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A manual search of the citations from these references was also used.
Step nine of the United Nations Children’s Fund/World Health Organization “Baby Friendly Hospital Initiative: Ten Steps to Successful Breastfeeding” states “give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants”.
This advice is widely disseminated by health care professionals and laypersons alike.
It is supported by several observational studies showing a strong association between pacifier use and early weaning .
Many breastfeeding experts warn that pacifier use may contribute to ‘nipple confusion’ or nipple preference, especially if introduced before breastfeeding has been fully established.
A recent randomized controlled trial done by Kramer et al  in Montreal, Quebec, compared two groups of mother-infant pairs and followed them for three months postpartum.
They concluded that pacifier use may be a marker of breastfeeding difficulties or reduced motivation to breastfeed, rather than a true cause of early weaning.
Another study randomly assigned healthy newborns to strict adherence to the United Nations Children's Fund/World Health Organization guidelines and another group to conventional care .
However, because of the many possible confounders and biases in studying human behaviour, the exact cause and effect nature of this factor remains elusive.Both groups were actively encouraged to breastfeed.They found no significant differences in breastfeeding frequency or duration in the first six months of life, despite high rates of pacifier use in both groups (69% to 76%).Pacifier use is still widespread in today’s culture, and a recent Canadian trial reports up to 84% of infants use one at least some of the time .Pacifiers have been implicated in early weaning  and dental problems ]17].
The pacifiers were negative for the major pathogens that cause otitis media .