Centre: Institute Nurses’ Network and Community and Child Health Nurses and Western Australian Centre for Evidence Based Nursing and Midwifery in collaboration with the Joanna Briggs Institute for Evidence Based Nursing and Midwifery
Non-nutritive sucking is a normal behaviour of newborn infants and children. Non-nutritive sucking comprises of various types of sucking behaviours such as sucking on: digits (fingers, thumb and toes); pacifiers (also known as dummies, soothers or comforters); teats on bottles containing water or sweetened water; and clothing, rugs or toys.
This review will focus on pacifier non-nutritive sucking in infancy and early childhood. A pacifier is a device which is placed in the mouth to stimulate sucking behaviour. A pacifier is usually similar in material and shape to a teat. The major difference between a pacifier and a teat is that the pacifier is attached to a broad, flat disk of plastic that covers the child's mouth to prevent ingestion.
Pacifier use is always initiated by a carer, either a parent of the child, a health professional, a relative, or a friend. A pacifier may be introduced for a number of different reasons. As the name suggests, the most common reason for pacifier use is ‘to soothe or calm’ a distressed child. Pacifiers are also used to prevent the sucking of thumbs and other objects, and as an aid to weaning. Vogel and Mitchell (1997) found that although mothers and health professionals held negative views towards dummy use, they acknowledged its use for an unsettled baby.
The reasons why some carers decide to use a pacifier are many and varied, based on cultural mores, past practice, health care policy, and occasionally, substantive research. Webster (1999) noted that Neonatal Nurses identified culture, experience, parental wishes, research and policy as influencing their practice. A Western Australian survey of Child Health Nurses and Midwives found that as many advised pacifier use as did not (Callaghan, 1994). It was found that the advice given by these health professionals was not based on a consistent and coherent rationale, rather the advice was based on personal experience, or the belief that it was simply a matter of parental choice. The results of this study also indicated that parents introduced pacifiers for many different reasons and that they were mainly influenced by the advice of family members and health professionals.
The prevalence of pacifier use varies between western societies and within communities. In a case control study in New Zealand, Mitchell et al (1993) reported the prevalence of dummy use for controls (mean age 15 weeks) varied between 5% in the South island compared to 32% in the North island. In the United Kingdom, North et al (1999) reported that two thirds of infants up to the age of six months had used pacifiers. Similarly, two thirds of infants aged approximately 3 months in Western Australia had used pacifiers (Callaghan et al, 1998).
A preliminary search of the literature has identified almost two hundred references/articles related to diverse aspects of pacifier use. Pinelli and Symington (2000) have published a Cochrane Collaboration review of pacifier use in relation to premature infants. The review noted non-nutritive sucking significantly decreased length of hospital stay for preterm infants. It also suggested there were no short-term negative effects of pacifier use. To our knowledge there has, however, been no systematic review examining the impact of pacifier use on full term healthy infants and healthy young children.
It is postulated pacifier non-nutritive sucking reduces stress during infancy (Field in Lewis Ed, 1999; Riese, In Lewis (Ed), 1999; Fox and Schaefer, 1996). Pacifier use has also been discussed in relation to infant temperament (Riese, 1995), attachment (Lehman et al, 1992), crying behaviour (Makoi, 1990), and motor activity (Woodson et al, 1985).
Studies focusing on healthy infants and children have investigated pacifier use in relation to shortened breast feeding duration, reduced exclusivity of breast feeding (Barros, Victora et al, 1995; Aarts, Hornell, et al, 1999; Riva, Banderali, et al, 1999;), and breast feeding problems such as sore nipples, and poor sucking technique (Centuori, Burmsz, et al, 1999; Howard, Howard, et al, 1999; Righard & Alade, 1992).
Research has highlighted adverse outcomes of pacifier use in relation to dentition, the development of malocclusion, and the development of dental caries. A consistent finding has been a positive association with pacifier non-nutritive sucking and malocclusion (Bowden, 1966; Paunio, Rautava & Sillanpaa, 1993; Karjalainen, Ronning, et al, 1999). There is also some evidence that non-nutritive sucking contributes to the early development of dental caries (Ollila, Niemela, et al, 1998; Gizani, Vinckier & Declerck, 1999).
Recently, it has been revealed that pacifier use may be protective against Sudden Infant Death Syndrome (SIDS) (Mitchell, Taylor, et al 1993; L'Hour, Engelberts, et al, 1999; Arnestad, Andersen & Rognum, 1998). However, a large study in the United Kingdom does not confirm these findings and advise caution until further research is undertaken (Fleming et al, 1999).
Other child health outcomes that have been associated with pacifier use are: increased oral and gastro-intestinal flora leading to infection (Manning, Coughlin & Poskitt, 1985; Hannula, Saarela, et al, 1999); otitis media (Niemela, Uhari & Motytonen, 1995; Jackson & Mourina, 1999); changes in oro-facial development (Drane, 1996); and speech development (Barlow et al, 1992).
Based on this initial search of the literature a number of key issues have been identified. Of these key issues, five have been selected for review: 1) The extent to which pacifier nonnutritive sucking reduces stress during infancy; 2) The impact of pacifier non-nutritive sucking on the duration and quality of breast feeding; 3) The possibility of a protective effect for pacifier use in relation to SIDS; 4) The effect of pacifier use on the developing dentition and general oral health; and 5) The possibility of an increase in oral and gastro-intestinal flora leading to infection, due to the use of a pacifier.
As previously discussed, the advice given by nurses and midwives to the parents of infants and young children regarding the use of a pacifier varies greatly according to individual understanding and personal experience. In turn, parents are obliged to make a choice about the use of a pacifier based on the opinions of those advisors they trust rather than on confirmed evidence. Clearly, there is a pressing need for a review of this literature and the subsequent development of a practice guideline for health professionals involved with the care of infants and young children.
To comprehensively review all relevant literature related to pacifier non-nutritive sucking for full term healthy infants and young children.
The specific review questions to be addressed are:
What is the evidence of adverse and/or positive outcomes of pacifier non-nutritive sucking in infancy and early childhood in relation to each of the following subtopics?
˜ Infant calming and stress relief.
˜ Breast feeding.
˜ Sudden infant death syndrome.
˜ Dentition and oral health.
˜ General oro-pharyngeal and gastrointestinal infections.
Criteria for considering studies for this review
Types of participants:
˜ Healthy term infants and healthy young children up to the age of five years.
˜ Pre-term infants, infants and young children with serious illness and congenital malformations.
˜ Pacifier use related to procedural pain relief.
Types of interventions:
Interventions of interest are those related to pacifier non-nutritive sucking in all settings, home or health care. This review will take into account type of pacifiers, additives, timing and duration, and age of child.
Types of outcome measures:
Outcome measures will include, but not be confined to, research related to:
˜ Effectiveness to promote infant calming and stress reduction.
˜ Duration of breastfeeding, length of exclusive breast feeding, breast feeding problems such as cracked nipples and poor sucking technique.
˜ Possible protective strategy to reduce SIDS in infancy, thus reducing infant mortality.
˜ Increased incidence of dental caries, and abnormal dentition and oro-facial development.
˜ Increased incidence of oro-pharyngeal and gastrointestinal infections.
Types of Studies:
This review will be conducted according to the best evidence available for each of the subtopics with the types of research studies likely to vary according to each sub-topic. Randomised controlled trial and quasi-experimental research will be reviewed. Non-randomised, other experimental or observational designs will be considered for inclusion in a narrative summary to enable the identification of current approaches and possible future strategies for optimising infant and child wellbeing.
The review will comprise published and unpublished research and relevant literature since 1960. Articles and research will be restricted to those reported in English.
Electronic searches will be conducted exploring nursing, medical, biological and ancillary health databases. These include:
Expanded Academic Index
Australian Medical Index
Science Citation Index
Other applicable databases.
Dissertation Abstracts International, Conference proceedings, and the Royal College of Nursing Australia database will be searched for unpublished studies.
All studies identified during the database search will be assessed for relevance to the review based on the information provided in the title, abstract and descriptor/MeSH terms, and a full report will be retrieved for all studies that meet the inclusion criteria. Studies identified from reference list searches will be assessed for relevance based on the study title.
Where possible, references cited in research articles will be inspected for completeness of data. Experts (key researchers and clinicians) in some of the sub-topics will be contacted for guidance and suggestions. For the initial review all available abstracts will be considered for relevance to the systematic review. In instances when the abstract is not available the original article will be obtained.
Dummy, dummies, pacifier(s), soother(s), comforter(s), non-nutritive sucking, infant, child, human, infant care.
Assessment of methodological quality
Methodological quality of studies will be assessed using an evaluation tool which will be developed on an existing tool used by the Joanna Briggs Institute for Evidence Based Nursing and based on the work of the Cochrane Collaboration (Oxman, 1994), and the Centre for Reviews and Dissemination at the University of York (NHS Centre for Reviews and Dissemination 1996).
Two reviewers will independently assess all the articles and disagreements between reviewers will be resolved by discussion with a third reviewer. Assessment of quality will commence with experimental studies (randomised and quasi-randomised trials) and will be extended to include research using other methodologies (experimental and observational) in the absence of sufficient randomised controlled trials. Levels of evidence and research quality will be considered for each of the subtopics.
Data will be extracted by two independent reviewers using an evaluation tool which will be developed and piloted prior to use. This tool will include information such as study identification, type of design; details of randomisation (if used), study population, and intervention; outcomes and quality of study assessment. When necessary, the principal primary researcher will be contacted to obtain missing information.
If a sufficient number of studies are identified focusing on a particular intervention of interest with appropriate available data, results from comparable groups of studies will be pooled in a meta- analysis. Based on the analysis, a relative positive and or negative effect of the intervention in each of the sub-topics will be estimated. When pooling of results is inappropriate the findings will be considered for inclusion in a narrative summary.
Heterogeneity between combined studies will be tested using standard chi-square test. Where possible, odds ratio (for categorical outcome data) or standardised mean differences (for continuous data) and their 95% confidence intervals will be calculated for each included study.
Development and dissemination of Guidelines
Following the completion of this Systematic Review it is our intention to develop “Best Practice Guidelines” for all nurses involved in child and family health. It is envisaged these guidelines will also be of value to other health professionals and to carers of infants and small children.
The “Best Practice Guidelines” will be developed under the auspices of the Joanna Briggs Institute for Evidenced Based Nursing and Midwifery. Further dissemination of information will include articles in referred nursing journals, conference presentations and seminars.
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