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The Pacifier Debate: In Reply

In Reply .—

We thank the authors for their interest in our article and their thoughtful comments.

We appreciate the updated US Preventive Services Task Force (USPSTF) grading scale and matrix provided by Drs Calonge and Petitti.1 We had not been aware of the newer scale when we conducted our meta-analysis, and thus our use of the 1996 methodology was an unintentional oversight. However, after carefully reviewing the methodology used currently by the USPSTF, we believe that our pacifier recommendation2 as a potential preventive strategy against sudden infant death syndrome (SIDS) would retain the B grading: fair to good strength of evidence of moderate net benefit. As stated in our article, we used the USPSTF taxonomy to classify our recommendation; the task force was in no way involved in the study or its conclusions.

We feel that our review of the evidence was “comprehensive, objective, and attentive to quality.”1 We conducted a comprehensive literature search beginning at 1966 and used an analytic framework for evaluating the quality of each study; we excluded from the meta-analysis any studies that were of lower quality. We included studies that measured the associations between pacifier use (the preventive service) and the health outcome of interest (ie, occurrence of SIDS) rather than intermediate outcomes. Because the best studies available used case-control designs, these would be classified under the hierarchy of research design as level II-2. Using the criteria for grading internal validity of individual studies would qualify them as having “good” internal validity.

Next, we examined the quality of the full body of evidence. Here, we found that the evidence for pacifier use at last sleep is highly consistent and internally and externally valid (generalizable). We also believe that the evidence is coherent, that is, makes sense on the basis of hypothesized mechanisms …