Dummy sucking and breastfeeding duration. Does a causal relationship exist? Critically Appraised Topic PFIG Acute Group Melissa Parkin

Objective Members of the PFIG Acute EBP group working in NICU’s and acute hospital settings routinely advocate the use of dummies in preterm and term infants who are NBM or demonstrate feeding difficulties. We became interested in the impact of dummy use on breastfeeding outcomes and wanted to know if a causal relationship existed between the two variables.

Question Does the use of a dummy in the first six months of life influence the duration of breastfeeding? Medline, CINAHL, OVID and Google websites were used

Evidence Victora CG, Tomasi E, Olinto MT & Barros FC (1993). Use of pacifiers and breastfeeding duration. Lancet, 341: Barros FC, Victora CG, Semer TC, Filho ST, Tomasi E & Weiderpass E (1995). Use of Pacifiers is Associated With Decreased Breast- Feeding Duration. Pediatrics, Vol 95, 4: Victora CG, Behague DB, Barros FC, Olinto MT & Weiderpass (1997). Pacifier Use and Short Breastfeeding Duration: Cause, Consequence or Coincidence? Paediatrics, Vol 99, 3:

Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D & Lawrence RA (2003). Randomized Clinical Trail of Pacifier Use and Bottle-Feeding or Cupfeeding and Their Effect on Breastfeeding. Pediatrics, Vol 111, 3: Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, & Hiller JE (2004). Effect of bottles, cups and dummies on breastfeeding in preterm infants: a randomised controlled trial. BMJ online. BMJ.com (published 18 June 2004)

Levels of Evidence Victora et al (1993) – Level IV Barros et al (1995) – Level IV Victora et al (1997) – Level IV Howard et al (2003) – Level III : 1 Collins et al (2004) – Level III : 1

Clinical Bottom Line With the exception of the Collins et al 2004 article, all the studies stated that early and frequent use of dummies in the neonatal period decreased breastfeeding duration. However, there was insufficient high level evidence to support these statements.

Clinical Practice It remains unclear whether the association between dummy use and breastfeeding duration is causal. Factors such as reverse causality (ie. breastfeeding difficulties may lead to dummy use rather than the reverse) and self selection of mothers may play an important role.

Where to from here? These studies may have implications for healthy, term infants but they do not address the many complex issues surrounding the feeding management of preterm and/or critically sick infants. Therefore we need to narrow our clinical question in order to address neonates with feeding difficulties.

Acknowledgements Valerie D’Souza Sophie Egan Jana Carr Brodie Warren Anne Rosten Natalie Diwakar Jennifer Hughes Keona Wilson Tamara Boyle Justine Hemmings