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Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Portuguese school children breastfeeding experiences
Experiencias de amamantamiento de niños portugueses en edad escolar
Dulce Maria Pereira Garcia GalvãoI; Isília Aparecida SilvaII
in Nursing Sciences. Professor, Coordinator of the Nursing School of Coimbra.
Coimbra, Portugal. firstname.lastname@example.org
IIPh.D. in Obstetrical Nursing. Full Professor at School of Nursing, University of São Paulo. email@example.com
Descriptive cross-sectional study on breastfeeding experiences, using a questionnaire with 1078 children aged between 7 and 12 years, in the 3rd and 4th years of primary education in public schools. Most children knew that they and their siblings had been breastfed and had used a pacifier. Few had seen their mother breastfeeding, seen their father close to their mother while breastfeeding their siblings, or reported that nurses in the school had talked to them about breastfeeding. Furthermore, when playing with their dolls, most girls did not pretend to breastfeed, and 771 (71.5%) reported their dolls had bottles, or pacifiers, and pretended to feed their dolls with a bottle. They say they would enjoy breastfeeding, but where embarrassed of doing that in public. The books and cartoons that these children usually read and watch do not show women breastfeeding. Many children consider breast milk to be the best food for the baby, but they have several misconceptions, and not all the children knew what breastfeeding was.
DESCRIPTORS: Breast feeding; Child; Knowledge; Attitude; Health Promotion.
Estudio descriptivo transversal, utilizando cuestionario, con 1.078 niños de 7 a 12 años, de 3º y 4º grado de Enseñanza Primaria de escuelas públicas, estudiándose experiencias de amamantamiento. La mayoría, 918 (85,2%) recordaba su amamantamiento; 895 (83%) utilizaron chupete. Unos pocos vieron a su madre amamantar, percibiendo la presencia paterna; o refirió que los enfermeros en la escuela exhibieron contenidos acerca del amamantamiento. Asimismo, la mayoría de las niñas no jugaba a amamantar a sus muñecas, 771 niños (71,5%) refirieron que tales juguetes poseían mamaderas o chupetes, siendo que los juegos consistían en fingir alimentar muñecas con dichas mamaderas. Relatan que les gustaría amamantar, pero no en público, por vergüenza. Los libros y dibujos animados seguidos por estos niños no muestran figuras de mujeres amamantando. Muchos niños consideran a la leche materna como el mejor alimento para el bebé. Se verifican falsos conceptos, varios ni sabían qué es amamantar.
DESCRIPTORES: Lactancia materna; Niño; Conocimiento; Actitud; Promoción de la Salud.
The process of deciding to breastfeed and maintaining that decision is complex and depends on several aspects that range from country to country, and, in the same country, from group to group, and people to people. That decision is related with the life history women and the meaning that they assign to it. Furthermore, it is associated with their experiences and with the education that they received since very early in life. It has been emphasized that there is a tendency that the message of encouraging breastfeeding takes place from childhood through adolescence, and that message should be given in formal as well as family education.
With the purpose to provide evidence-based contributions towards recovering the culture of breastfeeding and an awakening about the need to implement measures that promote breastfeeding, assigning it a position of a public health issue, and because of the inexistence of studies centered on Portuguese children and what they know, think, learn, and experience regarding breastfeeding, this descriptive, cross-sectional study was performed with a quantitative approach, with children enrolled in the 3rd and 4th grades of primary education in public schools that permitted to study and analyze the breastfeeding experiences that those children had.
The history of breastfeeding shows that it is determined not only by natural and biological aspects, but also by the everyday lives of families in their social and cultural environments(1). Breastfeeding is affected by the home environment, family members, health professionals and the community. Hence, it is affirmed that Mother's milk is formed biologically and the act of breastfeeding is constructed socially(2).
Today, it is scientifically disseminated that there is a positive effect on girls if they see their siblings being breastfed, and emphasis is given on the importance of teaching about breastfeeding as of kindergarten, so that women acquire this habit in their family and social environments before they become pregnant. Breastfeeding is a natural act that should be learnt as early as possible(3).
Considering that both male and female attitudes affect how social norms are formed, both girls and boys, from childhood through adolescence, should receive positive guidance about breastfeeding, which should occur not only through experience and formal education, but the advantages of breastfeeding should also be emphasized in family education. It has been acknowledged that the environment in which the child lives has a significant effect in their educational process.
Therefore, insisting that girls see their siblings being breastfed and disseminating contents about breastfeeding from as early as kindergarten may help women learn this habit in their family and social environments, so by the time they become pregnant they do not see breastfeeding as an obligation they must accept. Any health professional that believes in encouraging breastfeeding should be concerned with this issue. In this sense,
if children receive adequate information about breastfeeding since school, when they become mothers, girls would probably be more motivated towards breastfeeding, and boys would be more prepared to offer support to the mothers' decision(4).
However In some places, the truth is that it appears that the information is still not disseminated as we would like it to be, ... (5).
The importance of disseminating information about breastfeeding to scholars of both genders is based on the idea that the school represents the place that teaches knowledge that tends to affect the individuals' lives and attitudes permanently, as children are excellent means for transmitting information to their families, and may thus encourage their mothers to breastfeed and, in the future, when the girls become adults, they will encourage breastfeeding among their own children.
The main consequence of introducing the breastfeeding topic in schools is children and adolescents becoming familiar with this practice, because it is often for families to keep a distance from the breastfeeding process(6-7).
Children should receive correct information about breastfeeding, a right to women and children, and should also see it as an economy factor not only for the family but for the society as a whole. It is in this sense that
the school, while a safe and healthy space, facilitates the acquisition of healthy behaviors, and is, therefore, the ideal location to promote and maintain health in the school community as well as in the general community(8).
Therefore, schools may offer children the formal and conscious aspects involved in learning about breastfeeding, while the family and social contexts of the community provide unconscious opportunities of health education in this topic, because breastfeeding is a practice that should consist of a health promotion strategy and, thus, requires understanding the determinants associated with its interruption. There is scientific evidence showing that exclusive breastfeeding is the best way to feed children, and is the foundation for their biological and emotional development. Furthermore, it is known that breast milk protects children against infections during the first year of life, thus reducing chronic diseases in adult life(9).
To study and analyze the breastfeeding experiences of children in the 3rd and 4th grades of public primary education schools.
The study was performed with children in the 3rd and 4th grades of public primary education schools in the school district of Coimbra, Portugal.
In June, 2008, the Regional Education Board was contacted over the phone and a meeting was scheduled with the General Director to present the study and request formal approval. We were informed that all the formal procedures should be directed to the School Groups. In Portugal, not all Health, Education and Research Institutions have a Research Ethics Boards. Therefore, the studies are authorized by the person in charge at the institution where the study takes place and by the subjects involved, which is done using a document prepared by the researcher, which informs and clarifies the objectives and purposes of the study.
Therefore, meetings were held with the Directors of the Executive Councils of the eight School Groups of three District Councils in Coimbra, which were possible through a formal request by means of a letter asking permission to perform the study, which included all the explanations about what was intended, the study objectives, and a letter requesting the collaboration of parents and children, as well as a letter requesting the teachers to administer the questionnaires in the classroom. After receiving the parents' consent, the signed collaboration forms were collected. Written or verbal consent was obtained from six School Groups, i.e. 73 schools and 1,339 children enrolled in the 3rd and 4th grades of primary education.
The questionnaire used with children consisted mainly of closed questions, but also had some open and mixed questions. This permitted to obtain the children's socio-demographic data and obtain the answers to questions that guided this study: Do boys/girls know if they were breastfed? Is it common for children to see their mothers breastfeeding? Do the messages that we send out to children encourage breastfeeding? Do the social means of communication and their study and story books transmit a breastfeeding culture? What do children learn about breastfeeding in school? Do children play with toys that encourage this practice? What is the children's attitude towards breastfeeding?
In order to verify if the children understood all the questions easily and solve any doubts they could have regarding the content and order of the questions, and to check if the closed questions offered sufficient alternatives, i.e. covering all the answer possibilities, a pretest of this data-collection instrument was performed in November, 2008, in a primary education school of the referred Group, with 18 third-graders and 17 fourth-graders. Results revealed that the questionnaire needed a few adjustments. After the changes were made, a new pilot study was performed at another primary education school of the same referred Group, this time with 18 third-graders and 15 fourth-graders. This time, the children did not have any doubts about the questions or about the structure of the questionnaire, and they had no trouble answering the questions. Therefore, this was considered the final version of the questionnaire. It was also observed that the children took approximately 20 minutes to answer all the questions.
The questionnaire was applied by the teachers of each class between December 2008 and April 2009, in the classroom, during school hours, and on a day and time that was best for teachers and students.
Data analysis was performed using SPSS 15.0 software. Absolute and percentage frequencies and descriptive statistical measures were obtained considering the nature of the studied variables.
We reiterate that all ethical procedures were complied with - parents' informed consent, children's informed assent, in that only the children whose parents authorized their participation and agreed themselves to collaborate took part in the study.
Data collection was performed with a sample of 1078 children, with ages between seven and twelve years, and a small prevalence of males, 579 (53.7%), and most living in villages, 788 (73.1%).
Although 918 (85.2%) children knew they had been breastfed, only half, 467 (50.9%), were able to state for how long, which was during the first three months of their lives.
Also, most children had siblings, i.e. 784 (72.7%). Of the children with siblings, 644 (82.1%) knew that their siblings, including those older than them, had been breastfed, but it was among the small number of children with younger siblings, 372 (47.4%), that 271 (34.6%) referred seeing their mothers breastfeed, and 249 (31.8%) reported staying close to their mothers while she breastfed their siblings. There was also a small number of children, 312 (39.8%), who reported seeing their father staying next to their mother while she breastfed their siblings.
A total 895 (83.0%) children used a pacifier, and 532 (67.9%) reported that their siblings also used one.
A large number of children, 658 (61.0%), referred seeing family members and friends of their family breastfeed their babies, and when they visit a health center they often see images of a woman breastfeeding, which was reported by 719 (66.7%) children. However, 666 (61.8%) answered that it is not common for them to see women from their community breastfeeding in gardens and other public areas.
As to the most frequent way they see their mothers feeding children is on their breasts or using a bottle, according to 403 (37.4%) answers.
Almost all the children, 1,017 (94.3%), answered that there are no images in school that suggest breastfeeding.
Only 522 (48.4%) and 586 (54.4%) children, respectively, mentioned that at school and at home they heard about mothers breastfeeding their children. For 459 (87.9%) children, teachers were the ones who addressed the subject, while for the others, 358 (61.1%), it was the mothers who represented the greater number of agents of this educational/developmental process. Nurses were mentioned only 30 times as an educational element in this area of children's health education.
A total 626 (58.1%) children affirmed having watched a television show that addressed the topic of mothers breastfeeding their children, and 186 (17.3%) referred having heard about breastfeeding on the radio.
A large number of children, 771 (71.5%), answered that the girls' dolls, or the dolls of their sisters or girl friends had a bottle, and, yet, 760 (70.5%) of them said that the toys had pacifiers, 776 (72.0%) of the children reported that their dolls or their friends' dolls are not made for breastfeeding. Also, many children, 638 (59.2%), reported not talking to their friends about mothers breastfeeding babies, and less than half, 511 (47.4%), reported that when they play with dolls or see their sisters or girl friends playing with dolls, they pretend to feed their dolls, but most, 302 (59.1%), answered they use a bottle.
The children also informed that their books did not have any pictures of women breastfeeding, and neither of bottles, which was reported, respectively, by 639 (59.3%) and 609 (56.5%) children.
Many children, 674 (62.5%), watch cartoons in which none of the characters appear breastfeeding.
Although most children, 851 (78.9%), reported that later in life they would like to breastfeed their children or would like their wives to breastfeed, only 601 (55.8%) mentioned they would not feel embarrassed to breastfeed or that their wives breastfed in front of other people and, yet, 590 (54.7%) children informed they would enjoy seeing a women breastfeeding her child in public.
Although most children, 952 (88.3%), consider breast milk to be the best type of milk for babies, it was found they had misbeliefs and lacked knowledge about other advantages of breastfeeding, namely the advantages for mothers, the environment and the society.
Only 759 (70.4%) children mentioned they believed to know what breastfeeding was, and many of them did not identify breast milk as the best milk to feed babies.
The question addressed in this study was if the studied children knew how they were fed during the first months of their lives and, in case they did know, they were asked until what age that feeding occurred. The results were similar to those of studies developed by Brazilian authors(4,10), in which most of the interviewed children knew they had been breastfed. The remembrance of having been breastfed may have a positive effect on the studied girls regarding their decision to breastfeed in the future. However, only about half of them were able to tell for how long they had been breastfed, and they reported it was for three months. The study results, which explores breastfeeding data obtained in the national health inquiries of 95/96 and 98/99, regarding children aged five years or less, reveal that children were breastfed for at least seven days, 81.4% and 84.9%, with a respective mean breastfeeding period between 20.3 and 20.6 weeks(11). The present study result shows that the subjects were breastfed for a shorter period than what is recommended. Nevertheless, this fact is not surprising, because in Portugal women often breastfeed only for three months, which appears to be associated to the fact that mothers usually interrupt breastfeeding one month before their maternity leave is over.
Despite the perception that the number of families with an only child is increasing, this fact is not confirmed in the present study. However, in terms of the breastfeeding experiences that the studied children had, related to the fact of having siblings, it was found that elder siblings could watch their mothers breastfeed their younger siblings although the only a few children actually saw or stood close to their mothers while she breastfeed. Nevertheless, one aspect to be considered is also that most of those children knew that their older siblings had been breastfed. These results may indicate that although it is acknowledged that breastfeeding a baby in front of older children is the easiest and most natural way for youngsters to learn what breastfeeding is and to take this practice as a habit, Portuguese families do not always take advantage of those moments to show breastfeeding to younger children, even if it is a common topic in the family. The present study results are opposed to those of the Brazilian study(12) that showed that most of the studied children had been exposed to breastfeeding in their own homes.
Considering that the father is an important element in the process of breastfeeding, we sought to find whether this model of paternal participation in the breastfeeding was transmitted to children since an early age. It was observed that only a few children reported having seen their father sometimes next to their mother while she was breastfeeding a sibling. It would be completely pertinent for children to always include the father as an important element and active participant in their perception of the breastfeeding process. This data was observed in a study developed by Brazilian authors(10), who found that the studied children believed that the father's participation is very important in this process. Today, it is acknowledged that the support and encouragement from the partner and the couple's deciding together to breastfeed can mean the difference between successful and non-successful breastfeeding.
It is scientifically acknowledged that using pacifiers and artificial nipples has a negative effect on the maintenance and success of breastfeeding, as Not offering artificial nipples or pacifiers to children being breastfed is among the WHO recommendations(13). This is part of the ten steps to achieving successful breastfeeding. However, pacifier use was recurrent in the present study by the studied children and their siblings. This result could represent a negative influence on the culture of breastfeeding considering that children who are used to seeing their siblings using a pacifier, will eventually follow that model.
The regular sight of other women breastfeeding, especially in the same family or social group, is a privileged way for girls, adolescents and young women to develop positive attitudes towards breastfeeding. It is observed that families, close ones, and health services are elements that encourage breastfeeding among Portuguese children. The same is not true for community members. In the future, this fact may translate into further difficulties for the child in terms of the process of breastfeeding their children, such as feeling embarrassed, and finding it difficult to breastfeed when others are present.
The school, associated with families and the community, holds a strong responsibility in the promotion of their students' health and well-being, and assumes an important role in the process of their acquiring a healthy lifestyle. In this context, although it was found that all the studied children reported that they do not see any drawings, pictures, or posters in school that show a woman breastfeeding her baby, the teacher addressed the topic and stressed its importance. These results, contrary to those found in the study developed in Brazil(12), apparently show that teachers of the studied children are interested in teaching them about breastfeeding so that when they become mothers, the girls will feel motivated to breastfeed, and the boys will be prepared to support the mother's decision. However, [...] many opportunities are lost in school [...](2). One aspect that is important to be emphasized is the fact that nurses were stated only 30 times. Considering that the Health and Education Departments in Portugal have made efforts to implement health education at schools, a partnership was established aiming at an active collaboration between schools and health centers. That partnership resulted in the National Network of Health Promoting Schools; however, the participation of health professionals remains insufficient.
It is becoming more and more evident that children are assiduous spectators of social communication programs, particularly television, which play an important role in their entertaining and will influence their development. If used adequately, these programs permit children to go beyond their physical space and family environment. Depending on the programs a child watches, which requires careful parent supervision, there can be a significant contribution to education. Although some children mentioned having watched a television program that talked about mothers breastfeeding their babies, only a few children reported the same for radio shows. According to these results, until today, the latter social methods of communication have not been effective means in promoting breastfeeding among children. On the other hand, the difference observed in the answers may be related to the fact that children watch television more often than they listen to the radio.
As to the importance that playing has on child development, the present study results showed that children are exposed to toys that do not promote breastfeeding, on the contrary, they have incorporated devices that encourage a culture of artificial feeding. In addition, while playing, children do not talk to their friends about mothers breastfeeding their babies. These findings are similar to that of other studies(4,10), which had found, respectively, that only a small percentage of the interviewees always pretended to breastfeed or alternated between pretending to breastfeed and giving a bottle when playing with their dolls and that in childhood games, less than half the female scholars and very few male scholars reported that the dolls were breastfed. The results involving the toys were not surprising, because children follow the model that is transmitted to them. These data are concerning because the way children play may affect their future decision towards breastfeeding.
It is acknowledged that the place where children live affects their education process, and parents have a determinant effect on their children's future paths and choices, including their expectations towards the family and community, all of which have the power to influence on the children's decisions, therefore it would be suitable that children had more chances to talk about breastfeeding in their own homes. That is because it was found that only half the studied children affirmed they talked about breastfeeding at home, and most reported that their mothers were who talked about it. However, considering the number of children who stated they knew they and their siblings had been breastfed, it can be thought that this value is even higher.
This study aimed at learning how children defined breastfeeding and if they considered mother's milk to be the best type of milk for babies. Only 759 (70.4%) children mentioned they knew what breastfeeding was. Only about half of those, 409 (53.9%), referred that breastfeeding is Offering the breast to the baby. This data suggests that children might not relate breastfeeding only with its nutritional aspect, but also with relationship and bonding, as 180 (23.7%) children answered that breastfeeding is Giving the baby milk from the mother's breast. A total 144 (19.0%) children answered that breastfeeding was to Give the baby milk, and this statement differs from the others, because the child does not specify what milk is given, nor how it is given. Although in a small number, some children did bring up important aspects of breastfeeding, namely the fact they consider it natural, a healthy food, the best food, giving affection, satisfying needs.
As to the child's opinion about which milk was best, it was found that most answers pointed at the mother's milk being best, though many children lack this knowledge. Considering this result, it is important to inform children that during the first six months of life, exclusive breastfeeding is ideal for most infants, and that after that age, breastfeeding should be maintained along with complementary foods at least until the age of two years and while mother and child wish to continue, because breast milk is a high-quality food, and is an important source of energy, proteins, vitamins, minerals essential amino acids, and protection agents, keeps babies free from hunger and helps sick babies to recover their health quickly, in addition to permitting the continuation of the special mother/baby relationship.
The attitudes and values assigned to breastfeeding are developed at an early age and appear to affect the individuals' future behavior. It was found that although most children reported they would like to breastfeed in the future or that their wives breastfeed their children, only about half mentioned they would not feel embarrassed to breastfeed or to have their wives breastfeed in public, and, yet, that they would like to see a woman breastfeeding her baby in public. Previously, it was found that most Portuguese children were not used to seeing women breastfeed outside of their family environment, i.e., in public, and this experience could cause those children to develop a breastfeeding perspective with reservations and taboos. These results are similar to those found in other studies(4,10,12), confirming that although children state they would like to breastfeed later in life, they would be embarrassed to do that in public.
All children stated that breastfeeding is good and there was also a high number of children that considered that breastfeeding Is the best for the baby. However, it should be noted that the idea that breastfeeding Hurts the mother and that The mother's breasts get flabby, were also part of the studied children's imaginary.
There were also children whose opinions about breastfeeding were different from the presented aspects, as it was found that they focused mainly on the protective characteristics that breastfeeding has over diseases. This notion is only associated with the children, and it is not linked to the mothers' health. In this sense, the results of the present study were also similar to a study developed with Brazilian children(12).
Although we observed that many children consider breast milk to be the best food for babies, some children in the studied age group already have equivocated concepts and lack knowledge about other advantages of breastfeeding. None of the studied children mentioned the advantages of breastfeeding for the environment or the society, and only a few mentioned the advantages that breastfeeding has on mothers.
This study showed that although a large number of children knew they had been breastfed, many opportunities to promote breastfeeding in the home environment are lost, because only a few children actually see their mothers breastfeeding their siblings, and they also do not realize the active participation of the father in the process, while others use pacifiers, and, in most families, very little is spoken about breastfeeding. Also at schools those opportunities are lost, because only a few children reported that their teachers talk about breastfeeding. It is observed that health professionals have a small role, and many children reported there were no images of breastfeeding in their schools. Furthermore, this missed-opportunity is also observed in the community the children live in, as it is not common for them to see mothers breastfeeding in gardens and other public places. The social means of communication an books that children usually use also do not transmit any breastfeeding culture, and, most of all, their toys encourage games that reinforce the use of bottles and, consequently, artificial feeding.
It was also found that not every child knew what breastfeeding was and that breast milk was the best food for babies in the first months of life. The children were unaware about some advantages of breastfeeding and already had some misconceptions in this regard.
Despite the children affirming they would like to breastfeed or that their wives breastfeed later in life, they would feel embarrassed to do so, or if their wives did so in public.
Considering these results, it is necessary to develop intervention strategies with families, schools and health professionals with a view to raise awareness about the importance of teaching children, as of an early age, the values and practices of breastfeeding so they see it as something natural, and it may become part of their culture, education and of their family and everyday living. There is a need for health professionals to implement educational measures that promote breastfeeding among children, as a school health intervention strategy. These activities developed by teachers and nursing professionals who work in the school health team should include empowerment, the basic principle of health promotion.
This study presents elements that are important for developing further research using other methodologies that could explore and build constructs about what children know and learn about breastfeeding, and the subjective aspects implied in this process, at schools or in any other setting. As there has not been much investigation on this theme and object, we dealt with difficulties and limitations in the survey, as we did not find studies performed with Portuguese or other European children on this theme. We found only three studies performed with Brazilian children, with results confirming that, particularly in the Portuguese society, very few studies address this important theme among children, thus denoting its remarkable relevance.
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