Low value health care is a worsening international problem in the field of breastfeeding medicine

Low value care is a growing international problem

I acknowledge the devastating human rights issue of global under-provision of healthcare for mothers and babies, particularly in low and middle income countries, and the frightening impacts on maternal and infant mortality and morbidity. In the context of this inequity, my analysis nevertheless aims to raise awareness of the extent of inappropriate medicalisation and paramedicalisation of mothers and babies in the first months of life in high income countries. This constitutes a non-lethal but nevertheless disturbing form of mother-baby health care crisis, which poses costly downstream developmental and mental health challenges for genetically or psychosocially vulnerable families.

Despite the Choosing Wisely campaign, Preventing Overdiagnosis movement, and other national and international initiatives, it’s estimated that only 60% of health care remains aligned with evidence- or consensus-based guidelines. Thirty percent of health care is estimated to be of low value, and 10% to cause harm.1 Aronson 2022 recommends use of the term “too much healthcare”, noting the serious significant environmental and climate impacts of this trend.2, 3 Too much healthcare often implies too little effective healthcare.

Low value care is particularly common in the health systems of high income countries, which are also paradoxically characterised by rapidly growing and unsustainable health system expenditure.3 Too much healthcare also often occurs alongside underuse of health care in socioeconomically disadvantaged countries or populations.4, 5

It’s been suggested that overdiagnosis and overtreatment in health systems disproportionately originate from the US, where rates of overdiagnosis are highest in higher income populations. One research publication by historians suggests that overdiagnosis and overtreatment may be "the silent pandemic of the West".5A

Families who present with common infant care concerns receive large amounts of low value care

“Public health problems without easy solutions are fertile ground for large-scale over-activity in primary care.”6

The most common presentations in the first months of life are problems of breastfeeding, feeds, and unsettled infant behaviour

The most common presentations in the first months of life to community-based health professionals, secondary providers, and tertiary emergency departments in high income countries are problems of breastfeeding, feeds, and unsettled infant problems. One in five new parents report problem infant crying. One-third report infant sleep problems. And more than 80% of women report breastfeeding problems. In Australia, for example, 96% of women plan to breastfeed their baby at at birth, but only 39% are able to do so exclusively by the time their infant is 16 weeks of age. These mothers attribute the introduction of formula to low supply and infant weight gain concerns, nipple and breast pain, and unsettled infant behaviour.

This analysis focuses on breastfeeding and unsettled infant behaviour, framing the majority of bottle feeding as a secondary outcome of unresolved breastfeeding problems or misconceptions. I use this framing because of the observation that, when protected from environmental or physical obstacles, most women choose to breastfeed.

Although presentations of breastfeeding and unsettled infant behaviour typically interact together and cannot be effectively managed separately, the provision of health care for the common presentations of infancy is siloed between disciplines. This expensive, structural health system problem is exacerbated by siloed, single-issue breastfeeding advocacy and support organisations and non-profits, who tend to be dominated by shared ideological beliefs and who currently collectively act to exclude genuinely research-based, integrated, innovations in the clinical support of breastfeeding and unsettled infant behaviour.

Each of the common breastfeeding and unsettled infant behaviour presentations are modifiable risk factors for postnatal depression. However, health professionals report inadequate training in management of these presentations, and parents report high levels of conflicting advice. Unsurprisingly in this context, up to one in five new mothers and one in ten new fathers are diagnosed with postnatal depression and anxiety.

Why does it matter if families who present with breastfeeding and unsettled infant problems receive low value care?

The first months of life are a window of exquisite neuroplasticity in both mother and infant. Unsettled infant behaviour problems, fundamentally linked with breastfeeding and feeding problems, are associated with suboptimal development and mental health outcomes, particularly in psychosocially or genetically vulnerable infants, with life-long implications for mental health, burden of disease and health system cost. The rising incidence of mental health problems throughout the lifespan constitute a global health system crisis, requiring multi-factorial strategies including prevention from early life.7 Not breastfeeding is also linked with a range of health risks for both mother and infant.

Who provides services to families presenting with breastfeeding and unsettled infant problems?

I estimate, drawing on both clinical experience and the research, that the provision of low value health care for common infant behaviour and feeding problems in early life remains significantly higher than the 30% of low value care found more broadly throughout the lifespan. Low value care for these problems may be both medical and paramedical.

Social media and online programs are now dominant sources of information for parents who have problems with breastfeeding or unsettled infant behaviour. Families turn to a growing number of service providers, both publicly and privately funded, for assistance.

The providers may be general practitioners, paediatricians, emergency department physicians, registered nurses including maternal and child health nurses, midwives, International Board Certified Lactation Consultants, doulas, lactation counsellors, dentists, pharmacists, Ear Nose and Throat Surgeons, speech pathologists, physiotherapists, chiropractors, osteopaths, or other bodywork therapists. Overmedicalisation and paramedicalisation is systemic.

Low value care of breastfeeding and infant behaviour problems: overmedicalisation

Overmedicalisation is the framing of nonmedical issues in medical terms, and quickly leads to overuse of treatments with little benefit but significant harm and cost.4 Overmedicalisation and overtreatment result from financial, organisational, and sociocultural attributes of health systems.8

The detailed table found here details examples of the low value care often provided in response to the common problems of infancy, the evidence, and the risks associated with these treatments. In this section on overmedicalisation, I'll consider two examples.

Example 1: Anti-secretory medications for unsettled infants

In 2017, Coone et al updated a seminal 2014 article which threw a spotlight on the growing problem of paediatric overdiagnosis in the US, including treatments for infant gastro-oesophageal reflux and food allergy.9, 10 From 2015, in response to the research showing lack of efficacy in unsettled infants, the international Choosing Wisely campaign has warned against the use of anti-reflux medications for infant gastro-oesophageal reflux.11 Among Australian general practitioners, for example, a 2025 study shows that only 4.7% prescribe low value pharmaceutical care for the unsettled, puking infant (proton pump inhibitors, histamine-2 receptor antagonists, anticholinergic medications, colic mixtures and simethicone).12

Despite this positive outcome, Choosing Wisely does not yet address overtreatment of the range of other common infant care problems.11

Less encouragingly, in a 2024 survey of 2,716 paediatricians or paediatric residents from 16 European countries and Japan, 81% reported high levels of medical overactivity. Inappropriate use of acid suppression therapy for infant gastro-oesophageal reflux was ranked as a high level problem amongst their colleagues.13

Example 2: frenotomy in babies with breastfeeding problems

This example is dealt with extensively in other sections of Possums Breastfeeding & Lactation.

Low value care of breastfeeding and infant behaviour problems: paramedicalisation

Paramedicalisation refers to overuse of non-medical, non-evidence-based health concepts and treatment methods including Complementary and Alternative Medicines in management of health problems, alongside or instead of conventional, biomedical approaches. When a health problem becomes paramedicalised, these concepts and treatments expand into various aspects of life and healthcare, often with the perception that they are equally or more valuable than those authorized by medical science.13A

Infancy in high income countries is increasingly paramedicalised. Clinical breastfeeding support is currently dominated by bodywork therapists or IBCLCs trained in bodywork therapy, and who administer bodywork to infants for breastfeeding problems and unsettled behaviour. Providers and approaches include osteopathy, chiropractic care, craniosacral therapy, myofunctional therapy, and various types of mother and baby massages including Manual Lymphatic Drainage.

Although osteopathic treatments have demonstrated efficacy in adult treatment, in infants bodywork therapy lacks robust theoretical frames, lack genuine scientific evidence of efficacy despite high profile ‘evidence-based’ guidelines, [e.g. International Consortium of Ankylofrenula Professionals guidelines] and label infants with a wide range of anatomical and functional pathologies which are not congruent with genuine medical diagnoses, yet are vigorously promoted commercially. There is also no evidence or sound physiological rationale to support Therapeutic Massage of Lactation.

References

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2. Barratt AL, Bell KJL, Charlesworth K, McGain F. High value care is low carbon health care. Medical Journal of Australia. 2021:doi: 10.5694/mja5692.51331. 3A. Brodersen J, Schartz LM, Heneghan C. Overdiagnosis: what it is and what it isn't. BMJ Evidence-based Medicine. 2018;23:1-3.
3. Aronson JK. When I use a word .... Too much healthcare - overdetection. BMJ. 2022;378:doi:10.1136/bmj.o1963.
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