Nine things I wish lactation medicine doctors and health professionals who care for families with babies knew about research

For many years, I have wished that my lactation medicine colleagues and other health professionals who care for parents with infants knew about the following ten things.

1. Genuinely evidence-based clinical or educational health care programs or interventions (CEHPI) are developed using the principles of implementation science

It's commonly (and wrongly!) believed that a single study (or even an unpublished audit) can give rise to evidence-based practice. Although that might be true occasionally - for instance when a well conducted study, in particular a randomised controlled trial, legitimately changes practice, usually a layering of research studies using different methodologies is required to properly understand the impact of an intervention.

Implementation science is the science of translating research into clinical practice. Here are the steps required to develop a health CEHPI using implementation science. This process takes many years, and usually requires various research teams. It also requires funding.

1. Take a question which arises out of clinical experience. In other words, activate your curiosity, your dedication to your patients' wellbeing, your passion to make a difference!

2. What research already exists? What don’t we know? Systematically synthesise and analyse all existing research by either conducting a

   • A systematic review (still necessary to analyse systematic reviews for implicit biases in interpretation of data) OR

   • A metanarrative review. (The latter are often best suited to the kinds of complex problems we see in lactation medicine, given the heterogeneity of outcome measures.)

3. Develop theoretical models to explain what’s going on, if no-one knows for sure. Think critically about existing models (often implied e.g. reductionism or mechanistic) and draw on your knowledge of interdisciplinary perspectives. Be explicit about the theoretical frameworks you’re using. This requires naming your model, so that it is clearly distinguished from other models.

4. Peer review and publish the systematic or metanarrative reviews and theoretical models in order to make them available for debate and discussion within our collective health system intelligence. This becomes your contribution to the evolution of collective intelligence in our field. Your theoretical model needs to be available for debate, dissent, and refinement.

5. Translate the existing research, interpreted through our theoretical models, into a CEHPI. The CEHPI becomes part of what’s referred to as ‘grey literature’ initially.

6. Educate other health professionals in order to deliver the CEHPI in various settings, iteratively improving it in response to

   • Patient and health professional feedback

   • Data collected from feasibility and pilot studies, publishing your findings.

7. Evaluate the CEHPI by layering of various methodologies: e.g. observational studies; randomised controlled trials and publish your findings.

8. Iterative improvement of the program/intervention – the CEHPI is dynamic in response to evaluations.

All my other Wish List Items follow on from Item #1, above!

2. Clinical guidelines are built from consensus of experts, and are our best tool for quality assurance in medical or health practice - but we need to be aware of their limitations!

Consensus guidelines are another important tool by which 21st century Homo sapiens care for each other, a way of ensuring that health professionals provide the best possible care for humans' health and wellbeing.

But there is no such thing as neutral science. The belief that science can be completely objective is a myth which arises out of a mechanistic world view. For example, research is shaped by

• The gendered bias of funding provision

• The funding bias against primary health care research

• Lack of transparency of reviews and reviewers in the field of lactation medicine (out of step with transparent reviews being implemented across many disciplines), which allows certain reviewers to control what is able to be published without scrutiny or transparency

• $3,500 fee for open access publishing - so that independent researchers (who are often well placed to produce innovative or critical thinking) can't afford to publish

• Capacity to disseminate the research e.g. lactation non-profit exclude research and researchers from available education.

Science is inevitably shaped by the observer and the context. Good science aims to be respectfully explicit about this, and to control for (or at least be explicit about) context.

Because clinical guidelines are built from consensus, clinical guidelines are also by nature conservative, displaying a significant lag between evidence and practice. This conservatism is both a strength and a weakness, like so much in life. Here are external factors which can weaken the alignment between clinical guidelines and existing research.

• Clinical guidelines will fail to optimise the care being offered to patients if dissenting research-based voices are excluded from their development

• Clinical guidelines will fail to optimise the care being offered to patients if theoretical models are not explicit and debated, but assumed as fact. The reductionist lens is the most common assumed (or unconscious) theoretical model which affects interpretation of research in lactation medicine.

• Clinical guidelines generated in hospital or university settings typically fail to include primary health care clinician-researchers and as a result fail to optimise the care being offered to patients in the community.

Efforts have been made to distinguish between ‘evidence-informed’ and ‘evidence-based’ content, which I propose isn't helpful. As clinicians, how we help patients is only ever informed by evidence, regardless of how conclusive evaluation studies are. Our CEHP need to be

• Modified to fit the complexity of that unique patient

• Delivered in collaboration with that unique patient

• With the patient at the centre of decision-making.

This is the definition of ‘evidence-based’ practice used these days by the Oxford Centre for Evidence-based Medicine. This is why I consider the term ‘evidence-informed’ redundant.

A 2025 systematic survey of treatment guidelines by Ghadimi et al found that trustworthiness of clinical guidelines in medicine improved only modestly from 2010 to 2022 and remained suboptimal. Only 18.6% of 2022 clinical guidelines in health achieved a high score on critical trustworthiness items.

3. The term evidence-based has become a marketing tool. The montage approach to evidence is not evidence-based care.

We see around us, especially in the fields of breastfeeding and infant care, a great deal of what I call the montage approach to evidence, where an educator or clinician reads through and selects a range of citations to put at the bottom of an article, in order to claim that the approach they have offered is evidence-based.

• There is no clarity about theoretical frames or how those models have been translated into practice

• There are no evaluations of that particular mix of strategies which have been cherry-picked out and which are unique to that particular educator or clinician or guideline.

Any genuinely evidence-based approach to any clinical or educational problem is built through the steps of implementation science.

We need to be aware that the term ‘evidence-based’ has become a marketing tool, and holds very little meaning today, as every health intervention or education program in the care of parents with infants needs to promote their services as evidence-based.

4. Any genuinely evidence-based approach (e.g. to nipple pain, or to low supply) which has not yet been evaluated requires a name

Any genuinely evidence-based approach (that is, an approach built through implementation science) requires a name, so that it can be taught to others, and evaluated. Naming is a way of dealing with implicit and unconscious assumptions that this new way is 'the right' or the 'proven' or the 'factual' way - a big problem in lactation medicine. Naming addresses false beliefs in the neutrality of science.

The ABM guidelines, for instance, are dependent on the composition of the committees - who is in charge or the dominant individual in the committee, who is either intentionally or unintentionally excluded by from the committee, to what extent dissent is encouraged, to what extent committee members are able to critique existing research with an awareness of the lenses being applied and an understanding of methodological strength and weakness.

This is why the multiple theoretical frames and clinical approaches of Neuroprotective Developmental Care have names. This is the only way you can genuinely build up an evidence-base for complex interventions. Science is never neutral, but depends upon the observer. Behavioural clinical interventions, such as we need for breastfeeding problems or unsettled infant behaviour, are complex and need to be named and distinguished from other approaches so that the multiple steps of the program can be

1. Taught to others

2. Replicated and evaluated.

It’s the observer’s responsibility to be transparent about the lenses that are being used, but unfortunately these are commonly unconscious. For example, lactation medicine currently uses highly medicalised or reductionist lenses. Various lactation non-profits, for instance, in their clinical guidelines are not communicating neutral proven scientific facts, given the paucity of evidence concerning clinical lactation support, but a set of guidelines that have been collaboratively developed using various interpretations of existing research.

If you ever hear someone refer to Possums or NDC as branding, trying to make money off branding, please explain that in fact Possums or NDC uses names because this is a necessary part of genuinely research-based interventions, which can be taught to others, and evaluated! Without naming a new approach and distinguishing it from previous approaches, it is not possible to advance in a field. Many approaches to complex problems such as nipple pain which are presented as factual or neutral by leading individuals in the field of lactation medicine, should - if we were to be seriously evidence-driven - be named after the person who is puts forward that perspective, or by some other name that they choose.

5. Reviews are currently not transparent in the fields of lactation medicine and infant care

Difficulty getting publications through reviewers in Australia has been an issue throughout my professional life. Here, there is only a very small pool of medical reviewers, and often just one dominant reviewer being asked to consider lactation medicine manuscripts across multiple domestic journals. A reviewer can have exceptional knowledge in the field but nevertheless apply an interpretative lens which is highly medicalised, or reductionist. If the editor agrees with the reviewer, which they often do because the reviewer’s position is seen as the most conservative (even if for instance the reviewer promotes overuse of antibiotics, which is actually less conservative). Unfortunately this dominance of a single reviewer, without the commitment to public transparency which is the case across most other fields of medical science today, has the effect of limiting dissent or innovation.

I have had reviewers in lactation medicine claim, anonymously, that the gestalt method is ‘divisive’, or that it is self-promotional ‘advertising pup' (those were the words), or even - remarkably but true! - that my name should be deleted from the manuscript because lactation professionals would not want to read it if it had my name on it ...

6. The dissemination problem in the context of a (gendered) paucity of funding

University funded dissemination requires funding, not from the university itself, but from grants or philanthropy. These are very difficult to obtain, and independent researchers typically can’t invest the large amount of time required to submit repeatedly for grants and have them rejected. Yet in primary health care independent clinician-researchers are often best placed to offer innovations in the clinical care of their patients.

Charities and non-profits are typically unable to respond flexibly to the demands of constantly changing research and education needs, and are vulnerable to being used by others for personal financial or reputational gain. Non-profit governance varies significantly between countries and in the US, between states. Non-profits are not commercially ‘pure’ but are equally driven by commercial forces, using a range of strategies to counter competition.

Currently, lactation non-profits structurally exclude, for commercial and ideological reasons (which means they also extract content. If lactation non-profits were to become inclusive of clinician-researchers, they would celebrate diverse and conflicting contributions in education, holding the space for the discomfort but scientific necessity of dissent.)

7. Ethical acknowledgement of other (women’s) work

All the global lactation non-profits currently unethically exclude researchers and clinician-researchers from opportunities to educate, which seriously distorts the education available and allows flourishing of overdiagnosis, paramedicalisation, and overtreatments. This exclusion of growing numbers of researchers and researcher-clinicians, dozens internationally now, is historically structured into lactation non-profits and in my view is unlikely to change in the next decade.

Exclusion goes hand in hand with extraction. You can read about this here.

It's particularly important to support (even if this is through respectful dissent) the work of other women in the field of lactation medicine because of various systemic obstacles frequently encountered by those attempting to publish lactation medicine research.

• There is very limited research funding available.

• University or hospital based research typically doesn’t translate into effective community-based care.

• Primary health care is underfunded, and it is difficult to find funding for primary health care research.

• Funding challenges also impact upon dissemination - letting others know about the work.

8. "Absence of evidence is not evidence of absence"

The phrase "absence of evidence is not evidence of absence" (popularized by Carl Sagan) means that failing to find proof for a claim does not definitively disprove it. It highlights that a lack of observation (e.g., not finding a rare bird) is not the same as evidence that the thing does not exist.

However, in the absence of evidence, it's vital to develop theoretical models, name them, discuss and debate them. In the absence of evidence, we need to lean on what seems to be the most biologically or physiologically plausible, informed by clinical experience.

9. Structural exclusion of lactation researchers

Dissent is a vital part of the development of collective human intelligence, in health and in any other field.

The exclusion of researcher voices is a unique structural problem inherent in lactation non-profits globally, including here in Australia. This exclusion skews the education available to lactation medicine doctors and health professionals, facilitating overdiagnosis, paramedicalisation, and overtreatments. It’s a global problem which is holding back advances in lactation medicine. Exclusion of clinicians and researchers by lactation non-profits does not advance the wellbeing of breastfeeding women and their babies, and is likely even doing harm.

Recommended resources

Conversation with Professor Donna Geddes, University of Western Australia, about her research and what she wishes clinicians knew about reading research

The International Board of Lactation Consultant Examiners pulls commercial levers to cancel the Possums or NDC programs genuinely research-based lactation education.

The politics of exclusion and extraction: a call for change in the field of lactation medicine so that breastfeeding families receive the best possible science-based support

Selected references

Ghadimi M, Guyatt G, Zaror C, et al. Trustworthiness of treatment clinical practice guidelines has modestly improved since the introduction of Institute of Medicine standards: a systematic survey. J Clin Epidemiol. 2025;187:111962. doi:10.1016/j.jclinepi.2025.111962

Nilsen P, Sundemo D, Heintz F, et al. Towards evidence-based practice 2.0: leveraging artificial intelligence in healthcare. Front Health Serv. 2024;4:1368030. Published 2024 Jun 11. doi:10.3389/frhs.2024.1368030

S. D.Shapiro, I.Logvinov, and R. M.Thomas, “Redefining Evidence-Based Practice Through Patient Values: A Theoretical Innovation for Person-Centered, Value-Based Care,” Journal of Evaluation in Clinical Practice32 (2026): e70344. https://doi.org/10.1111/jep.70344.

W.Qi, “Rethinking Evidence in Contemporary Evidence-Based Medicine: A Critical Examination Into Emerging Forms of Clinical Practice,” Journal of Evaluation in Clinical Practice32 (2026): 1-9. https://doi.org/10.1111/jep.70369.