Overdiagnosis, overtreatment, and overservicing arise due to a relative lack of effective clinical tools
Our health systems predispose women to breastfeeding-related distress
Our health systems promote 'breast as best' but fail to educate health professionals in effective clinical lactation support. This predisposes women to breastfeeding problems and distress. Women are breastfeeding world-wide in the context of
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High levels of awareness of the benefits of breastfeeding for their baby, alongside powerful cultural narratives about the importance of being a 'good mother'
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Low levels of knowledge about what actually works in clinical breastfeeding support amongst breastfeeding support professionals, due to a relative lack of research and poor training opportunities
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High levels of mechanical nipple pain and infant distress at the breast, which are not identified and managed as problems (but instead women are told their latch is good and the baby has wind, allergy, or reflux)
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High levels of overdiagnosis and overtreatment of both maternal and infant in breastfeeding, which don't address the underlying problems, but are communicated authoritatively as best practice on the internet, in conferences, and in clinical protocols globally.
There is a world-wide trend to overmedicalisation and overtreatment and this is also true in the field of breastfeeding medicine
There is a Centre for Research in Evidence-Based Practice about an hour and a half’s drive away from where I live in Queensland, at Bond University on the Gold Coast. They have published ground-breaking research about the serious and growing problem of overdiagnosis and overtreatment, which is occurring world-wide – including in infants and children. This is a frightening international problem, because inappropriate medical or surgical treatments always come with risk of unwanted side-effects.
This Centre has also published studies showing that health professionals and patients typically believe surgery or medicines will be more effective than they actually are. (It’s not surprising that patients think this, since patients are influenced by information they receive from health professionals!) They’ve also shown that the risk of harm from interventions is underestimated by both health professionals and patients.
These findings are true of the help breastfeeding support professionals offer women and babies. Many twenty-first century breastfed babies are at risk of unintended harms due to their providors' efforts to help which lack either the support of research or a strong biological rationale.
I have closely monitored the overdiagnosis and overtreatment of reflux, allergy, and lactose intolerance in breastfeeding babies, and the overdiagnosis and overtreatment of thrush in breastfeeding women with nipple pain, over the past 35 years of my professional life, and have published regularly about these. As we discuss from the start in Possums Breastfeeding & Lactation, there are three main breastfeeding problems which are not being picked up, and instead, medical diagnoses are applied.
Misunderstandings about how the baby's tongue moves during breastfeeding drives overtreatment in breastfed babies
The most recent trend to unhelpful medical intervention has occurred over the past ten or fifteen years now. Breastfeeding support professionals have been operating from a model of breastfeeding biomechanics which claims, before all else, that tongue movement drives breastfeeding. This means that when there are problems of nipple pain or poor milk transfer, the tongue is blamed.
Many breastfeeding support professionals now believe that tight oral connective tissues or tight orofacial muscles restrict tongue movement. The frenulum under the tongue is mostly blamed, and also the frenulum under the upper lip. A ripple effect of abnormalities of nerves, fascia and muscles are said to impact on the tongue. Very complicated theories about this have been developed, which you might be told about.
A small percentage of babies may be born with a classic tongue-tie, which requires a simple snip (or frenotomy, a surgical procedure which cuts into the frenulum) using scissors to release the tongue. In cases of classic tongue-tie, the sooner this is done after birth, the better. You’ll notice a membrane under your baby’s tongue that extends close to the tip. You might also see a true heart-shape tug on the tip of the tongue as it moves, and the baby will not be able to extend the tongue over the lower gum to the lower lip. There is no reason to use laser, which risks deeper thermal damage. Remember though that many babies have a membrane that runs along the under-surface of the tongue, which is stretchy and a normal variant, and a divet in the tip of a baby’s tongue is also very common and normal.
The exponential increase in frenotomy rates in infants is consistent with overdiagnosis and overtreatment
But as a result of this outdated biomechanical model of breastfeeding, from the late 2000s in Australia, where I live, and elsewhere in the English speaking world, the rates of frenotomy have risen dramatically. Epidemiologists, the scholars who study these trends, tell us this exponential rate of increase is typical of overdiagnosis and overtreatment.
I saw early on that the growing over-use of frenotomy, particularly as the dentists and Ear Nose and Throat surgeons began to use laser, was in the bigger picture, merely another wave of this trend to over-medicalise our babies with breastfeeding problems, placing babies at unnecessary risk without genuine benefit. At least, without benefit compared to letting time pass without doing anything, since many breastfeeding problems have been shown to improve with time.
Why were we still turning to medical solutions that were already demonstrated (if we looked closely at the research!) not to work, but which instead (again if we looked closely at the research!) put our babies at risk?
I propose we use frenotomy for a range of breastfeeding problems, even when there is no classic tongue-tie, because as breastfeeding support professionals the clinical approaches that we have been using often don't work. I recently heard an educator teaching health professionals about craniosacral therapy for breastfeeding problems. She stated that she'd turned to the modality of bodywork therapy because so often the tools that she had available to her as an International Board Certified Lactation Consultant didn't work. Breastfeeding support professionals step in with overmedicalisation, paramedicalisation, and overtreatment in response to parents' need for help, when there aren't better clinical tools available to them.
This lack of effective clinical tools is what drives my passion to help make changes and find approaches that work when breastfeeding and fussy baby problems arise. The very first place to start is to understand how babies suckle.
Selected references
Hoffman T, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening and tests - a systematic review. JAMA Internal Medicine. 2015;175(2):274-286.
Hoffman T, Del Mar C. Clinicians' expectations of the benefits and harms of treatments, screening, and tests - a systematic review. JAMA Internal Medicine. 2017;177(3):407-419.
Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine. 2021;16(4):349-350.