The international trend to overdiagnosis and overtreatment affects clinical approaches to lactation-related nipple pain and damage

Overdiagnosis and overtreatment is widespread in the treatment of nipple pain and damage during lactation

Despite the known benefits of breastfeeding for both infant and mother, clinical interventions for problems such as nipple pain and damage remain a research frontier.1,2

Overuse of medical, surgical and pharmaceutical interventions is an increasingly serious international problem in health care more broadly.3-11 Both patients and clinicians typically overestimate the benefits of medical interventions and underestimate potential harms.12-14

It not surprising then, given the relative lack of research into clinical breastfeeding support, that overmedicalisation and overtreatment have stepped into this gap, to become significant problems in the care of breastfeeding women and their babies, including when nipple pain and damage emerges.8-19 Overmedicalisation and overtreatment are inevitable when research or clinical problems are responded to using a reductionist or medicalised lens.

The lack of evaluation studies also applies to the NDC Clinical Guidelines for Nipple Pain and Damage in Lactation, which aims to minimise unnecessary diagnoses and interventions. However, the NDC clinical translations are developed from robust, peer-reviewed and published theoretical modelling and physiological rationale, as well as from existing interdisciplinary research. Sometimes, the NDC work has required demonstrating the lack of evidence behind popular diagnoses, which I did in publishing a systematic review about candidiasis and the breast, here.

You can read more about NDC and implementation science here.

Common overmedicalised treatment of nipple pain and damage in lactation	Explanation (detailed in ref. 22)
Antifungal treatments for nipple candidiasis	Deep stabbing pain between breastfeeds, radiating or burning pain, pink shiny nipple and the white flakes of hyperkeratosis are caused by inflammation and nipple stroma microhaemorrhages due to repetitive mechanical microtrauma. Candida is a normal part of the nipple and areola microbiome and the infant oral microbiome.
Nifedipine or other calcium channel blockers for nipple vasospasm	Vasospasm is autonomic instability caused by repetitive mechanical microtrauma
Frenotomy and bodywork exercises for ankyloglossia	Although classic (anterior) tongue-tie occurs and requires simple scissors frenotomy, normal anatomic variations are typically misdiagnosed as tight oral connective tissues
Antibiotics and antifungals for painful white spots of the nipple, which are diagnosed as subacute mastitis or an extension of intramammary duct biofilm	There are three causes of white spots, discussed here. None require antibiotics or antifungals.
All Purpose Nipple Ointment	This combination of an antibiotic, antifungal and anti-inflammatory steroid should never be used.
Antibiotic ointment or cream (mupiricin) for exudate	A nipple wound's exudate is part of the healing process. Occasionally, an antibiotic is indicated for a true peri-wound cellulitis.
Pharmaceutical intervention for chronic pain e.g. gabapentin, SSRIs, propranolol	Nipple pain and damage in lactation is acute inflammatory pain, which ceases when breastfeeding or mechanical milk removal ceases. The use of medications for chronic pain places the woman at risk of side-effects, without evidence of, or rationale for, benefits.

Selected references

Care of breastfeeding mothers and babies is a research frontier

1. Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine. 2021;16(4):349-350.

2. Rey J. Frontier research: bringing the future closer. Lychnos: Notebooks of the Fundacion Generale CSIC. 2011;5(June):https://fgcsic.es/lychnos/en_en/forum/frontier_research_bringing_the_future_closer.

Calls to address the worsening international problem of overdiagnosis and overtreatment

3. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390:156–168.

4. Saini V, Brownlee S, Elshaug AG, Glasziou P, Iona Health. Addressing overuse and underuse around the world. The Lancet. 2017;doi:http://dx.doi.org/10.1016/50140-6736(16)32753-9.

5. Armstrong N. Overdiagnosis and overtreatment: a sociological perspective on tackling a contemporary healthcare issue. Sociology of Health and Illness. 2020;43(1):58-64.

6. Born KB, Levinson W. Choosing Wisely campaigns globally: a shared approach to tackling the problem of overuse in healthcare. Journal of General Family Medicine. 2019;20(1):9-12.

7. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390:156–168.

8. Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1-11.

9. Gupta P, Gupta M, Koul N. Overdiagnosis and overtreatment; how to deal with too much medicine. Journal of Family Medicine and Primary Care. 2020;9:3815-3819.

10. Stordal K, Wyder C, Trobisch A, Grossman Z. Overtesting and overtreatment - statement from the European Academy of Paediatrics (EAP). European Journal of Pediatrics. 2019;178(12):1923-1927.

11. Treadwell J. Overdiagnosis and overtreatment: generalists - it's time for a grassroots revolution. Journal of General Practice. 2016;66(644):116-117.

Both patients and clinicians overestimate the benefits of interventions and underestimate side-effects

12. 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.

13. 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.

14. Hanoch Y, Rolison J, Freund AM. Reaping the benefits and avoiding the risks: unrealistic optimism in the health domain. Risk Analysis. 2018;39(4):792-804.

The problem of overdiagnosis and overtreatment in the care of parents with babies

15. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.

16. Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49(4):e252-e256.

17. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018:88-89.

18. Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.

19. Lisonek M, Shiliang L, Dzakpasu S, Moore AM, Joseph KS. Changes in the incidence and surgical treatment of ankyloglossia in Canada. Paedaitrics and Child Health. 2017;22(7):382-386.

20. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health. 2021;17:DOI: 10.1177/17455065211031480.

21. Ellehauge E, Jensen JS, Gonhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.

22. Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2021:DOI: 10.1177/17455057221087865.

23. Douglas PS. Re-thinking benign inflammation of the lactating breast: classification, prevention, and management. Women's Health. 2022;18:17455057221091349.

24. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.

25. Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.

26. Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.