Nursing care in early childhood: contributions from intersubjective recognition Cuidar en enfermería en la primera infancia: contribuciones del reconocimiento

Objective: to understand the elements composing intersubjective recognition that are relevant for nursing care in early childhood in favor of comprehensive child development. Method: refl exive study based on the Honnethian concept of intersubjective recognition in the dimensions of affection, defense of rights, and social esteem. Results: nursing knowledge and practices, permeated by the intersubjective recognition in the mentioned dimensions, contribute to the dynamism of interpersonal relations, the production of co-responsibility, and shared construction of health care in early childhood, with benefi ts to comprehensive development. Conclusion: a successful coordination of the three intersubjective dimensions enables the expansion of the understanding on childhood and nursing care in child health in the fi eld of human development promotion, covering affection, defense of rights, and social esteem in the established relationships with future positive individual and social possibilities. Descriptors: Child; Child development; Nursing; Comprehensive Health Care; Interpersonal relations. RESUMEN Objetivo: comprender elementos constitutivos del reconocimiento intersubjetivo de relevancia para el cuidado de enfermería en la primera infancia, en pro del desarrollo integral infantil. Método: estudio refl exivo, fundamentado en concepto honnethiano de reconocimiento intersubjetivo en las dimensiones del afecto, la defensa de los derechos y la estima social. Resultados: los Cuidar em enfermagem na primeira infância: contribuições do reconhecimento intersubjetivo Nursing care in early childhood: contributions from intersubjective recognition Cuidar en enfermería en la primera infancia: contribuciones del reconocimiento intersubjetivo REFLEXÃO


INTRODUCTION
Interventions in favor of the development in early childhood, from zero to six years old, are critical for the entire life, with benefits for health, learning, autonomy, and social participation (1) .In the last decades, the field of neurosciences has contributed with scientific evidence demonstrating that the initial events of life affect the configuration of the brain functions, which are critical to the establishment of a solid development.On the other hand, it demonstrated that brain changes resulting from adverse environmental conditions, particularly maltreatment and psychosocial deprivations, whether in family or institutional contexts, may often lead to permanent damages to development (1) .
This evidence reaffirms the importance of human relationships.In the growth and development processes, the human being needs positive and appropriate interactions performed by people that are committed to their health and well-being in order to minimize their vulnerability to potential harmful environmental effects.Positive socio-affective relationships are essential for the constitution of the different dimensions of the functions and skills structured in early childhood (2) .
Therefore, it is important that children have their needs related to the development process met, and for that, daily care demands attention and protection (3) .This represents a challenge to health professionals, particularly those working in primary care, not only to prevent injuries, but also to expand the defense of child health (4) in different scenarios.Effective actions in the promotion and protection of the development in early childhood have a potential to reduce inequalities; and a number of solutions and benefits are associated with the efforts in the area of public health to overcome harmful neurodevelopmental consequences (1) .
In this context, nursing practices and knowledge may contribute to the empowerment and emancipation of individuals and communities, positively affecting human development due to its focus on care as the object of the profession.In order to achieve this aim, nurses need to have consistent references that guide their practice in the search for comprehensiveness, overcoming the limits that are present in the several scenarios of health care, as the needs of individuals that are often unnoticed or reduced to demands previously established by the health services.
Positive and negative effects of the technical and scientific transformations of health care have been discussed (5) .On the one hand, they point out the acceleration of the diagnostic resources, the precocity and intensification of therapeutic interventions, the improvement of prognosis and quality of life of patients with several health complications, and on the other hand the fragmentation of health care, segmentation of patients in organs and functions, increased costs and discriminatory access to the resources, dialogue gaps, and iatrogeny.In view of this, achieving comprehensiveness in child health care represents a challenge that requires knowledge supporting a broad understanding of their needs, especially in the aspects related to the promotion of human health.
In the perspective of contributing to the broad understanding of health care that supports the principle of comprehensiveness in child care, the present study presents a reflection on the concept of intersubjective recognition by Axel Honneth (6) aiming to give emphasis to care practices with a potential to promote comprehensive child development.Thus, the objective of the present study was to understand the elements of intersubjective recognition that are relevant for nursing care in early childhood in favor of comprehensive child development.

UNDERSTANDING INTERSUBJECTIVE RECOGNITION
The Honnethian concept of intersubjective recognition covers three dimensions: affection, rights, and social esteem (6) .The core of this framework consists in the dialectic processes of intersubjective relationships, and the interactions in each one of these dimensions contribute in a particular way to the moral development of individuals (6) .Individual experiences interpreted and experienced as disrespectful and unfair mobilize a struggle for recognition and search for self-achievement (6) .
The theory of recognition results from the approach known as "critical theory", which is proposed to understand social situations of inequalities, oppression, injustice, and disrespect in order to diagnose the negative phenomena in certain historical conditions and, at the same time, identify possibilities for practical overcoming of the diagnosed problems (7) .
In this approach, the fundamental idea is that the individuals develop and constitute their identities when they are recognized in an intersubjective way.Individuals will be able to achieve a "positive practical self-relation" with themselves when they are recognized by the other members of the community.The absence or false recognition has repercussions in a struggle for recognition in which the individual aims to restore or create conditions of reciprocal recognition (7) .The recognition enables the individual to develop this "positive practical self-relation" in search of bonds of both freedom and individual autonomy and community-and society-related bonds.
In the Honnethian approach, the concept of recognition is structured in the conception of self-relation, an interactive and dynamic process based on the normative pretensions inscribed in the relationships with which the individual tends to seek delimitation of their subjectivity (6) .The focus of the concept consists in providing different ways of practical selfrelation that are effective as self-confidence/mutual trust, selfrespect/mutual respect, and self-esteem/social esteem (6) .
In relation to the dimensions of recognition, affection is specifically the one that promotes self-confidence with contribution to the preservation of identity in social relations (6) .Supported by the psychoanalysis of Winnicott, Honneth emphasizes the importance of the experiences of diligent and continuous care by child caregivers as a condition for the development of a positive relationship, with deployment in other social relations (6) .In addition, it points out that every experience of affection actualizes the issue of dependence/autonomy resulted from the motherchild fusion from which the individual develops confidence in themselves and in the world (6) .
In the dimension of rights, the Honnethian approach supports the privilege of people with equal civil, political, and social rights (6) .The relations in this context generate self-respect through the awareness that they are seen as someone who deserves respect from others.In this approach, the situations that generate violation of rights and gaps in the defense and protection of people produce injustice, calling for the struggle for recognition (6) .
The dimension of the social esteem relations is related to the reciprocal acceptance between people, appreciated based on community values and leading to self-esteem.Thus, the relations of esteem promote the possibility of the individual to perceive themselves with a contribution to society, making reference to themselves (6) .In this context, the principles and values are taken as reference for personal attributes, collaborating to an expanded understanding of society.However, threats to dignity and damages to self-esteem result in lack of recognition.Acts of disrespect drives struggles as the experienced acts generate indignation and mobilizes actions.They represent the concretization of oppression and restrictions to self-achievement (6) .

NURSING CARE IN CHILD HEALTH AND THE DIMEN-SIONS OF RECOGNITION
In the present study, nursing care is analyzed according to the dimensions of intersubjective recognition (6) , considering the practice of nurses in child health care, in nursing appointments (NA), and in home visits (HV).
The actions conducted during NA or HV are aimed at supporting and enhancing the ability of the family to provide care and promote the child health .The stages of NA and HV make it possible to determine the needs and then health care.Traditionally, the perspective of health professionals privileges aspects of care for health maintenance and recovery.The incorporation of the perspective of intersubjective recognition (6) implies an expansion of the care in order to cover every essential needs for the child development, valuing them equally.
The essential needs for child development are: continuous supportive relationships; physical protection, safety and regulation; appropriate experiences to development; experiences that respect individual differences; establishment of limits, organization, and expectations; stable, supportive communities; cultural continuity (3) .Such needs refer to giving visibility to the family and actively available caregivers to establish interpersonal proximities, which should be included in the care processes.Therefore, this study points out the need to promote the strengthening of affective bonds and their understanding aiming at a better future.They are relevant in the early childhood care for the formation of the individual's autonomy, health, learning, social life, among other benefits (1) .
At the beginning of human life there is the stage of undifferentiated intersubjectivity; when it is matured and divided in a healthy manner through the intersubjective cooperation between the child and their reference person.It generates possibilities for the development of confidence, the ability to be alone, and safety.Thus, the split with symbiosis emanates the productive balance of delimitation that is necessary for living in society (6) .
In the context of NA in child care, health follow-up should be flexible and appropriate for each child, meeting the particularities of their health, the family and sociocultural contexts.NA and HV in child care include nursing interventions for: health followup and promotion of child growth and development, supervision of the immunization status, encouragement to breastfeeding and healthy eating, early detection, prevention and treatment of prevalent complications, especially respiratory infections and other infectious diseases, and particularly the strengthening and expansion of the family abilities for child care (8) .
In child-related care, studies in the area of nursing care point out the benefits of the practice of HV for vulnerable families, for child health surveillance, support to maternity, support, development of parental skills, and encouragement of positive interaction with the child (9) , with indicators related to the health of the women, family, and child care and development, collaborating to a reduction of morbidity and mortality rates, particularly in contexts of adversities (10) .In the context of health advocacy, HV are an intrinsic tool to the clinical practice in primary health care that provides a rich space for health professionals, especially nurses, to put in place comprehensive health care, with benefits for the child, family, and community.The practice of nurses, as a moment of care and defense of child health, enables an evaluation of the health of the child and their family and social contexts, as well as the identification of vulnerabilities and potentialities, interventions and guidance on several themes, and an interrelation with other professionals, services, and sectors (4) .
These aspects meet the mentioned legal dimension of the concept of recognition, in which every individual has to feel in equal conditions in terms of civil, political, and social rights.The professional should seek to implement legitimate actions and preserve the universal moral principle to the individuals in society.This dimension refers to citizenship, and therefore to the execution of the principles of freedom and social equality and participation.Publicizing and fulfilling rights related to health care are present in this agenda, as well as in the guidelines of the Child and Adolescent Statute and in the Brazilian public policies.A number of actions related to nursing care may and should deal with individual and family experiences in order to recognize disrespectful and unfair situations, mobilizing a struggle for recognition and the search for self-actualization.
The dimension of affection is linked to the encouragement and favoring of attachment as ways to protect the development of children and humanity.Care in the context of pediatrics promotes the establishment of bonds with the families to strengthen their potential and support them in the reorientation of their care when it is found to be necessary.Dialogical and emancipatory health education leads to a dissemination of knowledge that favors the understanding of the families on the needs of their children aiming at a healthy development and the valorization of the practices that meet the essential needs and encourage the achievements of the child.
The dimension of social esteem refers to the individual presenting contributions to the society and, from a self-relation, attempting to promote such aspect.Thus, all explicitness and valorization in terms of commitment to early childhood care may be implemented in a higher level of professional involvement and commitment, with the inclusion of families, caregivers, and the community.The presence of positive self-relations in the dimension of social esteem promotes solidarity and enables tenacity, particularly in terms of sharing and ressignification (6) .
Therefore, due to its set of knowledge and opportunities of practices that are frequent and close to the children, families, and social contexts where they live, and for being based on the reference of intersubjective recognition, Nursing may contribute for the development of self-confidence in affective relations, selfrespect in legal relations, and self-esteem in life in society.
Care is a reconstructive category of the health practices that involves considering the presence of the other and optimizing the interaction, aiming at having active presence, wealthy and dynamic intersubjective interactions, networks of dialogue, reception, accountability and expansion of horizons (5) , and in this sense it is promising when it is articulated to the concept of intersubjective recognition.
The Honnethian theoretical perspective enables an expansion of the approach that values the mutual recognition of peers (nurse-family-child) in the longitudinality of care, a fact that tends to intensify care comprehensiveness.These opportunities generate experiences that foster affectivity, autonomy, and the search for self-actualization.In this sense, aspects related to the universal access of children to comprehensive care, privileging the appropriate development in early childhood, also represent a challenge for the nursing practice, teaching, and research.

FINAL CONSIDERATIONS
In order to promote comprehensive development, the fundamentals of nursing care in early childhood should not be reduced to an individual perspective; it should cover the child, parents, other significant people, and the sociocultural context.
The present study aimed to point out the concern in relation to professional practices in the field of child health care aiming at preventing disrespect and lack of attention to the process of mutual and intersubjective recognition.Furthermore, it emphasizes the importance of valuing dialogue as an essential means to stimulate relations, produce co-responsibility, and favor the shared construction of care aimed at the comprehensive development of individuals with particular attention to children and their families.
For that, the conceptual framework was used to expand the understanding on childhood nursing care in the field of human development promotion, with a successful coordination of the three intersubjective dimensions -affection, defense of rights, and social esteem -that deserve to be contemplated in the established relations, with future positive individual and social possibilities.