ABSTRACT
Objective:
analyze the role of the nurse regarding early weaning in children younger than 6 months old.
Method:
qualitative and descriptive study. The nurses who performed the study did nursing consultation to children programmatically in family health units in Cuiabá - Mato Grosso. Data were collected in January and February 2012, through participant observation of nursing consultations. For data analysis, content analysis was used.
Results:
that nurses, in most cases, used appropriate strategies for the management of common problems in breastfeeding, although some behaviors have not yet proven scientifi c evidence about the benefi ts and/or damage to its practice.
Conclusion:
nurses addressed important aspects of breastfeeding during consultations and worked for the promotion and resumption of exclusive breastfeeding.
Key words:
Pediatric Nursing; Breastfeeding; Weaning
RESUMO
Objetivo:
analisar a atuação do enfermeiro frente ao desmame precoce em crianças menores de 6 meses de idade.
Método:
estudo descritivo de abordagem qualitativa. Participaram do estudo enfermeiros que realizavam consulta de enfermagem à criança de maneira programática em unidades de saúde da família em Cuiabá-MT. Os dados foram coletados nos meses de janeiro e fevereiro de 2012, por meio da observação participante da consulta de enfermagem. Para análise dos dados foi utilizada a análise de conteúdo.
Resultados:
os enfermeiros, na maioria das vezes, utilizaram estratégias apropriadas para o manejo dos problemas mais comuns na amamentação, apesar de algumas condutas não terem, ainda, evidência científica comprovada, quanto aos benefícios e/ou prejuízos à sua prática.
Conclusão:
os enfermeiros abordaram aspectos importantes do aleitamento materno durante as consultas e trabalharam em prol da promoção e do resgate ao aleitamento materno exclusivo.
Descritores:
Enfermagem Pediátrica; Aleitamento Materno; Desmame
RESUMEN
Objetivo:
analizar el papel de la enfermera en el destete precoz en ninos menores de 6 meses de edad.
Método:
estudio descriptivo y cualitativo. Participaran del estudio las enfermeras que realizaron consulta de enfermería a los ninos mediante programación en las unidades de salud de la familia en Cuiabá - Mato Grosso. Los datos fueron recolectados en enero y febrero de 2012, a través de la observación participante de la consulta de enfermería. Para el análisis de los datos se utilizó el análisis de contenido.
Resultados:
las enfermeras, en la mayoría de los casos, hacían uso de estrategias adecuadas para la gestión de los problemas comunes de la lactancia materna, aunque algunos comportamientos no han demostrado evidencia científica sobre los beneficios y/o danos a su práctica.
Conclusión:
las enfermeras trataban de aspectos importantes de la lactancia materna durante las consultas y trabajaran para la promoción y rescate de la lactancia materna exclusiva.
Palabras clave:
Enfermería Pediátrica; Lactancia Materna; Destete
INTRODUCTION
The child-oriented nursing consultation is a care methodol-ogy used by nurses to promote, protect and restore the health of children and their family. It uses care as a guiding axes growth and development of children, which is considered an important indicator of the quality of the health care provided to the child population.
Among the most relevant actions used by the nurse during a consultation with the child, we can highlight protection and promotion of breastfeeding (BF). It is a wise and natural strategy for establishing a bond of affection, child protection and nutrition. It is the most sensitive, economical and effective intervention for reducing infant mortality, defined as such by public policies, especially the Agenda for Commitment to Com-prehensive Child Health and Reduction of Infant Mortality(11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Agenda de Compromissos para Saúde Integral da Criança e Redução da Mortalidade Infantil. Brasília: Ministério da Saúde; 2005.).
The promotion, protection and support of breastfeeding is one of the guidelines of care proposed by the Agenda for Commitment, which must be articulated to integrate the actions in all three levels of care. The guidelines of this document recommend primary care teams to provide early care for pregnant women. It should ensure proper orientation about the benefits of breastfeeding for the mother, the child, the family and society, in addition to the benefits for mother and child. The promotion of breastfeeding exclusively for the first 6 months and then complemented with adequate food until 2 years of age should be promoted(11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Agenda de Compromissos para Saúde Integral da Criança e Redução da Mortalidade Infantil. Brasília: Ministério da Saúde; 2005.).
However, despite the policies and investments to improve the levels of exclusive use of breastfeeding in Brazil, the country is still far from meeting the recommendations of the World Health Organization (WHO). All children should be exclusively breastfed until reaching 6 months of life and, after this period, complementary feeding should be initiated, maintain-ing breastfeeding until at least 2 years of age(22 World Health Organization. Report of the expert consultation on the optimal duration of exclusive breastfeeding: conclusions and recommendations. Geneva: WHO; 2001.).
The II BF Prevalence Research in major Brazilian capital cities showed the current situation of breastfeeding and complementary feeding, analyzing the evolution of breastfeeding indicators from 1999 to 2008. Among other things, it showed that the city of Cuiabá-MT had the worst prevalence rate for exclusive breastfeeding (EBF) until the sixth month of life among the country's capitals, 27.1%, while the national rate was 41%(33 Venancio SI, Escuder MML, Saldiva SRDM, Giugliani ERJ. [Breastfeeding practice in the Brazilian capital cities and the Federal District: current status and advances]. J Pediatr (Rio J.)[Internet]. 2010 [cited 2014 Nov 10];86(4):317-324. Available from: http://www.scielo.br/pdf/jped/v86n4/a12v86n4.pdf Portuguese.
http://www.scielo.br/pdf/jped/v86n4/a12v...
). Therefore, the nurse and the health care professionals have a key role to play in reversing this situation and increasing breastfeeding rates in our reality.
Therefore, early weaning is still a fairly common problem in our midst. It is defined as the abandonment, total or partial, of breastfeeding before the baby is 6 months old. There are many causes that lead to early weaning. The reasons may be associated with culture, lifestyle and influence in society. Among the main causes of breastfeeding interruption are breast milk insufficiency; misinterpretation of the child's crys related to hunger; need by the mother to work outside the home to help with household expenses; pathologies related to the breast; and the child refusing to take to the breast, among others(44 Frota MA, Aderaldo NNS, Silveira VG, Rolm KMC; Martins MC. O reflexo da orientação na prática do aleitamento materno. Cogitare enferm. 2008;13(3):403-9.).
As a professional engaged in directly assisting women and children in the hospital and the community level, the nurse plays an important role in promoting and protecting breastfeeding, by strengthening community action, reorient-ing health services to pregnant women guidelines and mothers and in the formation and articulation of networks to support this practice.
Considering the importance of breastfeeding for the promotion of child health, and the nurse's role as the professional who can most directly spread, protect and support this practice, this study aimed to analyze the role of the nurse in early weaning in the nursing consultation to children under 6 months of age.
METHOD
This is a descriptive qualitative research, carried out in four family health units (FHU) in the city of Cuiabá-MT. The units were randomly chosen by sortation, including a unit of each of the city's four administrative councils. The participating subjects were four nurses who performed nursing consultations in a scheduled manner with children of 0 to 2 years in each unit.
Data was collected between January and February 2012, using participant observation of 21 nursing consultations in the units selected for the study. The observation was made from a script previously elaborated by the researchers and field diary records. For this article, specifically, 12 nursing consultations with children of 0 to 6 months were analyzed, a period during which EBF is recommended in free demand.
In addition to the data collected by observation, audio re-cordings of the conversations between nurses and mothers were performed. The dialogues were faithfully transcribed and later added to the descriptions of the observations made and the im-pressions of the researchers contained in the field diaries' records. After this step, consultations were named with the word "consultation" followed by a sequential number: consultation 1, consultation 2, consultation 3... consultation 12.
Data analysis was done, using the thematic analysis tech-nique(55 Bardin, L. Análise de conteúdo. Lisboa: Edições 70, 2011.). Thus, after the transcription of the recordings, the material was read through in its entirety, starting the pre-analysis and the exploration of the data. Then, the findings were systematical-ly organized and aggregated into reporting units, which allowed an exact description of relevant characteristics. We proceeded then to the categorization, which consisted of isolating the ele-ments of speech and impose a certain organization to the mes-sages, investigating what each had in common with the other. To develop this text, the record unit "breastfeeding" was selected and from it, the nurses' approach regarding early weaning was cut and selected for analysis.
The study was developed following the ethical principles of human research disciplined by the Resolution 196/96. The main project to which this subproject is linked to, was submitted to the Research Ethics Committee (REC) and approved under the protocol number 129/CEP-HUJM/2011. Nurses and mothers who agreed to participate in this research signed the Free and Informed Consent Form. They were informed of the objectives of the study, the type of desired participation and that they could choose to leave the survey at any time if they so wished. Anonymity and confidentiality as to the information provided were guaranteed.
RESULTS
The data provided by the analysis allowed for the con-struction of five categories: Nurse performance regarding a mother's return to work; Nurse performance regarding the use of a bottle; Nurse performance regarding a mother's production of weak, insufficient milk and milk that does not sustains the child; A grandmother's influence and the influence of the women in the Family regarding BF; and Nurse performance regarding breast problems and menstrual disorders.
Nurse performance regarding a mother's return to work
One of the concerns shown by the mothers and the nurses in the nursing consultation was that of the mother's return to work, since activities outside the household can compromise exclusive breastfeeding.
[...] tell me something, is he breastfeeding well? (Nurse. Field diary, consultation 15)
(the mother answers) Yeah, only now, at the beginning of the month, I'm going to decrease a little, since I'll be return-ing to work, so I'm going to give her NAN milk, only in the mornings. I didn't want to, but I'll be forced to [...]. (Mother. Field diary, consultation 15)
Regarding this subject, the nurses worked with the issue of breastfeeding rights at the workplace until the child is 6 months old.
[...] you have the right to leave work one hour before leav-ing time, you talk about this with him (employer). In truth, it works like this: half an hour at the first period and half an hour in the second period, so you can breastfeed [...]. (Nurse, Field diary, consultation 7)
Nurses provided alternatives for mothers to maintain exclusive breastfeeding, even with their return to work. One of the alternatives offered was to remove and store milk:
[...] and if for some reason you have to leave and something happens, and that means you have to use another source of milk, even then we don't recommend other milk, we al-ways tell mothers to remove their own milk and then store it in the refrigerator. And, if you have time you can read here, it explains everything about how it's you can store milk (shows the booklet for children's health). You can't take the child with you when you leave, you'll be de-layed two, three hours, you'll be worried about the baby. So you just have to do milk pumping, ok? (Nurse. Field diary, consultation 2)
Nurse performance regarding the use of a bottle
The use of beaks, pacifiers and bottles is one of the factors that lead to early weaning. During the observations of nursing consultations, we could see that the nurses were committed to discouraging the use of bottles in the infant feeding:
[...] do you continue to use the bottle? (Nurse. Field diary, consultation 1)
Yes, I'm still using the bottle (the mother answers during the nurse dialogue). (Mother. Field diary, consultation 1)
[... ] mom, like I told you before, he has a strong tendency to quit the breast, children tend to like the bottle more, the child can get confused with the breast nipple and bottle beak, so, the guidelines continue to be the same: it is ex-clu-si-ve breast-feeding. When he is feeding using the bottle, your milk pro-duction lessens [...]. (Nurse. Field diary, consultation 1)
[...] it is because she has three months, so we still have three months to fight for exclusive breastfeeding and there is also until she's two to keep breastfeeding her. So, this way it is for us to diminish the use of a bottle [...]. (Nurse. Field diary, consultation 6)
Regarding bottle-feeding, nurses guide the mothers to make use of a cup when feeding the child:
[...] do you want to breastfeed a lot? (answers affirmatively with a nod), So, don't use the bottle, use a cup to feed the milk. Because she won't confuse the bottle beak with the breast nipple, because it is a cup and she will drink, she'll take a few sips and will manage to drink [...]. (Nurse. Field diary, consultation 7)
[...] it is what we want, that the child keep breastfeeding until he is two and if you can't avoid the bottle, can't it be a cup instead? Because this way, when you put the milk in a cup, the child will drink, but won't confuse the nipples. Try, if you can't return to exclusive breastfeeding, at least we have to insist he keeps to the breastfeeding, ok [...]. (Nurse. Field diary, consultation 1)
Nurse performance regarding a mother's production of weak, insufficient milk and milk that does not sustains the child
The production of weak, insufficient milk and milk that does not sustain the child was also reported by the mothers during the nursing appointments as a cause for the introduc-tion of other types of milk:
[...] but you know why I give it, nurse? (refers to the artificial milk). It's because a lot of times, I feel my milk doesn't sus-tain him enough. Because he feeds, feeds, feeds, so than I try it, I give him a little NAN milk and then he sleeps [...]. (Mother. Field diary, consultation 16)
Every three hours, it is normal for the child to feed.(Nurse. Field diary, consultation 16)
But so, how, for example, when I give him the bottle [...]. (Mother. Field diary, consultation 16)
He sleeps. (Nurse. Field diary, consultation 16)
So, he ends up getting stuffed, with the tummy filled up, and then ends up sleeping, yeah!, Lasts longer, right? (Nurse. Field diary, consultation 16)
When he only breastfeeds, he wakes up on the hour [...]. (Mother. Field diary, consultation 1)
The following dialogues show how nurses work with mothers that have weak and insufficient milk productions:
[...] scientifically there's no such thing as weak milk. The milk that comes from you, from your breasts, from the breast's channels, is the proper milk, with all the nutrients and important substances needed to nourish, to feed the baby. There's no such thing as weak milk[...]. (Nurse. Field diary, consultation 16)
[...] milk is not weak. The milk satiates the child. The milk is strong, so the milk sustains the child and makes a child fatten up. I see chubby children that only took breastfeeding, you only have to know how to feed [...]. (Nurse. Field diary, consultation 8)
A grandmother's influence and the influence of the women in the Family regarding breastfeeding
The dialogues below show the family's influence in the maintenance of EBF:
(Nurse inquiring about the child's feeding) are you giving her water, tea? (Nurse. Field diary, consultation 1)
Only water because it makes the child thirsty. (Mother. Field diary, consultation 1) (Nurse interrupting the mother's speech) it doesn't cause thirst, who told you that?(authori-tarian voice) (Nurse. Field diary, consultation 1)
My mother [...]. (Mother. Field diary, consultation 1)
The milk (mother's) is almost 70% water, or even more, the child does not thirst for water. (Nurse. Field diary, consulta-tion 1)
(Mother talks over the nurse) the child doesn't feel thirsty? (Mother. Field diary, consultation 1)
[...] you don't have to give water, you are being influenced by your mother, but like, when you are home and your mother is not looking, tell her, like I told you, that you gave water! The child doesn't feel thirsty for water, water is going to be added when the child reaches 6 months, it is when food is introduced, with juice, fruit, but not right now[...]. (Nurse. Field diary, consultation 1)
[...] so no bottle, no water, no tea. Who influences you regarding the child's feeding and care? (Nurse. Field diary, consultation 8)
(The mother looks at her aunt, who stand with the child in her arms and they smile at each other) my aunt. (Mother. Field diary, consultation 8)
(The nurse looks at the aunt and continues the conver-sation) you are influencing? Okay, then! What are the recommendations? [...] family members help by giving support to the mother, because she is suffering, because there are cracks, because she is a first time mother, so she needs that kind of support [...]. (Nurse, Field diary, consultation 8)
Nurse performance regarding breast problems and menstruai disorders
Breast problems were identified as triggers for the intro-duction of breastmilk substitutes and bottle feeding among mothers who attended nursing consultations. Among the most prominent problems are nipple pain or sore nipples:
[...] and her breastfeeding? (Nurse. Field diary, consultation 6)
My breast nipple is not good, I'm not putting up so well with breastfeeding her. (Mother, Field diary, consultation 6)
Let me see you breast nipple. Does it hurt? (Nurse. Field diary, consultation 6)
It hurts when she feeds (puts her hand over her chest). (Mother. Field diary, consultation 6)
And you can see the little wound in your breast? Is it only on one? Or on both? (Nurse. Field diary, consultation 6)
This one is the one that's cracked. (Mother. Field diary, consultation 6)
Are you breastfeeding still? Or are you supplementing? (Nurse. Field diary, consultation 6)
I'm supplementing [...]. (Mother. Field Diary, consultation 6)
[...] I started giving NAN milk, but now I'm not giving him anymore. (Mother. Field diary, consultation 11)
What happened?[...] (Nurse. Field diary, consultation 11)
[...] at the hospital I used to say: - ah! I don't have milk any-more. Then, the others said: - no! You have to let him suckle and suckle. My breast got all hurt she suckled so much and no milk came out [...]. (Mother. Field diary, consultation 11)
The following dialogues show the behavior of nurses when coming across breast complications reported by the mothers:
[...] leave a little milk on the nipple. After the feeding, the milk has to remain, because he has healing power to improve your breast faster [...]. (Nurse. Field diary, consulta-tion 8)
[...] but are you doing something, taking milk and putting it around the breast? And you saw Doctor A. and he didn't give you anything? (Nurse. Field diary, consultation 6)
No. He told me to put the milk on the nipple [...]. (Mother. Field diary, consultation 6)
Another alleged problem reported by the mothers for early interruption of exclusive breastfeeding was the complaint of irregularity and increased menstrual flow, which they associated with weakness and reduction in milk production:
[... ] my period is coming three times a month, four. Last month I even found it strange, that's why I'm getting very weak. That's why I'm giving him the bottle [...]. (Mother. Field diary, consultation 1)
I don't have milk, remember I told you I had my period for 29 days? (Mother. Field diary, consultation 4)
And at night? (Nurse. Field diary, consultation 4)
At night he breastfeeds, but it doesn't sustain him. He cries all night and nothing comes out [...]. (Mother. Field diary, consultation 4)
But nothing really comes out (milk)? He, like I told you, you had this problem, but his suckling stimulates the production of milk. (Nurse. Field diary, consultation 4)
DISCUSSION
The promotion, protection and support of BF are part of the strategies used for reducing child mortality divulged by the Brazilian government. It is also part of the strategies used internationally, through the Millennium Development Goals, and nationally by the Pact to Reduce Maternal and Neonatal Mortality, the Pact for Life and the More Health Program.
In recent decades, the number of women inserted in the workforce and householders soared. In turn, the closeness of their return to work causes distress and anxiety in mothers, leading many of them to inappropriate practices, such as early introduction of foods and the use of bottles(66 Araújo OD, Cunha AL, Lustosa LR, Nery IS, Mendonça RCM, Campelo SMA. [Brastfeeding: factors that cause early weaning]. Rev Bras Enferm [Internet]. 2008 [cited 2014 Nov 10];61(4):488-92. Available from: http://www.scielo.br/pdf/reben/v61n4/15.pdf Portuguese.
http://www.scielo.br/pdf/reben/v61n4/15....
). To meet these demands, health professionals, especially nurses, should support them in this transitional process and prepare them for continuing to breastfeed in a more peaceful and enjoyable way.
The 1988 Federal Constitution guarantees the protection to BF through a maternity leave of 120 days, without loss of job and salary. It also guarantees the right of nursing mothers when they return to work, the break of an hour a day. The break can be split into two half-hour breaks to breastfeed your child until six months of age(11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Agenda de Compromissos para Saúde Integral da Criança e Redução da Mortalidade Infantil. Brasília: Ministério da Saúde; 2005.). In some states and cities, maternity leave was extended optionally to 180 days for workers in both the private and the public sphere.
In order to keep EBF after the mother's return to work, the rec-ommendation is to breastfeed frequently when at home, especially at night, to avoid the use of bottles and pacifiers, offering the supplement feed in a cup, teacup or spoon and practicing milk pumping during working hours. In this study, nurses acted with this in mind, stressing the importance of using such care and guiding nursing mothers to manual pumping of the breasts.
Manually milking the breast is a viable alternative not only to ensure breast milk for babies of mothers who work outside the home, but also to relieve breast engorgement and stasis of milk, preventing trauma to the nipple as a result of very full breasts and feeding babies who are sick or underweight and that cannot suckle(66 Araújo OD, Cunha AL, Lustosa LR, Nery IS, Mendonça RCM, Campelo SMA. [Brastfeeding: factors that cause early weaning]. Rev Bras Enferm [Internet]. 2008 [cited 2014 Nov 10];61(4):488-92. Available from: http://www.scielo.br/pdf/reben/v61n4/15.pdf Portuguese.
http://www.scielo.br/pdf/reben/v61n4/15....
). Despite being a simple technique, it does require some care, as well as dedication and knowledge for the mother to accomplish it. If performed improperly, it can cause pain and damage the nipples. For this reason, the nurse's performance is necessary, not only to guide the technique, but especially to promote the mother's self-confidence and guide her regarding the factors that may favor the milk flow.
This aspect is reinforced by the Agenda for Commitment, which defends the mother's right to receive guidance on the removal of milk by pumping, packaging and conservation for the baby's consumption, ensuring exclusive breastfeeding for the recommended time(11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Agenda de Compromissos para Saúde Integral da Criança e Redução da Mortalidade Infantil. Brasília: Ministério da Saúde; 2005.). In turn, the Booklet for Children's Health, a document prepared by the Ministry of Health, offers guidelines on how the mother can perform manual pumping, as well as the storage of the milk.
To the Ministry of Health, professionals should discourage the use of nipple dummies and bottles, due to their being pro-tagonists of early weaning, diarrheal diseases and problems in teething and speech(11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Agenda de Compromissos para Saúde Integral da Criança e Redução da Mortalidade Infantil. Brasília: Ministério da Saúde; 2005.).
Thus, pumped milk should be given to the baby, preferably in a cup, a teacup or a spoon with sterilizable materials and edges that do not hurt the baby. The use of these tools prevents confusion between natural and artificial nipples that occurs with the use of the bottle(77 Pedras CTPA, Pinto EALC, Mezzacappa MA. Uso do copo e da mamadeira e o aleitamento materno em recém-nascidos prematuros e a termo: uma revisão sistemática. Rev Bras Saúde Mater Infant 2008;8(2):163-9.-88 Ministério da Saúde (BR). Saúde da criança: nutrição infantil -aleitamento materno e alimentação complementar [Internet]. Brasília: MS; 2009b [cited 2014 Jan 10]. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, n. 23). Available from: http://189.28.128.100/nutricao/docs/geral/cadernoatenaaobasica_23.pdf
http://189.28.128.100/nutricao/docs/gera...
). The use of a cup to feed the baby is widespread in high-risk newborn feeding, especially pree-mies, so they might develop the ability to suckle, without loss to the ability of suckling the breast.
Not using nipples and bottles is one of the 10 steps to suc-cessful breastfeeding, as defined by the United Nations Chil-dren's Fund (UNICEF). This recommendation is due to the harm that the suction of beaks can cause in the breastfeeding process.
Arguably, the use of a bottle and artificial feeding affect the child completely in biopsychosocial aspects, compromising their growth and development. With this use, the infant is more likely to get sick, malnourished or gain too much weight, have anemia, lose the bond with the mother, have more allergic reactions, poor-ly develop facial muscles and teething and even have their speech impaired(99 Castilho SD, Barros AAF, Cocetti M. [Historical evolution of utensils used to feed non breastfed infants]. Ciênc saúde colet [Internet]. 2010 [cited 2014 Nov 10];15(supl):1401-10. Available from: http://www.scielo.br/pdf/csc/v15s1/050.pdf Portuguese.
http://www.scielo.br/pdf/csc/v15s1/050.p...
). It is the responsibility of health professionals, especially nurses, to discourage the use of nipples, bottles and other types of milk, in order to improve the quality of life of children and to contribute to the reduction of child mortality by maintaining the BF. Nurses can assume this responsibility because they are the health professionals who are closest to mothers.
Despite the positive or negative influence of the social and cultural values linked to maintaining lactation, it is known that the idea of weak, insufficient milk and milk that does not sustain the baby, is due to biological processes of stimu-lation and inhibition of the milk production, caused by in-adequate breastfeeding techniques and the mother's anxiety over the delay in milk letdown (milk letdown from 48 to 72 hours after childbirth). It can lead to the early introduction of other foods to the child, which carries greater reduction in breast milk production, falling into a vicious cycle. This may occur mainly due to a mother's lack of knowledge about these events, which in turn is the result of a lack of preparation for breastfeeding during prenatal care, or the cultural influence of family women and previous frustrated experiences with BF(1010 Frota MAF, Mamed ALS, Vieira LJES, Albuquerque CM, Martins MC. Cultural practices about breastfeeding among families enrolled in a Family Health Program. Rev Esc Enferm USP [Internet]. 2009 [cited 2014 Nov 10];43(4):895-901. Available from: http://www.scielo.br/pdf/reeusp/v43n4/en_a22v43n4.pdf
http://www.scielo.br/pdf/reeusp/v43n4/en...
).
Thus, the complaint of little milk is, often, because of an error in perception of the mother, caused by a lack of knowledge or previous beliefs about breastfeeding. The BF is a practice built and conditioned by the history of women's lives and experiences, the knowledge gained from childhood, the assistance received during pregnancy and after childbirth and the support they receive from family and society(1111 Marques ES, Cotta RMM, Magalhães KA, Sant'Ana LFR, Gomes AP, Batista RS. The influence of the social net of lactating mothers in the breastfeeding: the strategic role of the relatives and professionals of health. Ciênc. saúde colet [Internet]. 2010 [cited 2014 Nov 10];15(supl1):1391-400. Available from: http://www.scielo.br/pdf/csc/v15s1/049.pdf Portuguese.
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).
The results of this study showed that despite nursing mothers receiving information on breastfeeding, they do not follow most of the guidelines and continue to believe and value their previous beliefs and taboos, acting on their own when intro-ducing other foods before the child is six months old. For the authors of a study, this situation can be explained by the in-security or the fear that mothers have in relation to the baby's satiety and the quality of their own milk. A belief of little or weak milk is still very strong among them(1212 Parizotto J, Zorzi NT. [Breast-feeding: factors leading to precocious weaning in Passo Fundo, RS]. Mundo Saúde [Internet]. 2008 [cited 2014 Nov 10];32(4):466-74. Available from: http://saocamilo-sp.br/pdf/mundo_saude/65/08_Aleitamento_baixa.pdf Portuguese.
http://saocamilo-sp.br/pdf/mundo_saude/6...
).
The mothers of this research, who indicated that their milk is weak and does not sustain, believe in the quality of artificial milk, because they associate the child's sleep pattern with food satisfaction. When the child receives only breast milk, they tend to not be satisfied, reducing the interval between feedings. What happens is that breast milk takes longer to be ejected, because it depends on the stimulation and proper suction of the child to the mother's breast. Therefore, the infant will need more time to nurse at the mother's breast and if the breastfeeding period is insufficient, the child will need to nurse again after a shorter interval. In turn, the bottle milk flows faster from the container to the gastrointestinal tract of the child, because there are no barri-ers. This can satiate the child more quickly(88 Ministério da Saúde (BR). Saúde da criança: nutrição infantil -aleitamento materno e alimentação complementar [Internet]. Brasília: MS; 2009b [cited 2014 Jan 10]. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, n. 23). Available from: http://189.28.128.100/nutricao/docs/geral/cadernoatenaaobasica_23.pdf
http://189.28.128.100/nutricao/docs/gera...
).
In the management of breastfeeding, it is essential that health professionals be prepared to detect and propose appropriate and effective interventions for the main problems associated to this process, which generally relate to difficulties with the breastfeeding technique. Early intervention can restore adequate milk production, minimize maternal unrest and encourage people close to the family to support the nursing mother in moments of anguish and doubt in the practice of breastfeeding(1313 Silva AFM, Gaiva MAM, Bittencourt RM. Use of lacta-gogues in breastfeeding for mothers assisted by a health family unit. Rev RENE [Internet]. 2011 [cited 2014 Nov 10];12(3):574-81. Available from: http://www.revistarene.ufc.br/vol12n3_pdf/a18v12n3.pdf Portuguese.
http://www.revistarene.ufc.br/vol12n3_pd...
).
The influence of grandmothers on the EBF practice has been described in the literature. A study found that grandmothers advise mothers to introduce water, teas and other types of milk to children. It also showed that less contact between mothers and grandmothers increased the prevalence of breastfeeding among the surveyed lactating women, conclud-ing that grandmothers influenced negatively on breastfeeding, both in the duration and the exclusivity of it(1414 Susin LR, Giugliani ERJ, Kummer S. Influence of grandmothers on breastfeeding practices. Rev Saúde Públ [Internet] 2005 [cited 2014 Nov 10];39(2):141-47. Available from: http://www.scielo.br/pdf/rsp/v39n2/en_24034.pdf
http://www.scielo.br/pdf/rsp/v39n2/en_24...
).
For this reason, the importance of the nurse in the construc-tion of BF values is highlighted, working alongside the mother and the family, valuing and including them in the health education programs for breastfeeding. The nurse should respect the beliefs and feelings, seeking to be better prepared to support and positively contribute to the success of breastfeeding.
Breast problems may affect the quality of the BF and is one of the causes mentioned by mothers that leads to early weaning. The main factors associated with this problems are the mother's little schooling, primiparity and the lack of experience in previous breastfeedings(1515 Castro KF, Garcia TR, Souto CMRM, Bustorff LACV, Rigão TVC, Braga VAB. Intercorrências mamárias relacionadas à lactação: estudo envolvendo puérperas de uma maternidade pública de João Pessoa, PB. Mundo saúde. 2009;33(4):433-9.). These are frequent and are usually associated with difficulties in the breastfeeding technique, thus requiring proper assistance in handling it.
A mother's pain, discomfort, stress and insecurity caused by breast problems during EBF, lead lactating mothers to introduce the bottle as a means to relieve the symptoms and satisfy the nutritional needs of the child. Also, these symptoms reduce the production of oxytocin (hormone responsible for the ejection of milk through the breasts), further harming the BF process(88 Ministério da Saúde (BR). Saúde da criança: nutrição infantil -aleitamento materno e alimentação complementar [Internet]. Brasília: MS; 2009b [cited 2014 Jan 10]. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, n. 23). Available from: http://189.28.128.100/nutricao/docs/geral/cadernoatenaaobasica_23.pdf
http://189.28.128.100/nutricao/docs/gera...
).
Lesions on the nipples are caused, specially, by incorrect breastfeeding technique. This inadequate technique causes an also inadequate emptying of the breasts and breast engorge-ment, increasing pain for the mother during BF(66 Araújo OD, Cunha AL, Lustosa LR, Nery IS, Mendonça RCM, Campelo SMA. [Brastfeeding: factors that cause early weaning]. Rev Bras Enferm [Internet]. 2008 [cited 2014 Nov 10];61(4):488-92. Available from: http://www.scielo.br/pdf/reben/v61n4/15.pdf Portuguese.
http://www.scielo.br/pdf/reben/v61n4/15....
). It is necessary, when the nurse observes these situations, to minutely evaluate the mother and the breastfeeding technique used, seeking to identify correctly the problems and thus establish appropriate interventions.
The use of the pumped milk for treating cracked nipples was one of the nurses most used recommendations for the participants of this study. A mother's milk forms a protective layer que avoids dehydrations in the lower layers pf the epi-dermis, helping with healing(88 Ministério da Saúde (BR). Saúde da criança: nutrição infantil -aleitamento materno e alimentação complementar [Internet]. Brasília: MS; 2009b [cited 2014 Jan 10]. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, n. 23). Available from: http://189.28.128.100/nutricao/docs/geral/cadernoatenaaobasica_23.pdf
http://189.28.128.100/nutricao/docs/gera...
). The Booklet for Children's Health supports this recommendation, suggesting that the mother apply the milk to the wounded nipple. The Ministry of Health's manual for children's nutrition recommends a dry treatment for cracked nipples, suggesting that the breasts are exposed to sun and fresh air, and that the breast protective pads be exchanged every time they get wet(88 Ministério da Saúde (BR). Saúde da criança: nutrição infantil -aleitamento materno e alimentação complementar [Internet]. Brasília: MS; 2009b [cited 2014 Jan 10]. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, n. 23). Available from: http://189.28.128.100/nutricao/docs/geral/cadernoatenaaobasica_23.pdf
http://189.28.128.100/nutricao/docs/gera...
).
Another cause for early weaning mentioned by mothers of this study was irregularities in their menstrual periods. The association with milk production and the loss of menstrual blood and weakness may be considered as a cultural construction mothers hang on to. However, these occurrences can lead to anemia, which is a disease caused by the loss of red blood cells or by body iron deficiency, which does lead to fatigue and de-spondency. To avoid this problem, mothers should supplement their diet with ferrous sulphate, which can be obtained by an appropriate diet rich in iron. A mother's iron supplementation should begin when she is still in the pre-natal period(1616 Rodrigues LP, Jorge SRPF. The iron deficiency in pregnancy, labor and puerperium. Rev Bras Hematol Hemoter [Internet]. 2010 [cited 2014 Nov 10];32(2supl.):S53-S56. Available from: http://www.scielo.br/pdf/rbhh/v32s2/aop57010.pdf Portuguese.
http://www.scielo.br/pdf/rbhh/v32s2/aop5...
).
During lactation, the mother's organism produces a small amount of iron through the milk. However, the iron needed to maintain BF for six months is approximately 14% of the mother's body stock and represents half of what is usually lost during menstruation. Thus, while the woman is going through amenorrhea, the need for iron decreases in 50%, and when she returns to her regular periods, the body's iron reserves may drastically decrease, if the ingestion of this mineral is low(1616 Rodrigues LP, Jorge SRPF. The iron deficiency in pregnancy, labor and puerperium. Rev Bras Hematol Hemoter [Internet]. 2010 [cited 2014 Nov 10];32(2supl.):S53-S56. Available from: http://www.scielo.br/pdf/rbhh/v32s2/aop57010.pdf Portuguese.
http://www.scielo.br/pdf/rbhh/v32s2/aop5...
).
For this reason, it is important for the nurse to investigate what are the possible causes for the irregular menstruation, also performing a rigorous clinical evaluation, through physical exam and laboratorial exams, seeking to identify if anemia is already an issue. If it is, the women should be sent to evaluation and medical treatment, associated with a ferrous sulphate supplementation and an iron rich diet. For the mother to maintain breastfeeding, it is necessary that she be in good health, which will provide her with the disposition and the motivation necessary for this practice.
FINAL CONSIDERATIONS
The purpose of this research was to analyze the performance of the nurse when faced with early weaning of children under six months. The results showed that, most times, the nurses used appropriate strategies for the management of the problems commonly faced in breastfeeding, although some recommen-dations have yet to obtain the support of scientific evidence regarding the benefits or the damages to the practice.
On the other hand, nurses address important aspects of the BF during consultations and act in promoting and encourag-ing exclusive breastfeeding. The commitment and the responsibility of the professional was also present in applying ministerial recommendations and ordinances regarding BF and also the concern in passing this information on to mothers during consultations.
Despite the well-established scientific evidence about the benefits of breastfeeding, there are many factors involved to guarantee a successful practice. Therefore, the effective BF implementation does not depend only on health workers or nurses but involves many actors, such as, the society and the government, by means of public policies and laws, and the family, among others.
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How to cite this article:Monteschio CAC, Gaíva MAM, Moreira MDS. The nurse faced with early weaning in child nursing consultations. Rev Bras Enferm. 2015;68(5):587-93.
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14Susin LR, Giugliani ERJ, Kummer S. Influence of grandmothers on breastfeeding practices. Rev Saúde Públ [Internet] 2005 [cited 2014 Nov 10];39(2):141-47. Available from: http://www.scielo.br/pdf/rsp/v39n2/en_24034.pdf
» http://www.scielo.br/pdf/rsp/v39n2/en_24034.pdf -
15Castro KF, Garcia TR, Souto CMRM, Bustorff LACV, Rigão TVC, Braga VAB. Intercorrências mamárias relacionadas à lactação: estudo envolvendo puérperas de uma maternidade pública de João Pessoa, PB. Mundo saúde. 2009;33(4):433-9.
-
16Rodrigues LP, Jorge SRPF. The iron deficiency in pregnancy, labor and puerperium. Rev Bras Hematol Hemoter [Internet]. 2010 [cited 2014 Nov 10];32(2supl.):S53-S56. Available from: http://www.scielo.br/pdf/rbhh/v32s2/aop57010.pdf Portuguese.
» http://www.scielo.br/pdf/rbhh/v32s2/aop57010.pdf
Publication Dates
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Publication in this collection
Sep-Oct 2015
History
-
Received
27 Nov 2014 -
Accepted
09 July 2015