Nursing Care for People with Chronic Diseases and Pulmonary Infection by Coronavirus: An Integrative Review Article Consequences of Using Artificial Nipples in Exclusive Breastfeeding: An Integrative Review Consecuencias del uso de pezones artificiales para la lactancia exclusiva: una revisión integradora Consequências do uso de bicos artificiais para a amamentação exclusiva: uma revisão integrativa 10.5294/aqui.2021.21.3.2 Vitória de Oliveira Cavalcante1 Maria Lucilândia de Sousa2 Camila da Silva Pereira3 Nadilânia Oliveira da Silva4 Rodrigues de Albuquerque5 Rachel de Sá Barreto Luna Callou Cruz6 1 0000-0002-6140-3677. Universidade Regional do Cariri, Brazil. vitoria.cavalcante@urca.br 2 0000-0002-8223-7161. Universidade Regional do Cariri, Brazil. lucilandia.sousa@urca.br 3 0000-0002-5888-5150. Universidade Regional do Cariri, Brazil. camila.pereira@urca.br 4 0000-0002-4800-0937. Universidade Regional do Cariri, Brazil. nadilania.oliveira@urca.br 5 0000-0002-6374-3843. Universidade Regional do Cariri, Brazil. thais.alb@urca.br 6 0000-0002-4596-313X. Universidade Regional do Cariri, Brazil. rachel.barreto@urca.br Received: 25/01/2021 Sent to peers: 24/05/2021 Approved by peers: 06/08/2021 Accepted: 11/08/2021 Theme: promotion and prevention. Contributions to the field: This review provides a better understanding of the mechanisms by which the offer of artificial nipples to newborns interferes with the initiation or maintenance of exclusive breastfeeding. This may favor planning by multidisciplinary primary medical care teams focused on promoting, protecting, and supporting breastfeeding. To reference this article / Para citar este artículo / Para citar este artigo: Cavalcante VO, Sousa ML. Pereira CS, Silva NO, Albuquerque TR, Cruz RSBLC. Consequences of using artificial nipples in exclusive breastfeeding: an integrative review. Aquichan. 2021;21(3):e2132. DOI: https://doi.org/10.5294/aqui.2021.21.3.2 ABSTRACT Objective: To describe the consequences of using artificial nipples to exclusive breastfeeding. Materials and method: An integrative review carried out in the Medline®, Cinahl, Lilacs, Web of Science, and Scopus databases to answer the following question: What are the consequences of using artificial nipples to exclusive breastfeeding? Results: 38 articles were analyzed; the analysis gave rise to two categories: neonatal factors and maternal factors influencing exclusive breastfeeding. Breastfeeding interruption was the neonatal factor most associated with the use of artificial nipples, while the level of maternal education stood out as an intervening factor in exclusive breastfeeding. Pacifiers were the dummy type more commonly mentioned, followed by feeding bottles and nipple shields. Conclusions: The consequences of offering artificial nipples to breastfed infants are mostly negative and associated with the newborn, such as early weaning, refusal to breastfeed, impaired suction technique, incorrect latch-on, interference with orofacial development, and interruption of exclusive breastfeeding. Mothers who offered artificial nipples to their infants are more likely to experience pain, nipple fissures, frustration, and reduced interaction with their infants. KEYWORDS (Source DeOS): Breastfeeding; nursing bottles; bottle feeding; maternal and child health; artificial nipples. RESUMEN Objetivo: describir las consecuencias del uso de pezones artificiales para la lactancia exclusiva. Materiales y método: revisión integradora realizada en las bases de datos Medline®, Cinahl, Lilacs, Web of Science e Scopus para contestar a la siguiente cuestión: ¿cuál es la influencia que ejerce en la lactancia la oferta de pezones artificiales a los recién nacidos? Resultados: se analizaron 38 artículos; el análisis originó dos categorías: factores neonatales y factores maternos de influencia en la lactancia exclusiva. La interrupción de la lactancia materna fue el factor neonatal más asociado al uso de pezones artificiales, mientras el nivel de escolaridad materno se destacó como factor interviniente en la lactancia exclusiva. El chupo fue el pezón artificial más encontrado citado, seguido del biberón y del protector mamilar. Conclusiones: las consecuencias de la oferta de pezones artificiales a los bebés em la lactancia son, en su mayoría, negativas y relacionadas con el neonato, como el desmame temprano y el rechazo al seno, la succión perjudicada, el agarre inadecuado, la interferencia en el desarrollo orofacial y la interrupción de la lactancia materna exclusiva. Las madres que ofrecieron pezones artificiales a sus hijos están más propensas a sentir dolor, tener fisura mamilar, frustración y reducción de la interacción con su hijo. PALABRAS CLAVE (Fuente DeOS): Lactancia materna; biberones; alimentación artificial; salud materno-infantil; pezoneras. RESUMO Objetivo: descrever as consequências do uso de bicos artificiais para a amamentação exclusiva. Materiais e método: revisão integrativa realizada nas bases de dados Medline®, Cinahl, Lilacs, Web of Science e Scopus para responder à seguinte questão: qual a influência que a oferta de bicos artificiais aos recém-nascidos exerce na amamentação? Resultados: foram analisados 38 artigos; a análise deu origem a duas categorias: fatores neonatais e fatores maternos de influência na amamentação exclusiva. A interrupção do aleitamento materno foi o fator neonatal mais relacionado ao uso de bicos artificiais, enquanto o nível de escolaridade materno destacou-se como fator interveniente na amamentação exclusiva. A chupeta foi o bico artificial mais encontrado citado, seguido da mamadeira e do protetor mamilar. Conclusões: as consequências da oferta de bicos artificiais às crianças em amamentação são, em sua maioria, negativas e relacionadas ao neonato, como o desmame precoce, a recusa do peito, a sucção prejudicada, a pega incorreta, a interferência no desenvolvimento orofacial e a interrupção do aleitamento materno exclusivo. As mães que ofereceram bicos artificiais aos seus filhos estão mais propensas a ter dor, fissura mamilar, frustração e redução da interação com seu filho. PALAVRAS-CHAVE (Fonte DeOS):  Aleitamento materno; mamadeiras; alimentação artificial; saúde materno-infantil. Introduction Exclusive breastfeeding is considered the gold standard in infant feeding and, when maintained for up to six months of age, provides proven benefits to the mother-infant binomial, the family, and the society (1). However, breastfeeding is strongly influenced by external factors that can lead to the interruption of exclusive breastfeeding (EBF), such as the use of dummies — pacifiers and feeding bottles, for example —, which are affordable and geographically disseminated (2). According to the World Health Organization (WHO), EBF is the ideal form of infant nutrition up to six months of age, when solid foods are introduced as complementary feeding. The WHO has drafted the "Ten steps to successful breastfeeding" and does not recommend the use of feeding bottles and other dummies because they can potentially interfere with optimal breastfeeding practices (3). However, women in low- and middle-income countries show poor adherence to EBF, with only 37 % of infants under six months of age being exclusively breastfed (4). In Brazil, breastfeeding (BF) is initiated but more than half of Brazilian mothers interrupt it after the first month (5). BF indicators have been stable in Brazil since 2006: - 36.6 % of EBF in infants under six months of age and - 52.1 % of BF in infants under two years of age (6). It is known that the use of artificial nipples can lead to early weaning and/or reduced BF duration. However, the aspects and mechanisms by which this interference occurs must be clarified and discussed (7-9). Thus, this article aimed at describing the consequences of using artificial nipples to exclusive breastfeeding. Materials and methods Type of study Integrative literature review carried out in six steps: identifying the research question; setting inclusion and exclusion criteria; categorizing (extracting, organizing, and summarizing information); reviewing the studies; interpreting the results; and presenting the review (10). Identifying the research question The Population, Variables, and Outcomes strategy (Table 1) was used, which also allows for the identification of the most ap propriate descriptors for the search intended in the review. Table 1. Formulating the research question and identifying descriptors, with population, variables, and results from elements. Crato, Ceará, Brasil, 2020 Strategy items Components Subject descriptors Population Newborns Infant, newborn Variables Mamilos Educational technology Outcomes Consequences to breastfeeding Health promotion Source: Prepared by the authors based on research data. So, the question is: What are the consequences of using artificial nipples to exclusive breastfeeding? Setting the inclusion and exclusion criteria Original studies that answered the research question and were published between 2006 and 2019 were defined as inclusion criteria. This time frame is justified by the year when Law 11.265/2006 became effective, which regulates the marketing and appropriate use of food and dummies for infants and children. Duplicate references and studies unavailable for download were excluded. Methodology A paired search was carried out by two authors in March 2020, in the Medical Literature Analysis and Retrieval System Online (Medline®), Cumulative Index to Nursing and Allied Health Literature (Cinahl), Latin American and Caribbean Health Sciences Literature (Lilacs), Web of Science, and Scopus databases. The following controlled descriptors of the Medical Subject Heading (MeSH) were used: "breastfeeding", "pacifiers", "breastfeeding", "bottles". Two crossings were implemented using the Boolean operator "AND". A total of 1,239 references were identified in the databases, with the respective crossings (Table 2). Table 2. References found with the respective crossings (n = 1,239), 2020 Crossings Cinahl Lilacs Medline® Scopus Web of Science Total "breastfeeding AND pacifiers" 52 98 346 193 138 827 "breastfeeding AND bottles" 11 62 137 119 83 412 Total 63 160 483 312 221 1,239 Source: Prepared by the authors based on research data. This process resulted in 427 studies, but after excluding 37 duplicates, 390 studies were read in full. After careful reading, 247 studies were excluded for not addressing the desired population (infants aged 0 to 6 months) and 105 were excluded for not being available for download. Thirty-eight articles were included in the final sample. The flowchart of the Preferred Reporting Items for Systematic Review and Meta-Analysis (Prism) was used to illustrate the process of study identification, screening, eligibility, and inclusion, as shown in Figure 1. Figure 1. Flowchart for identifying, screening, selecting, and including studies. Crato, Ceará, Brasil, 2020 Source: Prisma flowchart for systematic reviews. Data were collected with the aid of a previously defined table, which included: author, year, journal/database, location, methodological design, level of evidence, and types of artificial nipples. Subsequently, the factors influencing the use of artificial nipples on breastfeeding were summarized, found in primary studies, giving rise to two categories: neonatal factors and maternal factors. Therefore, the articles found were numbered and the levels of evidence of the studies were categorized. Level 1: evidence resulting from a meta-analysis of multiple randomized controlled clinical trials; level 2: evidence obtained in individual studies with experimental design; level 3: evidence from quasi-experimental studies; level 4: evidence from descriptive (non-experimental) studies or with a qualitative approach; level 5: evidence from a case or experience reports; level 6: evidence-based on expert opinions. Results Thirty-eight articles were analyzed, initially characterized by authors, year, journal, database, location, methodological design, level of evidence, and types of dummies (according to Table 3). Table 3. Characterization of the primary studies included in the review, regarding authorship, year, journal, database, location, design, type of dummy found, and level of evidence. Crato, Ceará, Brasil, 2020 Authors and year Journal and database Location Methodological design Dummy Level of evidence Rocha, Verga, Sipsma, Larson, Phillipi, Kair, 2020 (2) Breastfeed Med Scopus The United States. Qualitative, 23 women, interview Pacifier 4 Zarshenas, Zhao, Scott, Binns, 2020 (11) Int J Environ Res Public Health. Medline Iran Prospective cohort, 700 women, interview Pacifier 4 Bezerra, Magalhães, Pereira, Gomes, Netto, Rocha, 2019 (7) Rev. Bras. Saúde Mater. Infant Scopus Brazil Cross-sectional study, 354 infants, interview Feeding bottle and pacifier 4 Maastrup, Walloee, Kronborg, 2019 (12) PLoS One. Medline Denmark Prospective cohort, 1,488 newborns and 1,221 mothers, questionnaire, telephone interview Nipple shield 4 Salcan, Topal, Ates, 2019 (13) Eurasian J Med. Scopus Turkey Cross-sectional, 2,166 babies, interview Pacifier and feeding bottle 4 Silva, Caminha, Silva, Serva, Azevedo, Filho, 2019 (14) JPediatr (Rio J). Lilacs Brazil Analytical cross-sectional study, 310 infants, database Pacifier 4 Wu, Gao, Sha, Zeng, Liu, Li et al., 2019 (15) Int J Environ Res Public Health. Medline Switzerland Cohort, 951 binomials, questionnaire, phone call Feeding bottle 4 Batista, Ribeiro, Nascimento, Rodrigues, 2018 (9) J Pediatr (Rio J). Web of Science Brazil Cross-sectional, observational study 427 binomials, questionnaire Pacifier and feeding bottle 4 Buccini, Pérez-Escamilla, Benicio, Giugliani, Venancio, 2018 (16) PLoS One. Medline England Secondary study, 42,395 infants, national BF prevalence research data Pacifier 4 Cruz, Reducino, Probst, Guerra, Ambrosiano, Cortellazzi et al., 2018 (17) Cad. Saúde Coletiva. Web of Science Brazil Cross-sectional, epidemiological study, 301 binomials, data from medical records Pacifier 4 Júnior, Mohr, Pereira, 2018 (18) Arq. Catarinense Med. Lilacs Brazil Randomized clinical trial, 132 mothers, interview, questionnaire, telephone call Pacifier 2 Manhire, Williams, Tipene-Leach, Baddock, Abel, Tangiora et al., 2018 (19) BMC Pediatr. Cinahl New Zealand Randomized controlled trial, 197 mother-infant binomials, questionnaires Pacifier 2 Silva, Cirino, Santos, Oliveira, Sousa, Lima, 2018 (20) Saúde e Pesquisa. Lilacs Brazil Quantitative, cross-sectional, descriptive-exploratory study, 546 newborns, form Pacifier and feeding bottle 4 Bomfim, Novaes, Bonanato, Navarro, Tedesco, Imparato et al., 2017 (21) Pesq Bras Odontopediatria Clin Integr. Scopus Brazil Cross-sectional, qualitative study, 156 binomials, interview Feeding bottle 4 Carvalho, Fonsêca, Nobre, Silva, Pessoa, Ribeiro et al., 2017 (22) Ciên Saúde Colet. Web of Science Brazil Cohort, 247 infants, semi-structured interview with mothers Pacifier 4 Dadalto, Rosa, 2017 (23) Rev Paul Pediatr. Scopus Brazil Cross-sectional, descriptive study, 114 binomials, interview Feeding bottle and pacifier 4 Silva, Pellegrinelli, Pereira, Passos, Santos, 2017 (24) Ciên Saúde Colet Medline Brazil Retrospective study, 12,283 mothers, secondary form data Feeding bottle and pacifier 4 Praborini, Purnamasari, Munandar, Wulandari, 2016 (25) Clinical Lactation. Web of Science The United States. Quantitative, cross-sectional study, 58 mothers and infants, observation, and questionnaire Feeding bottle, nipple shield 4 Figueiredo, Bueno, Ribeiro, Lima, Silva, 2015 (26) J. Hum. Growth Dev. Scopus Brazil Cross-sectional study, 25 mothers, structured questionnaire Pacifier and feeding bottle 4 Lindau, Mastroeni, Gaddini, Lallo, Nastro, Patanè et al., 2015 (27) Eur J Pediatr. Cinahl Italy Longitudinal study, 605 women, questionnaire Pacifier 4 Pellegrinel, Pereira, Ribeiro, Santos, 2015 (28) RevNutr. Lilacs Brazil Cross-sectional, retrospective study, 9,474 mothers, secondary form data Pacifier and feeding bottle 4 Carrascoza, Possobon, Ambrosano, Júnior, Moraes, 2014 (29) Rev. CEFAC. Web of Science Brazil Descriptive, exploratory, longitudinal, quantitative study, 120 binomials, questionnaire Pacifier and feeding bottle 4 Demitto, Bercini, Rossi, 2013 (30) Esc. Anna Nery. Lilacs Brazil Descriptive, exploratory, quantitative study, 378 mothers and 383 infants, structured interview Pacifier 4 Ducci, Vannuchi, Tacla, Souza, Reis, 2013 (31) Rev Min Enferm. Lilacs Brazil Quantitative cross-sectional study, 285 infants, interview with a questionnaire Pacifier and feeding bottle 4 Rocha, Garbin, Garbin, Saliba, Moimaz, 2013 (32) Pesqui Bras Odontopediatria Clin Integr. Lilacs Brazil Longitudinal, prospective study, 87 binomials, interview with a questionnaire Pacifier 4 Kaufmann, Albernaz, Silveira, Silva, Mascarenhas, 2012 (33) ver. Paul Pediatr. Web of Science Brazil Prospective cohort, 951 binomials, interview with a questionnaire Pacifier 4 Queluz, Pereira, Santos, Leite, Ricco, 2012 (34) Rev Esc Enferm USP. Web of Science Brazil Quantitative, cross-sectional study, 275 infants, questionnaire Pacifier 4 Salustiano, Diniz, Abdallah, Pinto, 2012 (35) Rev Bras Ginecol e Obstet. Lilacs Brazil Cross-sectional, analytical study, 667 infants, semi-structured interview Pacifier 4 Carrascoza, Possobon, Ambrosano, Costa, Moraes, 2011 (36) Cien Saude Colet. Web of Science Brazil Longitudinal study, 111 binomials, questionnaire Pacifier 4 Sanches, Buccini, Gimeno, Rosa, Bonamigo, 2011 (37) Cad Saúde Pública. Lilacs Brazil Cross-sectional, 170 binomials, 2 forms Pacifier 4 Roig, Martínez, García, Hoyos, Navidad, Álvarez et al., 2010 (38) Rev Lat Am Enfermagem. Scopus Brazil Cross-sectional, quantitative, descriptive study248 mother-infant binomials, interview Pacifier and feeding bottle 4 Vieira, Martins, Vieira, Oliveira, Silva, 2010 (39) J Pediatr (Rio J). Web of Science Brazil Cohort, 1,309 binomials, interview Pacifier 4 Araújo, Silva, Coutinho, 2009 (40) RevCEFAC. Lilacs Brazil Observational, cross-sectional study, 74 infants, infant assessment, filming, and recording Pacifier 4 Kishi, Caccia-Bava, Martinez, 2009 (41) Rev APS. Lilacs Brazil Quantitative, cross-sectional study, 53 mothers, interview with a questionnaire Pacifier 4 Marques, Cotta, Araújo, 2009 (42) Rev Bras Enferm. Web of Science Brazil Qualitative study, 19 mothers, semi-structured interview Pacifier 4 Parizoto, Parada, Venâncio, Carvalhaes, 2009 (43) J Pediatr (Rio J). Web of Science Brazil Comparison of three cross-sectional surveys, with 496, 674, and 509 infants, interview Pacifier 4 França, Giugliani, Oliveira, Weigert, Santo, Kohler et al., 2008 (44) Rev Saúde Pública. Web of Science Brazil Cross-sectional in a cohort, 211 binomials, interview and observation Feeding bottle and pacifier 4 Source: Prepared by the authors based on research data. Pacifiers were the type of dummy more commonly found in th studies, followed by feeding bottles and nipple shields. The summary of the consequences of the use of artificial nipples to exclusive breastfeeding is shown in Table 4. The consequences have been divided into two categories: neonatal consequences and maternal consequences. Table 4. Consequences of the use of artificial nipples to exclusive breastfeeding Consequences Evidence extracted from studies Neonatal Refusal to breastfeed (2, 26) Reduced crying — newborn soothing (26, 30, 43) Impaired suction technique (2, 9, 46, 12, 21, 26, 29, 36, 41, 44, 45) Incorrect latch-on (7, 9, 44, 45) Interference with orofacial development (2, 9, 46) Interruption of EBF (2, 12, 25, 26, 29-33, 35, 36, 39, 14, 40-46, 15, 17, 19-23) Early weaning (2, 17, 19-21, 23, 27, 31, 33, 34, 36, 39-41, 43) Maternal Nipple fissure/pain (9, 21, 30, 40, 45, 46) Frustration (23, 30, 37, 38, 45) Decreased interaction with the newborn (9, 13, 46) Source: Prepared by the authors based on research data. In the first category, the consequences that stood out were the interruption of EBF and early weaning. Regarding maternal consequences, the most prevalent were nipple fissure/pain, frustration, and reduced interaction with the newborn. Discussion Regarding the consequences of the use of artificial nipples to breastfeeding that are associated with the newborn, this review pointed out aspects that ranged from incorrect latch-on to longterm anatomical changes. One of the relevant effects of the use of artificial nipples on newborns related to exclusive breastfeeding may be changes to the latch and suction pattern. Disagreement on the mechanisms by which this relationship occurs has been found in the literature, with nipple confusion being one of the aspects mentioned. Nipple confusion is a situation in which the suction pattern of the infant is modified due to the properties of the dummy (rigidity and shape of the dummy and base). Consequently, the infant may lose interest in sucking the breast because it is harder to express milk compared to artificial nipples. The nipple confusion phenomenon is not fully elucidated, as research studies indicate that suction processing in the brainstem allows healthy term infants to adapt suction in response to the specific properties of each dummy being used (1). Thus, nipple confusion is a risk newborns are exposed to when using pacifiers, feeding bottles, or nipple shields. Another result of this study was newborns refusing to breastfeed due to the use of a pacifier or feeding bottle. Another hypothesis to explain the negative influence of pacifiers on the biomechanics of breastfeeding includes reduced demand for breast milk by the newborn, since pacifier non-nutritive sucking causes fatigue and reduced nursing sessions or breastfeeding suspension (45). Nevertheless, the pacifier is useful in conditioning and to help preterm infants transition from enteral or gavage nutrition to oral feeding during hospitalization in intensive care units. They also benefit from the weight gain that occurs by regulating gastric motility. Pacifiers with sensory technologies are being developed to quantify the pressure of the sucking pattern and thus gain a better understanding of neurological and motor development in childhood, and explore the potential diagnostic information contained in sucking patterns under various clinical conditions (46, 47). A positive outcome of the use of artificial nipples was reduced crying and the soothing effect for infants. This effect is also reported in the literature as a causal factor for using a pacifier (48). A study with a Spanish cohort showed that co-sleeping for more than six months seems to be associated with less anxiety, less negative sucking habits (with a pacifier or feeding bottle), and a lower incidence of malocclusions (49), which indicates that other strategies can be used to reduce infant's stress, such as bouncing and breastfeeding. As for feeding bottles, these similarly interfere with breastfeeding because of the great difference between the flow of milk that is extracted from the breast and that from the feeding bottle, making infants prefer the latter. Furthermore, breastfeeding is a complex task that requires the integration and organization of several different skills, demanding greater effort from newborns (9, 50). Regarding growth performance, partially breastfed and formula-fed newborns lag slightly behind exclusively breastfed infants in the first six months of life (51), confirming the benefits of maintaining exclusive breastfeeding. As a result of the use of artificial nipples, this study significantly revealed the negative influence on EBF, leading to interruption and early weaning. However, even though the use of a pacifier/feeding bottle is an indicator of breastfeeding problems, a woman's desire and intention to breastfeed must be taken into account. Given its decisive character for the success of exclusive breastfeeding, this is perhaps the most important indicator of breastfeeding duration. It should be mentioned that the success of breastfeeding depends on several factors, including sociodemographic, biophysical, and psychosocial factors (52, 53). This study also found factors associated with mothers as a result of the use of artificial nipples, such as the incidence of pain, nipple fissures, frustration, and reduced interaction with their infants. Nipple pain is related to breast trauma and infections, such as nipple fissures and candidiasis. Therefore, it has been shown that the use of pacifiers and feeding bottles is associated with a higher rate of nipple injury because it can potentially change the sucking pattern and interfere with a proper breastfeeding latch (54). In an Iranian study, pacifier use was a significant risk factor for acute mastitis in the first four weeks and between weeks 5 and 12 postpartum, being associated with duct obstruction, as the infant does not fully empty the breast, in addition to oral contamination with the transmission of pathogens to the breast (55). An experimental study concluded that pacifiers can potentially interfere with a mother's or infant's ability to read emotional expressions. That is, the harmful effects of the use of pacifiers in newborns imply the perception of less pleasant and less stimulating emotions (56). This finding corroborates a study with binomials in Australia, where mothers with depression were evaluated. When asked to interact with their infants, they inserted a pacifier into their mouths several times, which showed difficulty in interacting (48). Breastfeeding is not only a result of knowing the benefits and correct techniques or prior decision, but also of a woman's relationships with her social network. That said, women must get support from members of their primary network (relationship with family members, friends, or neighbors), who can help them with household chores and childcare. Taking the relationships established between breastfeeding women and the members of their social networks into account helps professionals address other aspects in addition to the biological aspects of breastfeeding (57), reaching dimensions that can lead to increased EBF duration. As a limitation, we emphasize the inclusion of studies with a low level of evidence. The descriptors also do not restrict knowledge that is associated with the nursing field. However, the findings allow nursing professionals to broaden their knowledge regarding the risk factors for interrupting EBF due to the use of pacifiers, feeding bottles, and nipple shields. Conclusions The consequences of offering artificial nipples to breastfed infants are mostly negative and associated with the newborn, such as early weaning, refusal to breastfeed, impaired suction technique, incorrect latch-on, interference with orofacial development, and interruption of EBF. Reduced crying and newborn soothing are positive outcomes of the use of artificial nipples during breastfeeding. Repercussions associated with the mother as a result of offering artificial nipples to infants include nipple fissures and pain, frustration, and reduced interaction with her infant. It can be emphasized that offering artificial nipples to infants of any age without the risk of discontinuing EBF is not guaranteed. The discussion about whether or not to use artificial nipples does not end here, considering that their use has been normalized by the population. 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