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Jornal de Pediatria

Print version ISSN 0021-7557

J. Pediatr. (Rio J.) vol.79 no.6 Porto Alegre Nov./Dec. 2003 



The pediatrician and exclusive breastfeeding



Marina F. Rea

Public health physician. Professor, School of Medicine, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil



The tendency towards increased maternal breastfeeding duration in Brazil has been revealed in many studies and reasons for this tendency has been offered1. The most up to date data, from 1999, come from a study of state capitals performed by the Health Ministry, which confirmed the tendency and also made a diagnosis of what has been happening in terms of exclusive breastfeeding2.

The World Health Organization (WHO) proposed that children from birth to four months of age on exclusive breastfeeding (defined as just breastmilk, without even water or tea, allowing only vitamin drops) be used as the indicator, but this has not always proved comparable. The 1986 Demographic and Health Survey (DHS) statistics returned a prevalence of 3.6%, while that in 1996 returned 40%; this last was criticized for the manner in which data was collected because the questionnaire used did not permit that mothers who claimed to give only breastmilk be asked about the offer of water or tea. Consequentially, this figure is probably an overestimate3.

Even though this figure cannot be directly compared with that from 1986, it seems obvious that one can claim that between 1986 (less than 4%) and 1996 (between 30% and 40%) there was an increase in exclusive breastfeeding.

In terms of the value of this increase, we are still far from achieving the recommendation: that all children are exclusively breastfed until six months old. Nowadays both the WHO and national policy agree on the recommendation of exclusive breastfeeding for six months and on the continuation of breastfeeding, with the addition of complementary foods, from six months until at least two years. The proportion of children on exclusive breastfeeding at 180 days in the state capitals in 1999 was just 9.7%1, far from the recommendation of 100%. What are the main reasons for this gap?

This is one of the issues on which Santiago et al. make us reflect in this issue of the Jornal de Pediatria4.

The importance of exclusive breastfeeding during the first months of life was documented with scientific proof only in the last years of the eighties. The first articles published on the subject were the bibliographic review by Feachem & Koblinski5 and the study performed in Pelotas by Victora et al.6, both concerned with infant mortality due to infectious diseases and diarrhea in particular, and its relationship with infant nutrition. It is difficult to gauge how long it took for pediatric colleges to find out about these articles and even more so when they changed their feeding recommendations: at the time they were recommending the introduction of pure water of tea between feeds from 12 to 18 hours onwards7, without, therefore, any period of exclusive breastmilk consumption.

Our country launched the National Breastfeeding Encouragement Program in 1981 with two large scale media campaigns in which the messages made no mention of "exclusive breastfeeding"1. Since these campaigns nothing has been done with a similar coverage, even when the recommendations were changed. There is no research into how mothers are to come to know that the recommended practice during the first six months is to give only breastmilk.

We know that the medical schools in our country, and in particular pediatric colleges, dedicated themselves to teaching childcare, giving prominence to artificial baby food as a fundamental component of nutrit5ion during the first year of life7. The role of the companies that produce baby formula and their advertising within medical schools is also well documented8,9. In terms of the value of texts or resolutions which control such advertising, such as the International Code (1981) and the Brazilian Baby Food Marketing Standards (1988), inappropriate advertising among health professionals of products which substitute breastmilk (baby formula, bottles and teats) is very difficult to stamp out.

In 1993, the Pan American Health Organization performed a study of the treatment of breastfeeding on the curricula of medical schools. Twenty percent of Brazilian medical schools were sampled and 10% of their students interviewed. The results showed that the number of hours dedicated to the theme is minimal and insufficient and interviews with students at the end of the course demonstrated that if they knew how to solve lactation complications this knowledge had not been gained fr4om the curriculum but from participation in extracurricular clinical activities10.

Santiago et al., in a paper published in this issue of the magazine, demonstrate that advice given to mothers by trained pediatricians contributes to exclusive breastfeeding. It further demonstrates that multidisciplinary teams trained in lactation are even more efficient at achieving improved exclusive breastfeeding rates. Such findings show the way: pediatricians must have both training and information that are up to date.

In a review of breastfeeding in clinical practice, the need of health professionals to update knowledge and skills was analyzed11. In the knowledge that undergraduate training on the subject can be considered inadequate, courses and training materials have been developed for graduates. The courses organized by the WHO and UNICEF (18 hours, 12 hours, for management, for counseling, etc.) have come to be widely used. It was, without doubt, training of this type which has aided the improvement of skills and the increase in knowledge of the practice of breastfeeding that was documented in the article. Such courses need to be incorporated into the curricula of medical schools and other health education institutions so that everyone who graduates is capacitated with the latest that is known on the subject.



1. Rea MF. Reflexões sobre a amamentação no Brasil: de como passamos a 10 meses de duração. Cad Saude Publica. 2003;19:109-18.

2. Araújo MFM. Situação e perspectivas do aleitamento materno no Brasil. In: Carvalho MR, Tamez RN. Amamentação, Bases Científicas para a Prática Profissional. Rio de Janeiro: Guanabara Koogan; 2000. p. 1-10.

3. Monteiro CA Panorama nutricional. In: UNICEF. A Infância Brasileira nos Anos 90. Brasília: UNICEF; 1998. p. 83-96.

4. Santiago LB, Bettiol H, Barbieri MA, Guttierrez MRP, Del Ciampo LA. Incentivo ao aleitamento materno: a importância do pediatra com treinamento específico. J Pediatr (Rio J). 2003;79:504-12.

5. Feachem RG, Koblinsky MA. Interventions for the control of diarrhoea diseases among young children: promotion of breastfeeding. Bull World Health Org. 1984;62:271-91.

6. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet. 1987;2:319-21.

7. Alcantara P, Marcondes E. Pediatria Básica. 6a ed. São Paulo: Sarvier; 1978. p. 117.

8. Rea MF. Substitutos do leite materno: passado e presente. Rev Saude Publica. 1990;24:241-9.

9. Sokol EJ. Em defesa da amamentação: Manual para implementar o Código Internacional de Mercadização dos substitutos do leite materno. São Paulo: IBFAN Brasil; 1999.

10. OPAS/OMS. Encuesta sobre enseñanza de la lactancia materna en escuelas universitarias de América Latina. Relatório mimeografado da OPS; 1993.

11. Giugliani ERJ. O aleitamento materno na prática clínica. J Pediatr (Rio J). 2000;76(Supl 2):S238-52.

1. Rea MF. Reflexões sobre a amamentação no Brasil: de como passamos a 10 meses de duração. Cad Saude Publica. 2003;19:109-18.