Breastfeeding consultancy during the COVID-19 pandemic: experience report

Abstract

Objective

to report the experience of breastfeeding consultants in caring for breastfeeding women during the Covid-19 pandemic.

Method

an experience report of breastfeeding consultancy services, online and face-to-face modalities, in the city of Fortaleza-CE, between March and April 2020.

Results

given the mothers' feelings of fear and anxiety, the consultants provided support through counseling, as well as guidance with a multidisciplinary team. All the women were breastfeeding and performing social distancing and personal hygiene care actions, the importance of access to reliable information sources being reinforced by the consultants. As for breast problems, preventive and curative interventions were carried out. The mothers' satisfaction with the consultant service was noticed.

Conclusion and implications for practice

breastfeeding consultancy is an aggregating device in women's health that favors both the promotion of breastfeeding and mental health during the Covid-19 pandemic. This report provides directions for a holistic practice, to improve the provided care quality, considering the current challenges of health promotion given the pandemic, and can foster new successful strategies.

Keywords:
Breastfeeding; Coronavirus Infections; Nursing; Consultants; Mental Health

Resumo

Objetivo

relatar a experiência de consultoras em amamentação no atendimento às lactantes durante a pandemia de COVID-19.

Método

relato de experiência de atendimentos de consultoria em amamentação, nas modalidades online e presencial, na cidade de Fortaleza-CE, Brasil, entre março e abril de 2020.

Resultados

diante de sentimentos de medo e ansiedade das lactantes, as consultoras prestaram apoio por meio de aconselhamento, bem como orientações com equipe multiprofissional. Todas as lactantes estavam amamentando e realizando distanciamento social e cuidados de higiene pessoal, sendo reforçado pelas consultoras a importância do acesso às fontes confiáveis de informação. Quanto aos problemas mamários, foram realizadas intervenções preventivas e curativas. Percebeu-se a satisfação das lactantes pelo serviço.

Conclusão e implicações para a prática

a consultoria em amamentação constitui-se como um dispositivo agregador na saúde das mulheres que favorece tanto a promoção do aleitamento materno quanto a saúde mental durante a pandemia de Covid-19. Este relato traz direcionamentos para uma prática holística, com vistas à melhoria da qualidade do cuidado prestado, levando-se em consideração os atuais desafios da promoção da saúde diante da pandemia e pode fomentar novas estratégias exitosas.

Palavras-chave:
Aleitamento Materno; Infecções por Coronavírus; Enfermagem; Consultores; Saúde Mental

Resumen

Objetivo

relatar la experiencia de consultores de lactancia materna en el cuidado de mujeres en periodo de lactancia durante la pandemia de Covid-19.

Método

informe de experiencia de los servicios de consultoría en lactancia materna en modalidades en línea y cara a cara, en la ciudad de Fortaleza-CE, entre marzo y abril de 2020.

Resultados

ante los sentimientos de miedo y ansiedad de las mujeres lactantes, los consultores proporcionaron apoyo a través de asesoramiento, así como orientación con un equipo multidisciplinario. Todas las mujeres amamantaban y practicaban el distanciamiento social y cuidados de higiene personal, siendo que los consultores reforzaron la importancia del acceso a fuentes confiables de información. En cuanto a los problemas mamarios, se realizaron intervenciones preventivas y curativas. Se notó la satisfacción de las madres lactantes por el servicio.

Conclusión e implicaciones para la práctica

la consultoría sobre lactancia materna es un dispositivo agregado en la salud de la mujer que favorece tanto la promoción de la lactancia materna como la salud mental frente a la pandemia de Covid-19. Este estudio proporciona instrucciones para una práctica holística, con miras a mejorar la calidad de la atención brindada, teniendo en cuenta los desafíos actuales de la promoción de la salud frente a la pandemia y puede fomentar nuevas estrategias exitosas.

Palabras clave:
Lactancia Materna; Infecciones por Coronavirus; Enfermería; Consultores; Salud Mental

INTRODUCTION

Breastfeeding consulting was regulated in the United States in the 1980s, through the International Board of Lactation Consultant Examiners (IBLCE). The breastfeeding consultant is a recognized professional in several countries, has a paid activity, follows a code of ethics with evidence-based clinical conduct, and acts in a well-defined manner in different environments: private clinics, home and/or hospital care, neonatal intensive care units, milk banks, outpatient clinics and communities; using clinical lactation management techniques, with demonstrations and observations, as well as contribution through education in health.¹

Thus, the importance of the role played by the lactation consultant in promoting, protecting and supporting breastfeeding is highlighted, directly influencing breastfeeding (BF) rates.² In addition, there is scarcity of national studies on the work of this consultant. Among the professionals working in the area, nurses provide assistance to women during the pregnancy-puerperal cycle and have legal support from their class council, having higher education and technical and scientific capacity to exercise this assistance in a qualified and ethical manner.³

With the advent of the new Coronavirus (Covid-19) and the serious global health problem, more than 15 million people worldwide have already been infected with Covid-19, which has caused 630,750 deaths, being declared by the World Health Organization (WHO) as a global public health emergency.⁴

There is still no consolidated evidence of vertical transmission of SARSCoV-2. Although some signs of placental alterations resulting from inflammatory processes whose suspicion falls on Covid-19⁵ have already been evidenced, the virus has not yet been found in samples of amniotic fluid, umbilical cord, swab of the neonate oropharynx and in breast milk.⁶

Thus, there is no robust scientific evidence to prove the relationship between SARSCoV-2 transmission and breastfeeding,⁶ which is why most of the neonatal guidelines do not contraindicate breastfeeding in mothers with Covid-19, considering that the benefits outweigh any potential risks for transmitting the virus from breast milk. However, it is necessary to take specific precautions such as wearing a mask during breastfeeding and hand hygiene measures.⁷

Given this panorama of uncertainties and the Covid-19 pandemic, breastfeeding women are more subjected to increased emotional changes in the face of the uncertainties in the current setting. Thus, mental health problems can be aggravated, requiring continuous and specialized support from health professionals. Thus, the importance is highlighted of breastfeeding consultants who, within their possibilities, should support breastfeeding women and, in this sense, should be searched for distance follow-up strategies, such as teleconsultations and educational actions in social media, among others.⁸

From this setting, the following question arose: How can breastfeeding consultants contribute to minimize the effects of the Covid-19 pandemic on the physical and mental health of the breastfeeding women? Therefore, this report aims at describing the experiences of breastfeeding consultants during the Covid-19 pandemic. This report proposes some strategies that deserve to be socialized in order to favor other professionals to be sensitive to the promotion of maternal and child health, providing qualified care that involves emotional support.

DESCRIPTION OF THE EXPERIENCE

This is an experience report of breastfeeding consulting services from an institution operating in the city of Fortaleza-Ceará, Brazil. The experience report consists of an important scientific narrative according to the postmodern condition, which has the power to circumscribe the experience, the place and its historical time, in a way articulated to a robust theoretical content.⁹

Consultancy happens with scheduled care to pregnant women and postpartum women, guiding and intervening in the process of breastfeeding and in the care of the baby. In addition, it also promotes courses for pregnant women and training for professionals in order to prepare them following the best scientific evidence.

The visits were performed by two consultants, nurses and members of the company, who are authors of the present study, from March 20^th to April 20^th, 2020, with 37 breastfeeding women. Given the recommendation of social distancing, 27 visits were performed online, through the WhatsApp and Instagram applications, and video calls were used as a way to visualize the dynamics of breastfeeding, as well as to seek greater proximity and bonding of the mother-baby binomial. However, in the cases where it was necessary, 10 visits were performed through home visits, and all the recommended care measures were used to prevent the transmission of Covid-19. The age of the breastfeeding women assisted ranged from 25 to 38 years old, all with more than 12 years of study, with children aged between six days and one year and three months old, who were breastfeeding.

The number of visits performed per day was reduced, due to the exposure and the need for time for the consultants, between one visit and another, to go to their homes to perform personal hygiene and cleaning of the materials used. In the face-to-face services, the consultants protected themselves using the following equipment: disposable apron, forfoot, disposable cap, N-95 mask, individual protection goggles and face shield mask.

Before making the home visit, the breastfeeding women were instructed about the permanence of only one companion during the service, and questioned about possible flu-like symptoms of such person and the home contacts. Upon arriving at the house, the consultants left their shoes outside the residence, disinfected the accessories used in the care with 70% alcohol and performed hand hygiene.

During the service, the consultants guided on the practice of breastfeeding, supported and encouraged adherence to BF, clarified doubts, and emphasized the solutions of the difficulties exposed by each mother. However, given the Covid-19 pandemic, it was noticed that most of the breastfeeding women were anxious, reporting fear and seeking information about their own care and the baby's care.

Given this longing of the breastfeeding women, the consultants decided to emphasize some care measures regarding Covid-19 infection, such as: support for negative feelings regarding the BF process and the Covid-19 pandemic, and guidance on measures performed for prevention and possible changes in breastfeeding. To carry out the guidelines, the consultants used the recommendations of the Ministry of Health (MoH), the Brazilian Society of Pediatrics (Sociedade Brasileira de Pediatria, SBP) and the Brazilian Network of Human Milk Banks (Rede Brasileira de Bancos de Leite Humano, rBLH).

Due to the fact that this study constitutes an experience report, it was not submitted to the evaluation of any Ethics Committee. However, during its development, the ethical precepts present in the norms of scientific research involving human beings were considered.

ANALYSIS OF THE EXPERIENCE

Support for breastfeeding women given the Covid-19 pandemic

During the treatment, breastfeeding women with negative feelings about the Covid-19 pandemic were perceived, such as fear, anxiety and uncertainty. In addition to the breastfeeding women sometimes verbalizing these feelings, it was also possible to understand them through non-verbal communication, when they manifested silence, crying and facial expressions of concern.

Given this psychological context, the health counseling technique was used in all breastfeeding consultations, which allowed the mother's understanding, the use of the ability to listen, to try to apprehend what the mother is feeling, which is sometimes difficult to verbalize.

During the pandemic, the constant dissemination in the news and social media of negative news such as increased contagion, hospitalization and deaths is notorious, which may even come to affect friends and family members of the breastfeeding women. News like these can trigger fear and anxiety in anyone and especially in breastfeeding women, as they are naturally in a phase of adaptation to a new moment in their lives. In this sense, the consultants guided the women to avoid overexposure to the news about the pandemic, being encouraged to use the social media to acquire and exchange information regarding motherhood, so the consultants made their personal contacts available to help at that time.

Knowing that the stressful factors can negatively impact on breastfeeding (oxytocin reflex), the consultants created viable strategies to support breastfeeding. Lives (online meetings in real-time) were developed to provide quality information and scientific basis to help them in this phase of motherhood and to answer the main doubts of the families. Some professionals in the maternal and child areas were invited to contribute to the participation in the lives, among them: psychologists, nutritionists, pediatricians, obstetricians, and physiotherapists.

It was sought to empower the women to breastfeed by clarifying that this is a way to protect their children by offering them the gold standard food, thus being encouraged to maintain breastfeeding.

Guidelines on Covid-19 infection prevention measures

During the anamnesis with the mothers, it was noticed that all were breastfeeding and practicing social distancing as recommended by the health authorities, in addition to basic personal hygiene care, such as hand washing, use of 70% alcohol and more frequent baths. With the baby, it was observed that the breastfeeding women maintained routine care, but emphasizing the cleaning of the house and the restrictions of visits. The restriction of visits, although it is a recommendation for this moment of pandemic, has repercussions on the absence of the support network (mothers, sisters, grandparents) much needed for some women.

The consultants reinforced the need to maintain this care and highlighted the importance of access to reliable sources, scientific articles, sites and social media of the Ministry of Health, the SBP and the Instagram of the breastfeeding consulting company.

During the visits, the presence of several doubts regarding the correct recommendations on the prevention of Covid-19 for the mother and baby was evident, such as: need to wear a mask even without flu-like symptoms, consequences of excessive use of alcohol gel and use of air conditioning in increasing proliferation of infection.

Thus, it was understood that there was a need to pass on information based on the best available evidence regarding BF maintenance.

Breastfeeding management given the changes

It was noticed that, with information on the importance of BF, the breastfeeding women insisted on offering breast milk (BM), even in the face of the adversities of the immediate puerperium, psychological changes, the pandemic setting, and the gap in the face-to-face support network, because they were in social distancing.

Despite the difficulties experienced, the women did not stop breastfeeding. However, some breast problems were identified by the consultants, such as pain and discomfort, decreased milk production and breast engorgement.

The face-to-face contact with the women who manifested breast-related problems allowed us to practice techniques with a preventive and curative approach. Each report was welcomed, the breasts were evaluated and guidelines were given on the correct management in the face of the situation: adjustment of latch-on and correct position to relieve pain, circular massages starting with the areola and relief milking for milk removal in cases of engorgement, guidelines to avoid breast absorbent and shells due to possible proliferation of microorganisms causing discomfort, use of milking protocols, care for water intake and feeding of the breastfeeding woman in cases of low production of BM, all of which are demonstrated in a practical and detailed way.

Importance of the pandemic consultancy

After the visits, it was possible to perceive the satisfaction of the breastfeeding women for the service provided, for the feeling of empathy, support, welcoming and safety transmitted to their families at this delicate moment, mainly due to being with their support network reduced.

As breastfeeding consultants, it was gratifying and pleasurable to receive this positive return from the mothers, because it demonstrates that exhaustive work in the face of the pandemic with rigorous care and adequate protection bring positive results for maternal and child health.

In none of the face-to-face visits was there any fear of contagion, because we believed that the protection equipment was sufficient for their protection. The most difficult aspect during the visits in this pandemic was the absence of affective touches, such as hugging the family assisted, petting the babies, being limited to just the gestures of farewells and essential care actions.

The practice of the consultant nurses is part of an interactive process, in which the bond with the patients is developed, and this includes considering their emotional aspect. It is a fact that the Covid-19 pandemic is generating countless psychological consequences in people. A study that analyzed 17,865 user posts showed that negative emotions and social sensitivity increased, while positive emotions and satisfaction decreased, being essential to create policies aimed at intervening early in the area of mental health.¹⁰

Several countries have been concerned about developing strategies that address mental health care to empower society and decrease panic among other mental disorders. Experts at the Peking University made suggestions for measures that can be effective, including: assessing the accuracy of the information disclosed, improving social support systems (family, friends) and using psychosocial services, emphasizing telephone and Internet counseling with health professionals.¹¹

A qualitative study that also evaluated the feelings of women in the period of the Zika virus epidemic showed reports of feelings of concern, fear and uncertainty in contracting the disease, as well as in generating harms to their baby.¹²

To promote emotional support to the breastfeeding women, the health counseling technique was used in all care actions, which allowed for the use of empathy, respect for the mother's time, to understand eye contact, posture, gestures, confidence and interest, always using suggestive language. Health counseling is a great ally of breastfeeding care, given its positive effect on this practice. A randomized controlled trial conducted with 300 women in India, which evaluated the effect of counseling and support by counselors trained in breastfeeding during the first six months of the child's life, showed BF onset within one hour after delivery in 73.4% in the intervention group, compared with 33.6% in the control group. Regarding BF, the mothers in the intervention group had higher rates (88.2%) when compared to the control group (OR 7.44; 95% CI: 3.98-13.92).¹³

In coping with the emergency situation in public health resulting from Covid-19, the Ministry of Health published TECHNICAL NOTE No. 7/2020-DAPES/SAPS/MS, which guides, according to the World Health Organization (WHO), the maintenance of breastfeeding due to lack of evidence to prove that breast milk can disseminate SARSCoV-2 and due to its benefits for the baby (MoH, 2020). In cases of mothers with Covid-19, in addition to maintaining breastfeeding, the Royal College of Obstetricians and Gynecologists (RCOG) emphasizes the need for necessary precautions such as the use of a mask by the breastfeeding woman and hand washing before feeding.^8,14

Given the technological advances involving information sharing, it is the responsibility of the health professionals to disseminate true and scientifically proven information disseminated by reliable sources. Several health organizations have been creating interventions to control the Fake News on the Covid-19 pandemic. In Brazil, the MoH created a WhatsApp channel to answer the doubts of the population, showing news that has already been found to be false, as well as providing sites from reliable sources, such as: The National Health Surveillance Agency, the Pan American Health Organization, the World Health Organization, the Virtual Health Library, and the MoH itself.¹⁵

It is known that breast milk is arguably the best food for the child, generating positive impacts on maternal and child health. However, breastfeeding is not a totally instinctive ability of the human being and needs to be learned and developed and, therefore, it is essential to support health professionals and the social support network because, without this, weaning can be earlier. Faced with the Covid-19 pandemic and the rapid spread of the virus, most breastfeeding women were complying with the WHO recommendations to maintain social distancing. In this way, the support network was limited to guidance from friends and family by phone or messaging apps.¹⁶

In this context, and in the midst of difficulties, some breast-related problems arose. It is believed that the complaints mentioned are related to the emotional aspects reported during the visits because, in the process of breastfeeding, the psychological motivations are factors that can interfere in the hormones involved in breastfeeding. When analyzing the relationship between post-traumatic stress and oxytocin levels, there is evidence that women with high post-traumatic stress have lower oxytocin levels (r(8):0.77; p: 0.026), being essential that nurses support and encourage lactation in mothers who have suffered post-traumatic stress.¹⁷

The performance of the consulting nurses was fundamental for BF promotion even in the current context. Diverse evidence analyzed from a systematic review indicated that interventions performed by breastfeeding consultants and counselors increase the prevalence of women initiating breastfeeding (OR: 1,35; 95% CI: 1.10-1.67), as well as improving breastfeeding rates at one month (OR: 1.49; 95% CI: 1.09-2.04) and the EBF rates (OR: 1.71; 95% CI: 1.20-2.44).¹⁸

In the pandemic setting, the women were harmed by the lack of a support network, which has become a worrying factor, because the physical presence of the family occupies the first place in the reference of Brazilian women. Having a family member nearby makes two peculiar aspects possible: the care actions being provided by the family members to the newborns and the support to the puerperal woman herself, conferring a feeling of strength and improvement of self-esteem.¹⁹

In this sense, the consultants sought action strategies similar to the Brazilian Unified Health System that are being carried out in the face of the pandemic: to disseminate information about care in preventing Covid-19, encourage self-care, promote virtual visitation and, when necessary, ensure care in safe conditions in face-to-face care.²⁰

Respecting the recommended social distancing, the main instrument used by the consultants for the service was the social media, which is widely recognized in the context of promoting BF, generating positive repercussions, bringing information to the target audience, promoting behavior changes and optimizing, with low cost and accessible to the population.

Given the Covid-19 pandemic, it was perceived how exhaustive it has been for the consultants to provide assistance care. A recent review showed psychological distress among health professionals exposed to Covid-19 due to exposure to high levels of stressful events, with the mental health care of the workers through telemedicine also being important.²¹

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

In the context of the Covid-19 Pandemic, breastfeeding consultancy is an aggregating device in women's health care that favors both BF promotion and the mental health of the breastfeeding women. In the presence of negative psychological feelings, it was possible to offer support through counseling, as well as guidance with a multidisciplinary team.

As in other services, the social media were essential to maintain the care of these breastfeeding mothers given the recommendation of social distancing. Given the gap in the support networks, the consultants sought to promote greater safety for women through welcoming and guidelines. Such activities are expected to continue after the pandemic.

It is pointed out how important it is to provide reliable information to support the mothers because, in addition to the difficulties common to the puerperium, they experienced the critical setting of the pandemic, in which false, negative and excessive news can significantly affect the mental health of breastfeeding women, and consequently, the breastfeeding process.

One limitation of the study is that the report involves only the perception of the consultants, and not of the mothers cared for. However, the report of this experience provides information and directions for a holistic practice of the professionals who support breastfeeding, with a view to improving the quality of the care provided. Dissemination and critical consumption of this experience are essential for the current challenges of health promotion in the face of the pandemic and can foster new successful strategies.

REFERÊNCIAS

• ¹
  International Board of Lactation Consultant Examiners. Position paper on the role and impact of the IBCLC [Internet]. 2020 [citado 2 out 2020]. Disponível em: https://iblce.org/
  » https://iblce.org/
• ²
  Chaves AFL, Vitoriano LNH, Borges FLP, Melo RDA, Oliveira MG, Costa Lima ACMAC. Percepção das mulheres que receberam consultoria em amamentação. Enferm. Foco. 2019;10(5):79-84. http://dx.doi.org/10.21675/2357-707X.2019.v10.n5.2519
  » http://dx.doi.org/10.21675/2357-707X.2019.v10.n5.2519
• ³
  Ministério da Saúde (BR). Parecer do Conselho Federal de Enfermagem nº 18/2016/CTAS. Solicitação de parecer a respeito de atividades de consultoria em amamentação [Internet]. 2020 [citado 18 maio 2020]. Disponível em: http://www.cofen.gov.br/parecer-no-182016ctas_47897.html
  » http://www.cofen.gov.br/parecer-no-182016ctas_47897.html
• ⁴
  Worldometer. Real time world statistics [Internet]. 2020 [citado 23 jul 2020]. Disponível em: https://www.worldometers.info/coronavirus/
  » https://www.worldometers.info/coronavirus/
• ⁵
  Shanes ED, Mithal LB, Otero S, Azad HA, Miller ES, Goldstein JA. Placental pathology in COVID-19. Am J Clin Pathol. 2020 jul;154(1):23-32. http://dx.doi.org/10.1093/ajcp/aqaa089
  » http://dx.doi.org/10.1093/ajcp/aqaa089
• ⁶
  Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W et al. Clinical characteristics, and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;6736(10226):1-7. http://dx.doi.org/10.1016/S0140-6736(20)30360-3
  » http://dx.doi.org/10.1016/S0140-6736(20)30360-3
• ⁷
  De Rose DU, Piersigilli F, Ronchetti MP, Santisi A, Bersani I, Dotta A et al. Novel Coronavirus disease (COVID-19) in newborns and infants: what we know so far. Ital J Pediatr. 2020;46(56):1-8. http://dx.doi.org/10.1186/s13052-020-0820-x
  » http://dx.doi.org/10.1186/s13052-020-0820-x
• ⁸
  Royal College of Obstetricians & Gynaecologists. Coronavirus (COVID-19) infection in pregnancy: information for healthcare professionals. Version 10 [Internet] 2020 [citado 23 jul 2020]. Disponível em: https://www.rcog.org.uk/globalassets/documents/guidelines/2020-06-04-coronavirus-covid-19-infection-in-pregnancy.pdf
  » https://www.rcog.org.uk/globalassets/documents/guidelines/2020-06-04-coronavirus-covid-19-infection-in-pregnancy.pdf
• ⁹
  Daltro MR, Faria AA. Experience report: a scientific narrative in the post-modernity. Estud Pesqui Psicol. 2019;19(1):223-37. http://dx.doi.org/10.12957/epp.2019.43015
  » http://dx.doi.org/10.12957/epp.2019.43015
• ¹⁰
  Li S, Wang Y, Xue J, Zhao N. Zhu, T. The Impact of COVID-19 Epidemic declaration on psychological consequences: a study on active weibo users. Int J Environ Res Public Health. 2020;17(2032):1-9. http://dx.doi.org/10.3390/ijerph17062032
  » http://dx.doi.org/10.3390/ijerph17062032
• ¹¹
  Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395(10224):37-8. http://dx.doi.org/10.1016/S0140-6736(20)30309-3
  » http://dx.doi.org/10.1016/S0140-6736(20)30309-3
• ¹²
  Silva FWO, Roscoche KGC, Farias RJO, Abreu LAF, Sousa AAS, Chaves AFL. Zika virus: feelings and practices of caregivers. Rev Enferm UFSM. 2020;10:e9. https://doi.org/10.5902/2179769239258
  » https://doi.org/10.5902/2179769239258
• ¹³
  Gupta A, Dadhich JP, Ali SM, Thakur N. Skilled counseling in enhancing early and exclusive breastfeeding rates: an experimental study in an urban population in India. Indian Pediatr. 2019;56(2):114-8. http://dx.doi.org/10.1007/s13312-019-1482-x
  » http://dx.doi.org/10.1007/s13312-019-1482-x
• ¹⁴
  Ministério da Saúde (BR), Secretaria de Atenção Primária à Saúde, Departamento de Ações Programáticas Estratégicas, Coordenação-Geral de Ciclos da Vida, Coordenação de Saúde das Mulheres. Nota Técnica nº 7/2020. Atenção às gestantes no contexto da infecção covid-19 causada pelo novo coronavírus (SARS-CoV-2). Brasília: Ministério da Saúde; 2020.
• ¹⁵
  Conselho Regional de Farmácia do Estado de São Paulo. Manual de orientação ao farmacêutico: COVID-19. São Paulo: Conselho Regional de Farmácia do Estado de São Paulo; 2020.
• ¹⁶
  Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Centro de Operações de Emergências em Saúde Pública. Especial: doença pelo coronavírus 2019. Brasília: Ministério da Saúde; 2020. (Boletim Epidemiológico, no. 7).
• ¹⁷
  Garfield L, Holditch-Davis D, Carter CS, McFarlin BL, Seng JS, Giurgescu C et al. A pilot study of oxytocin in low-income women with a low birth-weight infant: is oxytocin related to posttraumatic stress? Adv Neonatal Care. 2019;19(4):12-21. http://dx.doi.org/10.1097/ANC.0000000000000601
  » http://dx.doi.org/10.1097/ANC.0000000000000601
• ¹⁸
  Patel S, Patel S. The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes. J Hum Lact. 2016;32(3):530-41. http://dx.doi.org/10.1177/0890334415618668
  » http://dx.doi.org/10.1177/0890334415618668
• ¹⁹
  Lima SP, Santos EKA, Erdmann AL, Souza AIJ. Unveiling the lived experience meaning of being a woman breastfeeding with puerperal complications. Texto Contexto Enferm. 2017;26(3):e0880016. http://dx.doi.org/10.1590/0104-07072018000880016
  » http://dx.doi.org/10.1590/0104-07072018000880016
• ²⁰
  Facchini L. COVID-19: Nocaute do neoliberalismo? Será possível fortalecer os princípios históricos do SUS e da APS em meio à pandemia? APS em Revista. 2020;2(1):3-10. http://dx.doi.org/10.14295/aps.v2i1.73
  » http://dx.doi.org/10.14295/aps.v2i1.73
• ²¹
  Talevi D, Socci V, Carai M, Carnaghi G, Faleri S, Trebbi E et al. Mental health outcomes of the COVID-19 pandemic. Riv Psichiatr. 2020;55(3):137-44. http://dx.doi.org/10.1708/3382.33569
  » http://dx.doi.org/10.1708/3382.33569

Edited by

ASSOCIATE EDITOR Antonio José Almeida Filho

Publication Dates

• Publication in this collection
  16 Dec 2020
• Date of issue
  2020

History

• Received
  21 Aug 2020
• Accepted
  23 Oct 2020