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

<title>Abstract</title> <p>Background In 2018, Step 9 of the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) was revised; the prohibition of artificial teats and pacifiers for breastfeeding infants was replaced with a recommendation to counsel mothers on their use and risks. Our aim was to document pacifier/bottle use among mothers of healthy term infants in a Croatian tertiary referral hospital, assess staff compliance with counselling on risks, and compare pre- (Old BFHI) and post-2018 (New BFHI) Step 9 data. Methods Between November 2024 and February 2025, healthy breastfeeding mothers of healthy term infants who gave birth at University Hospital of Split were invited to participate. Mothers were interviewed face-to-face immediately prior to hospital discharge. Data were collected using UNICEF/WHO BFHI questionnaire for breastfeeding mothers. Data were compared with data collected in 2011 at the same maternity hospital, using the same methodology and questionnaire. Baseline maternal and infant characteristics, and Step 9 data were compared between groups (Old-BFHI vs. New-BFHI) using Chi-squared test, with p &lt; 0.05 considered statistically significant. Results A total of 370 mother-infant pairs were included in the study. Of these 53.2% gave their infant a pacifier versus 1.2% in the Old-BFHI group (p &lt; 0.001). Although more New-BFHI mothers were informed of pacifier/teat risks (18.1% vs 7.9%, p &lt; 0.001), 80.8% remained uninformed. In 94.9% of cases it was the mother who decided to give the pacifier, with the most commonly cited reason being to soothe the baby (57.4%; (113/197). Bottle use for supplementation increased significantly (32% vs 0.6%, p &lt; 0.001), with 93.7% of mothers using their own bottles. Conclusions The number of mothers on the postpartum ward using pacifiers and bottles for their healthy term newborns has increased markedly following the 2018 revision of BFHI Ten Steps; the majority of which remain uninformed by hospital staff of associated risks - far below global BFHI standards. Ensuring adequate staff time for counselling on the risks of pacifier/bottle use, using a standardized, evidence-based leaflet, is a priority if breastfeeding is to be protected, promoted and supported in maternity facilities.</p>