Pacifier and bottle use in Croatian maternity care before and after revision of Ten Steps

Imagine the first few days of a newborn's life as a delicate, high-stakes dance between a mother and her baby. In the world of science, this dance is often studied under the umbrella of "lactation support," a field dedicated to helping families start breastfeeding successfully. For decades, experts have worried about "nipple confusion"—the idea that if a baby gets used to a fast-flowing plastic bottle or a rubber pacifier, they might forget how to nurse at the breast, which is softer and requires more work. To protect this dance, hospitals used to have a strict rule: no plastic teats, no pacifiers, just skin-to-skin and the breast. But in 2018, the global rulebook changed. Instead of a hard "no," the new rule became a "talk about it." The idea was that if mothers were fully informed about the risks, they could make their own smart choices. This shift turned the hospital staff from gatekeepers into guides, but it also raised a big question: If the rule is now to "counsel, not forbid," are the guides actually doing the talking, or are they just watching the dance change?

This study, conducted in a major hospital in Split, Croatia, decided to check the floor to see how the dance has changed since the new music started playing in 2018. The researchers looked at two groups of mothers: one group from 2011 (when the "no pacifiers" rule was strict) and a fresh group from 2024–2025 (after the rules were updated). They wanted to see if the new "informed choice" approach actually led to better outcomes, or if it accidentally opened the door for more bottles and pacifiers without the necessary warnings.

The findings paint a picture of a dramatic shift in behavior. In the "Old" group from 2011, almost no one used a pacifier; it was a rare sight, used by only 1.2% of babies. But in the "New" group, the pacifier usage skyrocketed to 53.2%. It's as if the strict "Do Not Enter" sign was replaced with a "Please Read the Warning Sign" sign, and suddenly, half the people walked right in. Similarly, the use of bottles for extra feeding jumped from a tiny 0.6% to a significant 32%.

Here is the twist: the study suggests that this surge happened not because mothers were making perfectly informed decisions, but because the "counseling" part of the new rule wasn't happening enough. Even though the new guidelines asked staff to explain the risks, the data shows that 80.8% of the new mothers were not told about the dangers of using a pacifier or bottle. It's like a driver's ed class where the instructor hands out the car keys and says, "You can drive, but you should know the risks," without actually explaining what those risks are. In fact, when mothers did use a pacifier, 94.9% of the time, it was the mother's own decision to soothe the baby, not a recommendation from the nurses. The most common reason given was simply to calm the baby down.

The paper argues that the old, strict prohibition was actually easier to enforce and perhaps more effective at keeping breastfeeding on track because it didn't rely on staff having endless time to talk to every single mother. The new approach, which relies on "informed choice," seems to have stumbled because the hospital staff are stretched too thin to provide the deep, one-on-one counseling required. The study suggests that without that extra time and a clear, standardized way to explain the risks, the "freedom" to choose might just be leading to more confusion and less breastfeeding. The authors conclude that if hospitals want to protect breastfeeding, they need to make sure their staff actually have the time to do the talking, perhaps by using simple, clear leaflets to help explain the risks, rather than just hoping the new rules will work on their own.