Overmedicalisation and paramedicalisation in times of catastrophic environmental crisis
"Lactation is probably the only bodily function for which modern medicine has almost no training, protocol or scientifically-acquired knowledge." Jiminez et al 2017 Plos One
There is a world-wide trend to overmedicalisation and overtreatment
The Centre for Research in Evidence-Based Practice is about an hour and a half's drive away from where I live in Queensland, at Bond University on the Gold Coast. They publish ground-breaking research about the serious and growing occurence of overdiagnosis and overtreatment, which is occurring world-wide, including in infants and children. This is a frightening international problem, not just because its terrible costly for health systems and for families, but 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. Twenty-first century breastfed babies are often at risk of unintended harms due to our well-intentioned efforts to help.
A Preventing Overdiagnosis conference
It is not surprising, really, that over-medicalisation of mothers and babies with breastfeeding problems is rampant in this extraordinary era of catastrophic environmental crisis.
I presented a workshop called Preventing Overdiagnosis in the First Months of Life in December 2019, at the 5th International Preventing Overdiagnosis Conference. I'd put in an abstract because that year the conference was held in my home country, Australia.
Then, when we stepped outside into the university grounds during the breaks, right in the heart of Sydney, we discovered that the sun was burning scarlet through a thick brown haze. Our throats quickly became sore.
"What on earth is happening?" delegates from all around the world asked each other, deeply unsettled as the sun drifted like a clot of blood above us, a strange and frightening portent of dystopian futures.
Bush-fires.
Just two months later, the pandemic exploded into our lives and onto our TV screens, but at the time of this conference (unless you were amongst that small group of global health expert who had already been preparing for the ominously-named Disease X), the pandemic was still unimaginable.
It was an exciting conference of four hundred international delegates. Plenary sessions focused on overdiagnosis, for instance of hypertension, or of prostate and breast cancers-in-situ. Most of us there knew that the rampant overdiagnosis and over-use of medical technologies is related to the climate crisis. Both are symptoms of a human society that values technological mastery of nature and unrestrained market forces over a sensitive responsivity and alignment with the natural world. Now we face unthinkable and global species extinction and climate catastrophe, emerging after just a few centuries of this biologically-disruptive belief system.
Overdiagnosis and overtreatment thrive in our times of unrestrained market forces and environmental destruction
We live in urgent times. There's every reason to believe that those wriggling, mewling little babies I see each day in the clinic, those gorgeous quivering little chunks of the universe, so new, so sensitive, so sensate, so utterly innocent, will be subject to a future where the population of the planet drops dramatically, some estimate by sixfold, through disease and conflict due to the pressures from climate change, with all the intimate personal horror this implies playing out in their lives. Market forces, which benefit small numbers of wealthy and powerful people and which have captured many of the levers of our democracies, control policy settings and may yet, if we're unable to act collectively for change, control our babies' destinies.
We live in times of severely normalized disconnection from the natural world, when profits in business prevail over concern for individual, social, and planetary good, when extreme lies are told with such conviction and aplomb that ordinary people don't know what to believe. These same market forces also shape the experiences of women as they give birth and breastfeed their babies.
Market forces reward technological interventions. Research institutions prioritise biomedical research over research into complex primary health care innovations. Private educators offering continuing professional development points bring in popular personalities who best reflect popular views to ensure their business profits. These same forces, amplified in social media, have driven the exponential increase in infant frenotomy, for instance. We live in an increasingly complex and biologically disrupted world, with unregulated social media punishing unpopular or dissenting perspectives. We live in the end-game of the neoliberal world view, and as a direct result, the care of mothers and babies with breastfeeding, cry-fuss, sleep or mood problems is highly medicalized.
Our health system has blind spots concerning breastfeeding and unsettled infant behaviour
At the conference, I didn't feel my talk went particularly well. I had put a great deal of time into preparing the slides, too much, perhaps, and only a small number of delegates turned up. Frankly, the care of mothers and babies is not a priority even for those committed to health system reform. This lack of interest comes at the end of a long history of devaluing the mother of a baby in Western societies, though from the Industrial Revolution onwards this devaluing co-existed with a paradoxical sentimentalizing of motherhood and the stay-at-home mother.
Among the delegates who came to my workshop, there was a natural birth advocate who wished to discuss the unnecessary medicalization of birth, a serious related problem but not my field, and not the advertised focus on my talk. Another doctor wanted to talk about the overtreatment of infant conjunctivitis with antibiotics, which of course matters because of anti-microbial resistance, but is a minor problem compared to the widespread overuse of proton pump inhibitors, maternal elimination diets, and frenotomy in breastfed infants, with their serious risk of unintended harm.
I often wonder why aren't people shocked to hear that our babies are routinely and unnecessarily treated with proton pump inhibitors, which have been shown to increase the risk of bone fracture and allergy and asthma and infections? I wonder why people aren't shocked to hear that breastfeeding mothers are still regularly and unnecessarily advised to avoid a range of foods in their diets, which increases their babies' risk of allergy later on? Why aren't people shocked to hear that our babies are routinely treated with unnecessary oral surgery, which (particularly if by laser) risks pain, breast refusal (or conditioned dialling up at the breast), infection, loss of sensation of the front part of the tongue, and, on rare occasions, life-threatening blood loss? Why aren't people shocked to hear of the extent to which paramedicalisation has overtaken clinical breastfeeding support, in the absence of supporting evidence, or scientific rationale, and at great cost to both parents and the health system?
I had hoped to address a scandalous level of overdiagnosis and overtreatment of breastfeeding mother-baby pairs and unsettled babies at the conference, but I didn't manage to pull it off.
A genuine health system commitment to the implications of the Developmental Origins of Disease would urgently prioritise effective, evidence-based help for the common problems of early infancy
If our health system was truly committed to addressing the Developmental Origins of Health and Disease, effective, consistent, research-based help for breastfeeding women and their babies, minimizing unnecessary medical interventions, would be a national and international health system priority.
A fifth of Australian forests went on to burn in the 2019-2020 bushfire season which followed that conference on Preventing Overdiagnosis, just before the pandemic hit. A 2021 Australian Climate Council report, led by Professor Will Steffen, pronounced that Australia had to half its emissions by 2030 to reach net zero emissions by 2040.
“That's what we need to do - the science is very clear on that - and a lot of technologies are now coming into place to make those goals feasible," Professor Will Steffen said on the ABC news at the time of the report's release. "What's stopping us is ideology, politics and vested interests.”
How does one live with this? The only way to a healthy, life-sustaining relationship between the human being and the natural world is by a careful piecing together, step by step, using the breathtakingly clever tools of 21st century science, combined with a cultivation of joy and wonder. When it comes to breastfeeding, in my own way, I'm committed to a careful piecing together, step by step, of the best of our scientific knowledge, in order to support enjoyment, ease, and wonder.
| Iatrogenic condition | Causes (selected examples) |
|---|---|
| Formula use | Inability to address clinical breastfeeding problems |
| Nasogastric tube feeding | Anxiety about weight, failure to detect positional instability problems or conditioned dialing up |
| Conditioned dialling up with breast or bottle | Rigid feeding schedules, Frenotomy |
| Long-term allergy | Maternal elimination diets if breastfeeding |
| GORD | Inappropriate diagnosis of reflux |
| Anxiety and depression | Inability to help with breastfeeding problems or advice that worsens breastfeeding problems; First wave behavioural approaches to sleep; Feeding routines |
| Breast compressions during breastfeeds | Positional instability risking nipple pain, fussiness during feeds, poor milk transfer |
| Breast massage and ‘lymphatic massage’ | Worsened mastitis |
| Conditioned dialling up at the breast or bottle; Loss of sensation anterior tongue | Side-effect of laser or deep scissors frenotomy |
| Poor weight gain | Feed spacing |
| Nipple thrush | Nipple and breast tissue drag |
| Suck swallow breath disco-ordination; Aspiration | Positional instability |
| Oral connection tissue restrictions (in the absence of classic tongue tie) | Positional instability, breast tissue drag |
Selected references
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;Published online January 8 http://dx.doi.org/10.1016/S0140-6736(16)32585-5.
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.
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.
Jimenez E, Arroyo R, Cardenas N, Marin M, Serrano P, Fernandez L, et al. Mammary candidiasis: a medical condition without scientific evidence? PLoS One. 2017;12(7):e0181071.
Steel N, Abdelhamid A, Stokes T. A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients. Journal of Clinical Epidemiology. 2014;67(11):1251-1257.
Winzenberg TM, Gill GF. Prioritising general practice research. Medical Journal of Australia. 2016;205:529.