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Subject:
From:
Susan Burger <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Thu, 7 Apr 2011 07:16:04 -0400
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Dear all:

The Cochrane review suffers from a major problem in that they do not use plausibility criteria to analyze issues in the depth necessary to determine if the right questions were even asked.  What I was taught at Cornell was to analyze all the potential factors that contribute to a condition and analyze the actions that could alleviate that condition.  Sometimes the factors that contribute to the condition are DIFFERENT than the actions that will alleviate the condition.  In this manner, you can see those factors that have a positive or negative effect and identify ways to look at those factors so as to avoid setting up a study where the impact is buried when two antagonistic factors cancel each other out.  

Take for instance the impact of selenium on cancer prevention.  If you study this in a population that eats food grown in selenium rich soil, you would not see any impact and in fact might increase the risk of selenium toxicity (which is very serious).  If you study this is in a population that eats food grown in selenium depleted soil you might see some benefit.  If you didn't take into account the initial selenium status of that particular population you might cancel out the effects.  China has areas of selenium deficiency and selenium excess and it would be easy to see how doing a metaanalysis of studies conducting on selenium supplementation in China might yield a "no effect" situation if the proper screening criteria were not applied. 

When I looked at the Cochrane review on use of growth charts, I was disappointed in the shallowness of the thinking that went into their selection criteria. I had hoped for something that built upon a review that was done back in the 1990s.  Al I gained from that article was a few more articles to read, but the older review which was conducted by someone who had actually researched the topic, was far more important for gleaning an understanding of the impact of growth curves on public health nutrition programs.

The other issue about pacifiers that I think really is true -- is that there is a reverse causality issue.  There is one article that suggests that use of the pacifier increases due to breastfeeding problems and that the problem preceded the pacifier.  I absolutely see this in my clientele.  Parents who never would have used a pacifier end up using a pacifier when their baby has a breastfeeding problem.  This does not mean, however, that the pacifier does anything to help the situation and often does make the situation worse.  How this type of use of the pacifier is important!! You cannot merely take the pacifier away and tell the parents everything will be hunky dory.  You have to replace the pacifier with a real solution.

If you read Betty Carson Bowles article on "Promoting Breastfeeding Self-Efficacy" in the latest issue of Clinical Lactation you will understand why this is so.  If you tell them there is a problem with the use of the pacifier without giving them a doable solution for the behavior that triggered them to use the pacifier, then their fear response will trigger denial, resistance, and defensive avoidance.  First you must give them a reason why continued use of the pacifier is a problem and give them a doable solution to fix the underlying problem.

Best regards, Susan E. Burger, MHS, PhD, IBCLC

Sincerely,  Susan E. Burger, MHS, PhD, IBCLC

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