Phytotherapy in pediatrics : the production of knowledge and practices in Primary Care

Objective: To demonstrate the use of phytotherapy as a therapy adopted in the context of Primary Care to Childhood. Method: Observational and analytical fi eld research, with quantitative-qualitative approach. A semi-structured survey was used on socio-demographic and ethnopharmacological variables, audio interview and daily observation. Results: The production of knowledge about phytotherapy constitutes a family heritage, but incorporated data resulting from the daily experiences shared by the community. The main factors were: easy access to this resource, high costs of conventional treatment, diffi culty in accessing medical services and belief in the power of plants. The attributed meanings were: prevention and treatment of injuries, rescue of memory and of experiences, factor integrative with nature and aggregative among members of the community. Final considerations: Rescuing this tradition brings a new meaning to health care. Descriptors: Phytotherapy; Pediatrics; Knowledge; Population; Health Care. RESUMO Objetivo: Evidenciar o uso da fi toterapia como terapêutica adotada no contexto da Atenção Básica à Infância. Método: Pesquisa de campo observacional e analítica, com abordagem quantitativo-qualitativa. Utilizou-se questionário semiestruturado relativo às variáveis socio-demográfi cas e etnofarmacológicas, entrevista gravada em áudio e observação no cotidiano. Resultados: A produção de conhecimento sobre a fi toterapia constitui-se numa herança familiar, mas incorporou dados resultantes das experiências cotidianas compartilhadas pela comunidade. Os fatores mantenedores dessas práticas foram: fácil acesso a esse recurso, altos custos do tratamento convencional, difi culdade de acesso a serviços médicos e crença no poder das plantas. Os sentidos atribuídos foram: prevenção e tratamento de agravos, resgate da memória e de vivências, fator integrativo com a natureza e agregativo entre membros da comunidade. Considerações fi nais: Resgatar essa tradição traz um novo sentido aos cuidados de saúde. Descritores: Fitoterapia; Pediatria; Conhecimento; População; Assistência à Saúde. RESUMEN Objetivo: Evidenciar el uso de la fi toterapia como terapia adoptada en el contexto de la Atención Básica a la Infancia. Método: Investigación analítica y de campo observacional, con abordaje cuantitativo-cualitativo. Se utilizó un cuestionario semiestructurado relativo a las variables socio-demográfi cas y etnofarmacológicas, entrevista grabada en audio y observación en el cotidiano. Resultados: La producción de conocimiento sobre la fi toterapia se constituye en una herencia familiar, pero ha incorporado los datos resultantes de las experiencias cotidianas compartidas por la comunidad. Los factores mantenedores de estas prácticas fueron: fácil acceso a ese recurso, altos costos del tratamiento convencional, difi cultad de acceso a los servicios médicos creencia en el poder de las plantas. Los sentidos atribuidos fueron: prevención y tratamiento de agravios, rescate de la Phytotherapy in pediatrics: the production of knowledge and practices in Primary Care Fitoterapia em pediatria: a produção de saberes e práticas na Atenção Básica Fitoterapia en pediatría: la producción de saberes y prácticas en la Atención Básica


INTRODUCTION
The use of plants as a source of medicine by man is as old as the history of mankind; and the origin of this knowledge is confounded with its own existence (1) .It emerged, as human beings sought to meet their basic needs through chance, observation, and attempts (2) , and there were reports of their use in various civilizations of antiquity (3) .
According to data from the World Health Organization (WHO), 80% of the world's population depends on traditional practices in Primary Health Care, and 80-85% of this portion uses plants or preparations based on vegetables, deserving in Brazil, the programs involving phytotherapy developed in the Primary Health Care of the public health network of many municipalities and states (4) .
Primary Health Care (PHC) in Brazil is defined as the initial contact of the user with the healthcare network of the health system and constitutes a set of actions, both individually and collectively, covering the promotion and health protection, disease prevention, diagnosis, treatment, rehabilitation, harm reduction and health maintenance, with the aim of developing comprehensive care that impacts on health situations, the autonomy of individuals and determinants and health determinants of collectivities.In order to do so, it is necessary to use care practices and democratic and participative managements that consider the dynamics existing in the land where the population lives and the subject in its singularity, and in its socio-cultural insertion (5) .
In Brazil, in May 2006, the National Policy on Integrative and Complementary Practices (PNPIC) was approved by the Ministry of Health (MS) in the Unified Health System (SUS); the approval of this National Policy has triggered the development of new policies, programs and actions in all governmental spheres; among them those that contemplate the use of medicinal plants and phytotherapy in SUS (5) .However, an adequate program involving phytotherapy should incorporate the set of values, beliefs and attitudes that determine the life habits of the population, to become an efficient strategy in its improvement (6) .
Regarding the use of medicinal plants in children, mothers' "caring" practice involving this resource is based on knowledge transmitted from generation to generation, which guarantees the maintenance of health and the cure of diseases (7) .At the international level, there are few research studies with representative populations on the use of herbal products in children, which justifies the low prevalence of this use found in several studies (8) .
Understanding how health care is practiced by families through the use of phytotherapy requires knowing the symbolic representations linked to the transmission of this knowledge, which is expanded in the exchange of knowledge between family members and the environment in which they live (9) .
The study of practices using phytotherapy in pediatrics plays a relevant role in PHC, since they involve the interaction between knowledge, health care partnerships, use resources accessible to the community and with therapeutic potential, value customs and local beliefs, strengthening the bond between users and the community with health teams, promoting users' autonomy, humanization and integral care within the public system, since they are linked to the real health needs of this population.

OBJECTIVE
The objective of this study is to show the use of phytotherapy as a therapy adopted in the context of Primary Care to Childhood.

Ethical aspects
The research was approved by the Research Ethics Committee of Centro Universitário Cesmac and with modifications through notifications.All volunteers received clarifications regarding the objectives, procedures, risks and benefits of their participation, being assured of the right to confidentiality and the possibility of withdrawing from the research at any time, without any kind of loss, with the signature of the Free and Clarified Consent Term as an inclusive framework in the study.The Municipal Health Department of the city of Maceió granted authorization to use the environment of the Health Unit.The research was conducted according to the ethical standards based on the guidelines of Resolution CNS N o .466/12.

Design, place of study and period
Observational and analytical field research with quantitative-qualitative approach.The procedures adopted in the study followed the flowchart shown in Figure 1.
The research was carried out in the land of a Basic Health Unit, located in the municipality of Maceió/AL.The Unit is part of the 7th Municipal Administrative Region, being a reference for the pediatric care to the adjacent localities.The neighborhood where it is located has an area of 20,383km2 and a population of 71,441 inhabitants, distributed in 19,735 households.The number of children and adolescents registered had the following distribution by age group: 0-4 years: 6,024; 5-9 years: 6,419; 10-14 years: 7,366 and 15-19 years: 6,913.The number of deaths in children under one year of age between August 2009 and July 2010 was 12.The number of literates totaled 58,998.Only 1,527 households had a general sewage network with rainwater harvesting and 5,964 had water supply through the general network.In relation to nominal monthly household income, the majority were in the range of 1 to 2 minimum wages (10) .Data collection took place from February to May 2016.

Analysis of results and statistics
Socio-demographic and ethnopharmacological data, obtained from the use of the survey, were tabulated in a Microsoft Excel® 2007 spreadsheet and treated through descriptive statistics, using frequency distribution.

Theorical and methodological references
In the qualitative approach, we used the ethnographic approach of the conversational researcher in everyday life (11) , which focuses and values common places and their redescriptions as places of knowledge production, as well as the researcher's positioning in this daily life, in a continuous negotiation process of collective meanings.In order to do so, it was used daily observation (12) , which proposes the coexistence of the researcher in spaces of a collective nature, sharing the culture that sustains them and seeking to understand the senses produced by people in their daily interactions.The consequent impressions of the researcher were recorded in a field diary (13) .
The theoretical-methodological approach of Discursive Practices and Production of Senses in Daily Life (14) was used to analyze the material produced.This methodological theory considers the production of meanings as a social, dialogic practice that happens in the everyday process and involves the language in use.It is guided by Social Constructionism, according to which the criteria and concepts that are used to describe, explain and make choices are human constructions, products of conventions and practices socially founded and historically located.
In the study of Discursive Practices, Dialogical Maps (15) , or maps of association of ideas, are instruments used in the analysis, through which the context of the themes, the dialogues and expressions present in the speech, as well as the repertoires linguistic expressions (16) , which are the terms and figures of language used to describe the world, which denote the way the speakers position themselves on the subject, allowing us to perceive the versions of reality that are produced.

Methodological procedures
In the qualitative approach, we used the ethnographic view of the conversational researcher in the daily routine through the technique of observation in the daily routine, which had as a research instrument an interview recorded in audio, whose themes were approached through guiding questions and the use of the field diary.The interviews were conducted in the volunteers' homes, which were located near the Health Unit.

Data source
The number of participants for the qualitative study was defined by progressive inclusion, interrupted by the criterion of information saturation, and included 08 volunteers.

Population or sample; inclusion and exclusion criteria
The group of collaborators included in the study was formed by parents or guardians of children and adolescents enrolled in the SUS, who used the Pediatric Ambulatory of the Basic Health Unit during the period corresponding to the research.Exclusion criteria included those known to be mentally ill or who had an intellectual inability to respond to the proposed questions because they were considered as vulnerable groups.The sample calculation was performed using the online OpenEpi ® program, considering the average monthly number of 350 visits performed by the Pediatric Sector, using the following criteria: 5.5% of acceptable error, Confidence Interval (CI) of 99 % and frequency expected to use 80% medicinal plants (4) .The sample was determined in 176 individuals who received, as identification, a sequence of letters and numbers to preserve their secrecy.

Study protocol
The volunteers were approached through a verbal invitation in person, held at the Unit itself, while waiting for or after the service.The quantitative approach adopted the descriptive and analytical method, using as a research instrument an interview using a semistructured investigative survey, previously validated by the Delphi Technique, containing questions related to socio-demographic and ethno-pharmacological variables.The survey was grouped into two groups: the first one containing general and socio-demographic information (gender, age, profession, naturalness and educational level) and the second group including questions about knowledge about the use of medicinal herbs in children and adolescents.A previous training of the executing team and Pilot Test was carried out, with application of the same in 10% of the sample.
The contact was initially made with four participants who indicated the others from their network of relationships.The preservation of secrecy was performed through the use of animal codenames, chosen by the researcher because they correlate with the characteristics and facts observed during the interviews (Figure 2).

Collection and data organization
Data derived from audio recording were transcribed and organized into Dialog Maps and Analysis Categories.The information was systematized in tables with the identification of the locators of the themes that emerged during the interviews and were later grouped into two analytical categories that established a dialogue between the conversations and the research objectives.

Data analysis
For the interviews recorded in audio, an adaptation of the technique of analysis based on the theoretical-methodological assumptions of the Discursive Practices and Production of Senses in the Daily Life (14) was applied in order not to fully and sequentially describe the listening, but to be a interlocutor in the writing: it was realized the attentive listening repeatedly of the content recorded in audio, in a directed and guided listening with the purpose of systematizing a set of senses from the speeches produced in the conversations, in a perspective of dialogical interaction with the present voices, seeking to capture the way people speak, the voices that were present in this speech and the linguistic repertoires (16) .Thus, based on this attentive listening and based on the meanings of the repertoires found in the discourses, the locators of themes, from which the Dialogical Maps (15) and the two categories of analysis were elaborated: Popular Knowledge in Pediatrics: origin and transmission and Phytotherapy in pediatrics: everyday life and use (Chart 1).

Socio-demographic data
The study included 183 people, of whom 176 participated in the interview using a survey, from which the statistical data of the survey (97.72% female), and 08 participated in the recorded audio interview (75% female).One of the collaborators participated in both stages of the research.Regarding the age group, 36.93% were aged between 21-30 years, followed by 34.66% in the age group of 31-40 years.Regarding the occupation, 49.43% reported only household activities as housewives, 10.23% reported being domestic servants and 5.11% if they were called autonomous.With regard to level of education, 75% were considered literate, with the following distribution: 35.8% complete secondary school; 23.3% incomplete basic education; 15.34% complete basic education; 11.93% incomplete secondary school; 6.82% incomplete higher or technological education; 4.55% complete higher or technological education; 1.14% semi-literate; 0.56% completed technical education and 0.56% never studied.As for naturalness, 90.34% were from Alagoas State, 71.7% were born in Maceió and the others, from cities in the countryside of the state.

Popular knowledge in pediatrics: origin and transmission
The account of the use of medicinal plants in children and adolescents occurred at a frequency of 96% among respondents, with the origin of this use, been reported as a family tradition that is passed between generations, with the first contacts still occurring in childhood.The circulation of this knowledge is given in oral form of transmission within the family context, but also extends to relations between them and members of the community to which they belong, which is the exchange of information.The indications of the use of plants as medicines were made by relatives (77.56%), by neighbors (8.29%) and by medical orientation (7.8%).On the form of recording this knowledge, it occurs exclusively in memory.

Phytotherapy in pediatrics: everyday life and use
The birth of the children was pointed out as the main factor for the recovery of knowledge related to the use of medicinal plants, causing these mothers to seek in their memories and conversations with their ancestors, a more natural treatment to be used in their children.
In this community there were 692 citations of 54 medicinal plants for use in pediatrics, with emphasis on Fennel (10.98%),Boldo (Peumus boldus) (10.12%),Mint (9.83%), Pineapple (9.39%), Mint in general (8.24%),Citronella (6.65%), Garlic (6.21%), Lemongrass (5.2%), Aroeira tree (3.76%) and Ginger (3.03%).The others were 26.52%, as described in Table 1.The main indications of use were for cough, abdominal pain, colic, as a calming and expectorant, and there is also a description of use for oral hygiene, control of fever, sore throat, ear pain, headache, general pain, such as anti-inflammatory, healing, vermifuge and antidiarrheal.The plants have also been cited for the treatment of sinusitis, urinary tract infection, infections in general, renal lithiasis, asthma, allergic pruritus, skin diseases and anemia.It should be noted that several species were cited as being of daily use for the prevention of diseases.
The motivating factors of the use of medicinal plants were: the easy access to this resource, the high costs involved in conventional treatment, the difficulty of access to medical services and, mainly, the belief in the power of plants.In this population, 96.6% stated that they believe in the curative power of plants, with this treatment being always considered efficient by 54.76% of the participants and sometimes efficient by 45.24%.
The herbicide purchase was followed by the distribution described in Table 2, with emphasis on home-grown cultivation, with the following cultivars being the main cultivated species: Mint (16.46%),Citronella (15.19%),Lemongrass (14.77%),Peppermint (7.17%) and Fennel (5.49%).Regarding the meanings and meanings attributed to the use of medicinal plants in children, their importance was emphasized in the context of Primary Care as a factor of health promotion and prevention of diseases due to their daily use and for the treatment of diseases, with emphasis on their use rational, thus promoting the reduction of damages and ensuring the maintenance of health.

Socio-demographic data
The predominance of female participation in communitybased research, which investigates the use of medicinal plants, has already been pointed out in the literature (1)(2)9,(17)(18)(19)(20) and in the present study, this fact is evident since 96.72% of the According to Ceolin et al. (9) (2011), women are considered important pieces in the transmission of this knowledge, as well as in family health care practices. Regardng the age group, the study contrasted with the majority of the researched literature, mainly by people over 40 years (18,(20)(21)(22)(23) , which is justified by the fact that in this community the number of parents or guardians of children (71.59%) and of these mothers, despite the economically productive age, were out of the labor market, only exercising activities in their own homes as housewives (49.43%), being able to devote more time to the health care of their children.Regarding the level of schooling, the data of the research differed from the literature consulted whose participants had the complete or incomplete elementary school education (9,18,21) , which demonstrates that the use of plants as medicines is also practiced by people with level of advanced education, since in this community this use was even made among people with complete higher education or technological.

Popular knowledge in pediatrics: origin and transmission
A high frequency of the use of medicinal plants in childhood was evidenced: 96% of the parents stated at some point already have used this resource in the treatment or relief of pathologies in their children.Du et al. (8) (2014) presented the prevalence, patterns and determinants of the use of herbal products among children and adolescents in Germany, whose prevalence was 5.8%, but in the comparison of data obtained in his study with international studies he found periods of evaluation of use varying enormously, from the last 07 days to the last 12 months, not having standardization in the different studies in pediatrics, making comparisons and generalizations of results difficult.
The origin of the use of plants as medicines, in agreement with the literature (1)(2)6,9,(20)(21)24) , constitutes a tradition that is transmitted between the generations and was pointed out as a result of the observations of these practices performed by their ancestors, with the first contacts happening in childhood, as Owl shows: As I was raised with my grandmother, my grandmother learned from my great-grandmother, and everything my grandmother learned I learned.(Owl) Regarding the time of plant use, the interviewees did not know how to use it, but reported that they had already done so long ago.For Kangaroo Father, this use is confused with his own story: The transmission of knowledge about the use of plants in childhood found, in the family context, the main form of transfer of this knowledge, occurring in the oral form of transmission, according to the literature (2), but it exceeded family ties receiving contributions from the indications made by neighbors and by health professionals, a fact also pointed out in the literature (2,25) , incorporating new data through the search in books, research in electronic media and even in television programs, a fact also pointed out by Soldati et al (2) (2015), who affirm that this learning is not characterized by a passive process, but an interactive and complex process in which information is re-evaluated and reconstructed, constituting a dynamic process.This learning has gained new entanglements, especially in everyday conversations with older people, through their experiences and experiences as described in the scientific environment (2,20) and pointed out by Owl: On the subject, conversations in the daily life, Batista et al. (26) (2014) affirm that the conversations are relevant protagonists and active in the production of knowledge, being an important means of social interaction and the main way of socialization, in which the places of living, diversity, dialogue and encounter.
In this community there is no written record of this knowledge, being restricted to the memory, the rescue of that knowledge.When questioned about memories related to plant use, respondents reported their childhood and affective relationship with their ancestors, with the female figure of the grandmother being described as the main transmitter of this knowledge.
On the relationship between grandparents and grandchildren, Oliveira et al (27) (2009) point to the term "avosity" as a kinship between the generations from a personal, family and social point of view, highlighting the determining role of grandparents in psychic structuring of the subject, these being the main socializing agents of the children after the parents, making the child know and value their culture.

Phytotherapy in pediatrics: everyday life and use
The first experiences of using medicinal herbs in pediatrics among these mothers occurred with the birth of the children, being this factor, significant for the rescue of this knowledge, as shown by Kangaroo: The pediatric plants, presented in the study, are among the most widely used in the literature studied (6,18,(20)(21)(22)(23)(24)28) ; except for Ginger, Garlic and Pineapple, which were not among the most cited. As n the present study, in the literature there are records of the popular use of medicinal herbs to combat cough, relief of abdominal pain, as a sedative and expectorant (6,(17)(18)21).
The motivating factors pointed out by the participants for the use of medicinal plants find similar records in the consulted literature (1,7,18,21,24) .In the research, Araújo et al. (7) (2012), analyzing the use of medicinal plants in the treatment of childhood respiratory diseases, showed the wide acceptance of medicinal plants, the good results of their use and confidence in this knowledge, emphasizing that for some mothers this is almost always the only resource to treat their children, either due to the lack of conditions to purchase medicines, when they are lacking in the public network, or because of the credibility and ease of meeting the herbs and/or for its low cost.
In the purchase of medicinal plants, home-grown cultivation was important, making gardens and gardens acquire a new meaning in the use of the land, not only those of their own homes, but also those of their families, neighbors, the surroundings, squares and gardens also highlighted in the literature (6,(20)(21)(23)(24)28) . Zank et al (20) (2015), investigating the health practices in the Brazilian semiarid region that involved the use of medicinal plants, highlighted the use of backyards as important places of plant purchase, with reports of the use of the Peppermint and Citronella, species also mentioned among those cultivated in the present study.Only when the interviewees did not have the herbs in their territories did they buy them in trade and with the plants experts.
The plants are inserted in the daily life of family relationships, having use in childhood from a preventive measure to the control of fever, relief and treatment of respiratory, gastrointestinal and urinary pathologies.As pointed out in the literature (9) , medicinal plants stand out as part of a cultural system that unites the people of this locality through common practices and beliefs, giving them a sense of belonging, reinforcing the bonds of friendship and cooperation, constituting a factor of integration with the nature and an important resource in the Primary Care, acting in the promotion and maintenance of the health of the collectivities.

Study limitations
Due to the limited number of research involving the use of medicinal plants in pediatrics, there were difficulties in comparing the results found in the study, comparing them with data from community surveys in general that involved the use of phytotherapy, without necessarily including the report of this study.use in children.New studies covering the use of herbal medicine among children and adolescents are necessary for a better evaluation of the theme.

Contributions to the nursing area
By rescuing the knowledge about phytotherapy circulating in this community, the discussion about health care comes to the fore, rethinking the quality of the services offered and how far the official health systems are from the social reality of these communities, since they are sometimes based on practices that are not related to daily health needs, but rather to the integrality of the issues that the subjects produce and their affective, political and cultural dimensions that determine the processes of illness and cure of this population.
The practices aimed at the use of phytotherapy in pediatrics in PHC are relevant, since they are oriented to carry out actions of health promotion and prevention of diseases, treatment of pathologies and harm reduction, to strengthen the user's links with health teams, with emphasis on popular participation and user autonomy, promoting health maintenance.

FINAL CONSIDERATIONS
The production of knowledge about medicinal plants for use in pediatrics, in addition to being a family heritage, incorporated new data resulting from experiences shared in the daily life, being inserted in the mothers' care practices, aiming the well-being of their children, integrating the people and having in affective relationships an important factor that makes this knowledge transmitted between generations, respecting the traditions of their ancestors.
Factors related to maintaining this practice included: easy access to this resource, high costs involved in conventional treatment, difficulty accessing medical services, but mainly belief in the power of plants.The multiplicity of meanings attributed to its use in the context of Primary Health Care has revealed itself as a curative measure of diseases, preventive of injuries, as part of the daily experience inserted in the daily use of it, as an affective practice and to rescue memory and experiences , as an integrative factor with nature and as an aggregative measure, because it unites members of the same family and those, with the community in which they are inserted, being part of a tradition that broadens in the social relations of the daily life of this population, guaranteeing them identity cultural and sense of continuity.
The offer of actions and services involving the use of phytotherapy in pediatrics as an integrative practice in Primary Care promotes the appreciation and rescue of the community's popular knowledge, strengthening ties with the health team, since individuals feel familiar with the proposal offered therapy, allows the exchange of knowledge and the construction of new knowledge, strengthens the rational use of medicinal plants, stimulates the autonomy and co-responsibility of the population, broadens the offer of therapeutic resources and strengthens the integrality in health.

Figure 1 -
Figure 1 -Flowchart of the methodology used in the research, Maceió, Alagoas State, Brazil, 2016

Chart 1 -
Categories of analysis of interview themes, Maceió, Alagoas State, Brazil, 2016 Category I -Popular knowledge in pediatrics: origin and transmission Category II -Phytotherapy in pediatrics: everyday life and use -Origin of use -Experiences with the use of medicinal plants -Circulation of knowledge -Factors related to the use of plants as medicines -Search for phytotherapy information -Use of land -Memories related to the use -Plants in the daily life of the community

I
use it often from the time I had my boys [...] Because when I was young I did not care either.But when I had my house, my children, I was looking for: mother, what is the use of it?(Kangaroo)

Table 2 -
Purchase of medicinal plants by the community, in percentage values, Maceió, Alagoas State, Brazil, 2016 talk and I learn.I talk mainly with people older than I [haha] [...] O woman ... look, such a disease, well, what is good, what is good, what is good?Then it begins [...] instead of learning one, I learn four, five [...] [haha].(Owl)