O'Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr Adolesc Med 2009;163:378-82.
Question
Among infants who are breastfeeding, does the use of a pacified increase the risk of decreased breastfeeding duration or exclusivity?
Design
Systematic review.
Data Sources
MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE, and bibliographies of identified articles.
Study Selection and Assessment
1098 reports were obtained through a search. 29 studies that fit inclusion criteria were included in the review (4 randomized controlled trials, 20 cohort studies, and 5 cross-sectional studies). Two independent reviewers abstracted data and scored these studies for quality; disagreements were settled through consensus with a third investigator.
Main Exposure
Pacifier use.
Main Outcome Measures
Breastfeeding duration or exclusivity.
Main Results
Results from 4 randomized controlled trials revealed no difference in breastfeeding outcomes with different pacifier interventions (pacifier use during tube feeds, pacifier use at any time after delivery, an educational program for mothers emphasizing avoidance of pacifiers, and a UNICEF [United Nations Children's Fund]/World Health Organization Baby Friendly Hospital environment). Most observational studies reported an association between pacifier use and shortened duration of breastfeeding.
Conclusions
The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity. The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean. Ongoing quantitative and qualitative research is needed to better understand the relationship between pacifier use and breastfeeding.
Commentary
This study attempts to answer a critically important dilemma for clinicians– what should we advise parents regarding pacifiers and breastfeeding? Pacifier use during naps and bedtime may reduce the risk of SIDS; however there are concerns that pacifiers may negatively impact breastfeeding. Although the authors conclude that “the highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity,” the evidence that they present actually suggests that the jury is still out and begs for more high quality studies. Though their literature search yielded 29 articles, O'Connor et al based their conclusion largely upon 4 randomized controlled trials (RCT's) using a quality rating system that they developed for this review. It is not clear why the authors developed their own system rather than use existing quality rating systems (e.g. US Preventive Services Task Force, Jadad, etc.). According to the Grading of Recommendations Assessment Development and Evaluation group (GRADE)1 who provide a system for assessing the strength of evidence for recommendations based on 4 key features: study design, quality, consistency, and directness, these RCTs actually provide low evidence for assessing the association between pacifier use and breastfeeding. None of the RCT interventions directly address pacifiers at nap or bedtime and each was compounded with other issues such as bottle usage, supplementation feeds, or indirect recommendations rather than the intervention itself. O'Connor et al also illustrated how RCTs lacked consistency in interventions and outcomes. Though the authors emphasize the higher level of evidence provided by RCTs, many would consider observational studies a suitable and perhaps ideal study design to understand harms. Ultimately, this review points out the weakness of existing RCTs which provide low evidence for a recommendation, and as such it emphasizes the importance to look further into existing observational studies. Additionally, it offers suggestions to improve future research on this critically important topic.
Reference
1. 1Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al.GRADE Working GroupGrading quality of evidence and strength of recommendations. BMJ. 2004;328:1490–1494.
Oregon Health & Science University, Portland, Oregon
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