showed a significant
impact on duration of breastfeeding (HR 1.87,
95% CI 1.382.55, and HR 1.78, 95% CI 1.29
2.45, respectively).
After the second observation, 123 (44%) mothers
were classified as having effective breastfeeding tech-
nique and 108 (39%) ineffective breastfeeding tech-
nique. A second observation was not available for
the remaining 46 (17%). The result of the second

Table 3. Logistic Regression Analysis of Pacifier Use and Breastfeeding Technique Associated with Reported Early Breast-
feeding Problems, Unadjusted and Adjusted for Confounding Factors

Crude (n = 574) Adjustedb (n = 550)

Characteristics na OR (95% CI) p OR (95% CI) p

c
Nonpacifier users with effective BF 108 1.00 reference 1.00 reference
c
Nonpacifier users with ineffective BF 99 2.44 (1.362.39) 0.003 2.34 (1.254.36) 0.008
Pacifier users with effective BFc 194 1.33 (0.782.24) 0.294 1.42 (0.812.47) 0.219
c
Pacifier users with ineffective BF 178 3.23 (1.915.46) 0.000 3.31 (1.885.80) 0.000
a
Number of observations from health visitors registration form and mothers report in questionnaire 1, missing values excluded.
b
Confounding factors: education, earlier breastfeeding experience, and formula supplement within 5 days after birth.
c
Initial observations of effective breastfeeding technique.
BF = breastfeeding.

Table 4. The Influence of Ineffective Breastfeeding Technique in Second Observation on the Duration of Breastfeeding and
Breastfeeding Problems. Crude and Adjusted Estimates from Cox Regression Analysis (Duration) and from Logistic Regres-
sion Analysis (Problems) Stratified on Pacifier and Nonpacifier Users

Breastfeeding Durationb Breastfeeding Problems

Hazard Ratio ORb

Characteristics for Mothers (n = 231) (n = 214) (n = 228) (n = 211)

after Correction na Crude (95% CI) Adjusted (95% CI) Crude (95% CI) Adjusted (95% CI)
Nonpacifier users
Mothers with effective BFc 42 1.00 reference 1.00 reference 1.00 reference 1.00 reference
Mothers with ineffective BFc 40 1.26 (0.801.98) 1.16 (0.721.86) 1.05 (0.442.51) 1.11 (0.422.93)
Pacifier users
Mothers with effective BFc 81 1.25 (0.851.84) 1.03 (0.671.57) 1.28 (0.602.72) 1.28 (0.543.02)
Mothers with ineffective BFc 68 1.60 (1.072.38) 1.32 (0.862.05) 1.52 (0.693.31) 1.54 (0.633.76)
a
Number of second observation from health visitors registration form, and mothers report in questionnaire 1, missing values excluded.
b
Confounding factors: education, earlier breastfeeding experience, and formula supplement within 5 days after birth.
c
Second observation of effective breastfeeding technique, after initial observation and correction
BF = breastfeeding.
40
observation showed no significant differences in
breastfeeding duration among groups (Table 4). The
crude risk of breastfeeding cessation was increased in
mothers who still had ineffective breastfeeding tech-
nique after correction and also used a pacifier (HR
1.60, 95% CI 1.072.38), but the excess risk was
reduced and no longer statistically significant when
adjusted for potential confounders. Further analysis
showed no interaction between the effects of the two
risk factors (p = 0.718). The independent effects of
ineffective technique and pacifier use were also not
statistically significant (result not shown). The results
for early breastfeeding problems were similar
(Table 4).
Discussion
Data on effective breastfeeding technique were col-
lected systematically from health visitors after instruc-
tion from the training course. Data on early problems
and pacifier use were based on mothers self-reports
and collected at an early stage, independently of the
breastfeeding duration. The procedure reduced the
risk of recall bias and ensured that data have a
predictive value.
The use of self-reported data may be a limitation of
the study. A positive response to questions on early
breastfeeding problems and pacifier use reflected the
subjective interpretation of the individual mother.
However, we found a strong connection between
mothers evaluation of early problems and later
breastfeeding problems collected in the second ques-
tionnaire in the follow-up period. Pacifier use is
accepted in Denmark, but underreporting is possible
because mothers know that health professionals rec-
ommend avoiding pacifier use. Furthermore, we lack
data about the level of pacifier use. Generally, mis-
classification of the study variables is most likely to
be nondifferential since data from mothers were
collected independently and before outcome data.
We found that ineffective breastfeeding technique
was strongly associated with breastfeeding problems,
which is consistent with earlier findings by Righard
and Alade (11,15). Unadjusted associations between
ineffective breastfeeding and shorter breastfeeding
duration were also reported by Righard and Alade
(11), but our multivariate analysis indicated that inef-
fective sucking technique led to breastfeeding prob-
lems that subsequently influenced breastfeeding
duration. The findings support the recommendation
that health professionals should be attentive to mothers
breastfeeding technique because ineffective breastfeed-
ing technique is related to early and later breastfeeding
problems.
BIRTH 36:1 March 2009
Santo et al also reported a large number of mothers
with ineffective breastfeeding technique at an initial
observation (26). Of the four observed factors, only
effective sucking and effective milk transfer showed
a significant impact on the duration of breastfeeding
in the unadjusted analysis. Milk transfer, measured
as audible swallowing, was also the variable that
Riordan et al (27) found significantly related to
human milk intake more than 96 hours after birth,
suggesting that milk transfer is the most valuable
indicator for an effective breastfeeding technique.
Sucking, measured as deep rhythmical sucking, may
be another indicator for an effective breastfeeding
technique when the definition, unlike that used in
the study of Riordan et al (27) is associated with
a change in sucking related to the onset of milk. The
suggested indicators include active processes from the
mother and the baby, both of which play a significant
role in milk removal, according to a study by Ramsay
et al (9).
Our results indicate that ineffective position and
latch contribute to early breastfeeding problems, but
do not have a direct association with breastfeeding
duration. Several assessment tools for effective breast-
feeding technique, which include these two factors
(2831), show only modest or no evidence for corre-
lation with breastfeeding duration (32,33). In agree-
ment with our findings, Schlomer et al (34) reported
a higher score on two of the assessment tools associ-
ated with more breastfeeding problems.
Most mothers in our study used a pacifier for their
children, and in accordance with other studies, we
found that this use was negatively associated with
breastfeeding duration (16,17,19,35). Moreover, in
accordance with Binns and Scott (17), we found pac-
ifier use had an independent impact on breastfeeding
duration, not mediated by ineffective breastfeeding
technique or breastfeeding problems. A significant
association between ineffective breastfeeding tech-
nique and pacifier use has been reported (15, 16),
and Aarts et al (19) described a reduced number of
breastfeeding meals in connection with pacifier use.
These associations were not present in our study.
According to our results, early pacifier use and inef-
fective breastfeeding technique created different prob-
lems for the breastfeeding mother, and if both factors
were present, the risk of premature breastfeeding
cessation was further increased.
A single correction of the ineffective breastfeeding
technique apparently had no or only little influence
on breastfeeding duration and did not solve the
problem. These findings are in agreement with
results from two randomized trials (12,13) that
showed no effect on breastfeeding duration or nipple
trauma after mothers received postpartum education
BIRTH 36:1 March 2009
in positioning and attachment. In addition, Wallace
et al (36) found no effect of the Hands Off inter-
vention, designed to facilitate the achievement of
correct positioning and attachment by mothers and
babies for effective feeding. Prolonged guidance may
be necessary if correction is needed. Moreover, the
absence of positive results from such correction sup-
ports efforts to prevent ineffective breastfeeding
technique.
Recent studies have pointed to the importance of
early skin-to-skin contact for mother and newborn
and the babys self-attachment to the breast (37,38).
Self-efficacy and confidence have recently been iden-
tified as important markers for the breastfeeding
experience (3942). Ideal or rigid descriptions for
effective technique may reduce a mothers confidence
in the breastfeeding process.
The results of our study are based on representative
data from a Caucasian population in an affluent
Western society with a strong tradition for breastfeed-
ing. The process of observing the breastfeeding couple
is universally applicable according to the World
Health Organization (23), but since mothers interpre-
tation of breastfeeding problems may depend on cul-
tural factors, the findings may not be generalizable to
other populations.
Conclusions
Our results indicate that observation and confirma-
tion of breastfeeding technique may be important to
help mothers in the stage when they are establishing
breastfeeding to avoid early and later problems, but
breastfeeding technique is less useful to predict breast-
feeding duration. Pacifier use is independently associ-
ated with a shorter duration of exclusive breastfeeding
and should be avoided in the first weeks after birth by
mothers who want to breastfeed.
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