Knowledge of health professionals about breastfeeding and factors that lead the weaning: a scoping review Conhecimento de profissionais de saúde sobre amamentação e fatores que levam ao desmame: uma revisão de escopo

Resumo Esta revisão avaliou o conhecimento dos profissionais de saúde (PS) sobre amamentação e fatores que levam ao desmame. Realizou-se buscas em quatro bancos de dados eletrônicos e literatura cinzenta. A estratégia de busca incluiu termos Mesh e sinônimos. Não se adotou restrição de idioma ou data. Estudos avaliando o conhecimento dos PS sobre amamentação e desmame foram elegíveis. Estudos recuperados pelas buscas foram avaliados por dois examinadores independentes. Dos 1.417 estudos recuperados, 35 foram incluídos. Muitos países e PS de diferentes áreas foram analisados. Nenhum estudo avaliou o conhecimento dos dentistas. Embora os PS conheçam os benefícios da amamentação, a duração recomendada pela Organização Mundial da Saúde, exclusiva ou não, não está alinhada com o endosso de todos os PS. Considerando o desmame, a informação é escassa. No entanto, os PS estão atentos às principais causas potenciais do desmame precoce. O conhecimento dos PS é conflitante sobre amamentação e incomum sobre o desmame. Não foram encontrados estudos que apresentassem dados sobre o conhecimento de dentistas sobre a temática. Investigações quanto ao conhecimento dos mesmos e medidas de educação para todos os PS são necessárias, considerando que são frequentemente questionados sobre o tema. Palavras-chave Aleitamento materno, Desmame, Pessoal de saúde, Conhecimentos, Atitudes Abstract This review evaluated the knowledge of health professionals (HP) about breastfeeding and factors that leading the weaning. A search was performed in four electronics databases and the grey literature. The search strategy included Mesh terms and synonyms. No language or date restrictions were adopted. Studies that evaluated the knowledge of HP about breastfeeding and weaning were considered eligible. The studies retrieved by the searches were evaluated by two independently examiners. From 1,417 studies retrieved, 35 were included. Many countries and professionals from different health areas were analyzed. No studies evaluated the dentists’ knowledge. Although the included HP know the benefits of breastfeeding for health, the length of breastfeeding recommended by the World Health Organization, exclusive or not, was not aligned with all professionals’ endorsement. Information about weaning is scarce; however, HP are mindful of the main potential causes of early weaning. The knowledge of HP is conflicting about breastfeeding and unusual about weaning. Furthermore, no studies were found that presented data on the knowledge of dentists on the subject. Thus, assessments of dentists’ knowledge and education measures for HP are necessary since they are frequently questioned about these issues.


introduction
The American Academy of Pediatrics and the World Health Organization (WHO) recommend that infants receive human milk exclusively for the first six months of life and that breastfeeding continue beyond the first or second year of life as long as a family deems appropriate 1 . Breastfeeding offers numerous health benefits for both the baby and the mother in the short and long term. Exclusive breastfeeding reduces the risk of infant mortality by protecting the baby from infectious and chronic diseases, as well as promoting his sensory and cognitive development 2 .
The term weaning refers to the long transition process in which the child changes from the total dependence on breast milk to the complete interruption of feeding with milk 3,4 . Therefore, weaning begins with the introduction of any food other than breast milk and ends when the baby is fed with milk for the last time. Complementary feeding is the period between these two milestones, that is, the association of other foods together with milk 5 .
Therefore, WHO and United Nations International Children's Emergency Fund (UNICEF) have suggested implementing a program called Ten Steps to Successful Breastfeeding in all institutions providing maternity and newborn services worldwide. The program seeks to support breastfeeding in ten steps, such as ensuring that the professionals involved have sufficient knowledge, competence and skills to support this practice, as well as counseling mothers on the use and risks of feeding using bottles with teats and sucking on pacifiers 6 .
In this context, a multiprofessional team is the ideal, where the dentist, as a health professional, should be included being able to guide the woman on the importance of breastfeeding since there is a strong relationship between natural breastfeeding and the development of the stomatognathic system 7 .
Therefore, knowing the importance of breastfeeding for general health of the baby, this scoping review aimed to evaluate in the available literature the knowledge of health professionals about breastfeeding and weaning, mainly related to exclusive breastfeeding time, weaning age and factors that may be related to early weaning. Thus, this review sought to answer the following question: "What does the literature report about the knowledge of health professionals on breastfeeding and weaning and what are the work areas of these professionals?"

Materials and methods
This scoping review was developed and conducted following the recommendations of Arksey and O'Malley's 8 and Levac, Colquhoun and O'Brien 9 .

information sources and search strategy
The search was performed in four electronic databases (PubMed, Lilacs/BBO SciELO and Web of Science) and the grey literature (Open Grey and Trip Database) up to April 2020. The search strategy included the health terminology identified at the Medical Subject Headings (Mesh terms) and synonyms related to the review objective and adapted for each database. There was no language or date limitation. The terms used to construct the strategies were "weaning", "breastfeeding", "health education", "health knowledge, attitudes, practice", "health education", "health knowledge, attitudes, practice", "health personnel" and "allied health personnel". An expert librarian (DMTPF) guided all process of definition of the included terms in the applied search strategy, as well as the search in each database. The combinations of the terms used in each database are described in Chart 1.

eligibility criteria and selection of studies
Based on the PCC framework 10 , the inclusion criteria were cross-sectional study, qualitative study, and self-report survey design with humans (P), found by online search strategy (C) to assess the knowledge of health professionals about breastfeeding and weaning as primary or secondary outcomes (C). Two reviewers (MLD and KRD) analyzed independently the titles and abstracts of the articles retrieved from searches to identify those potentially eligible for this study. The exclusion criteria were animal and clinical trials studies, literature or systematic reviews, guidelines, editorials, letters to the editor, studies with health students and/or professionals from areas different of health, studies about mother's knowledge, studies that assessed knowledge after an intervention and studies that did not cover the topic relevant to the review objective. If some abstract did not provide enough information for a definite decision, full articles were evaluated. Uncertainties about inclusion were discussed with a third reviewer (AFG), who had read the respective titles and abstracts. Studies available in more than one database were considered only once. Finally, a hand search was performed in the reference list of the included studies. When the full texts were not available, the authors were contacted by e-mail and the research gate website (eight articles were requested by this means). The EndNote website was used for literature management.

Data extraction
Data extracted of the included studies were: characterization of the study (authors, year of publication and country), study design (cross-sectional, qualitative study and self-report survey design), sample (professional category and number of participants), methodology used (questionnaires or others) and main results (exclusive or not exclusive breastfeeding, exclusive and combined breastfeeding time and factors that lead to weaning and others results). When these data were not available in the full texts, the authors were contacted by e-mail and the research gate website. The data collected were analyzed descriptively. Figure 1 presents the flow diagram with the search process. A total of 1,417 studies were identified and 1,362 records remained after the removal of duplicates using the reference manager website. Posteriorly, another 1,310 studies were removed after their titles and abstracts have been evaluated because they did not meet the inclusion criteria. Fifty-two full texts were read and 17 were excluded due to not fulfilling the inclusion criteria. The reasons for the exclusions are described in Figure 1. Ultimately, 35 studies were included in this scoping review. (mh:(weaning)) OR (tw:(weaning)) OR (mh:(breastfeeding)) OR (tw:(breastfeeding)) AND (mh:(health education)) OR (mh:(health knowledge, attitudes, practice)) OR (tw:(health education)) OR (tw:(health knowledge, attitudes, practice)) AND (mh:(health personnel)) OR (tw:(health personnel)) OR (mh:(allied health personnel)) OR (tw:(allied health personnel)) OR (tw:(health professionals)) SciELO ((subject:weaning) OR (subject:breastfeeding)) AND ((subject:health education) OR (subject:health knowledge, attitudes, practice)) AND ((subject:health personnel) OR (subject:allied health personnel) OR (subject:health professionals)) Web of Science #3 AND #2 AND #1 # 3 TS=("health personnel" OR "allied health personnel" OR "health professionals") # 2 TS=("health education" OR "health knowledge, attitudes, practice") # 1 TS=(weaning OR breastfeeding)

Study characteristics
Open Grey (weaning OR breastfeeding) AND ("health education" OR "health knowledge, attitudes, practice") AND ("health personnel" OR "allied health personnel" OR "health professionals") Trip Database (weaning OR breastfeeding) AND ("health education" OR "health knowledge, attitudes, practice") AND ("health personnel" OR "allied health personnel" OR "health professionals") Source: Authors.
States of America (USA), four in Brazil, two in Australia, two in Turkey, two in Pakistan and two in Puerto Rico. The other countries that carried out a study were China, Sweden, Chile, Norway, Egypt, France, Lithuania, Iraq, Nigeria, England and India. The articles were written in four languages, English, Portuguese, Spanish, French and Chinese. Twenty-six cross-sectional studies, five qualitative studies, two descriptive studies, one self-report design and one exploratory study were selected. Questionnaires were used by 27 studies as a method of assessing knowledge, the number of questions ranged from 10 to 139. The other forms of evaluation were interviews and focus groups, chosen by six and two studies, respectively.
A total of 43,579 health professionals were investigated. Of these, 4542 were nurses, 1763 were doctors, 893 midwives, 177 nutritionists, 119 nursing technicians, 99 paramedics, 65 health educators, 29 pharmacists, 23 community health agents, 12 medical office assistants and 1 dental assistant. In four studies, the professional category was not described and one study did not differ the number of nurses from the number of midwives, totaling 35,809 professionals. No studies that evaluate dentists' knowledge were found.
When the knowledge about breastfeeding was investigated in general -such as the benefits, the difference between the formula used, importance of colostrum -four studies reported a high knowledge level related to breastfeeding [11][12][13][14] . Other studies reported regular knowledge level [15][16][17] or good knowledge level 18 for most of the investigated sample. With regard to the benefits of breastfeeding, the professionals cited: best source of nutrition for babies [19][20][21][22] , protection against infections in babies 19,[23][24][25][26] , increased immune function [23][24][25] , prevention of maternal diseases -such as breast cancer 27,28 , increased emotional bond between mother and child 28 , be convenient 22 and that it is a cheap food 19,22,28 .  Most participants reported that one of the advantages breastfeeding for the family, prevention and promotion of child and maternal health, through the prevention of maternal and child diseases. Another advantage very emphasized by most nurses was the increase in emotional bonds between mother and child and family, as well as family unity and increased bonding. In addition, nurses highlighted the economics and practicality of breastfeeding as an advantage Sims et al. 74% of doctors recommended exclusive breastfeeding to their patients, while 19% advising a combination of formula and breast milk. 61% recommended breastfeeding for at least 6 months and 24% for the length of time the mother prefers. 44% will recommend starting breastfeeding during the first hour after birth and 38% as early as the mothers wants to. Doctors were asked about contraindications to breastfeeding responding: the use of illicit drugs (94%), HIV (93%), Hepatitis B e C (57% e 55%), breast abscess (55%), mastitis (22%) and cracked nipples (15% Questionnaire 90.8% would encourage more frequent breastfeeding when there was concern regarding the mother's milk supply in the first two weeks, whereas only 1.3% would supplement with glucose and 0.3% would supplement with formula. 88.2% recommended increased breastfeeding when the concern was jaundice in an otherwise healthy 4-day-old infant, however, while 5.5% would supplement with glucose water and 1.3% would supplement with formula. 96.1% would not stop breastfeeding in a patient with mastitis or in the presence of concern over milk supply Questionnaire HPs were slightly less likely to recommend breastfeeding to working mothers, mothers in school, and adolescent mothers. They did not recommend breastfeeding for mentally retarded mothers. nutritionists and nurses were more likely to recommend breastfeeding to a mother who had made the decision to bottle-feed than were doctors. Doctors were less likely to think that breastfeeding was incompatible with working outside the home or attending school than were nurses. nutritionists were more interested in breastfeeding and lactation management than were nurses. Nurses were more likely than dietitians and doctors to think that mastitis and engorgement are reasons to discontinue breastfeeding Hull The duration of exclusive breastfeeding was investigated by eleven studies. A high level of recommendation was reported by two authors, reaching more than 90% of participants who recommended exclusive breastfeeding until to six months 27,29 . Regular level of recommendation was found in four studies, where the recommendation up to six months ranged from 49% to 61% among professionals [30][31][32][33] . In five studies, a low knowledge level about the time of exclusive breastfeeding was observed 22,26,[34][35][36] where the percentage reached up to 61% of error in the recommendation 36 . Eight studies assessed knowledge about the duration of breastfeeding. Of these, three reported a high knowledge level of the sample with a recommendation level for breastfeeding continuation up to 24 months by 70% 26 , 83.1% 29 and 84.8% 27 of the professionals, respectively. The other four studies reported a low knowledge level about breastfeeding time 21,22,31,36,37 , where 66% of the sample did not recommend that it would be performed until 12 months 36 and almost half of another sample (45%) did not agree or were not sure about that time 21 .
In two studies 43,44 the professionals pointed out causes that can influence early weaning, such as: maternal mental health conditions, breast surgeries, prescribed medications, social situations, socioeconomic conditions, return to work 43 , families that were not well informed, families that prefer a formula, a nurse's recommendation, a nursing team that did not encourage breastfeeding, a neonatologist's recommendation, doctors that do not encourage breastfeeding and inadequate lactation consultation 44 .
The barriers highlighted by health professionals to promote breastfeeding were: lack of knowledge and psychological support to mothers 45 , lack of professional time 33,45 , need for training, being comfortable to guide mothers only when they asked, and they do not believe that they can influence the mother 33 .

Discussion
Breastfeeding is a natural process of mammals that has health and psychological benefits for both mother and baby 2 . As evidenced by our results, most professionals are familiar with these benefits 19,[21][22][23]27,28,32 . However, according to the World Health Organization (WHO), almost two out of three babies are not exclusively breastfed until the age of six months, a fact that has not improved in decades 46 .
The economic benefit of breastfeeding was highlighted among the health professionals who participated in the reviewed studies 19,22,28 , being considered the cheapest way to feed a baby. Despite this benefit, Melin, Björklund and Zwed-berg 43 reported that doctors believed that one of the factors related to the mothers' decision not to breastfeed or stop after a few months would be the socioeconomic condition, since low-income countries have lower rates of breastfeeding. This behavior contradicts the findings of a major literature reviewed that states that, with a few exceptions, the duration of breastfeeding in high-income countries is shorter compared to low-income countries 47 .
In our results, many professionals agree that they play an important role in the approach of breastfeeding 43,44 and that they act directly in this process helping with breastfeeding techniques, advice on infant feeding methods 19 , prenatal counseling and lactation problems 13 . However, professionals report that they receive guidelines about the benefits of breastfeeding during their courses, but practical training on breastfeeding techniques is insufficient 32 . Melin, Björklund and Zwedberg 43 highlight that courses are concerned with the type of baby's nutrition and not with the practical of breastfeeding itself. Thus, health professionals reported having acquired their knowledge about the practical of breastfeeding with professionals different from their own area 45 , or through their own experience as mothers or still through the observation of mothers in the community that they live or work 25 , and also through lectures 15 .
It is important to report that attitudes and practices about breastfeeding and weaning were not actually evaluated in the present study, as there were no studies that assessed such outcomes, which could be a limitation. This was the reason why the keywords "attitudes" and "practice" appears in the search strategy, but nothing is presented about this issue. Two studies show that the level of professional qualification influences the knowledge about breastfeeding of health professionals, where professionals with higher educational background had a higher rate of knowledge than those with less education 14,41 . In our work, studies with graduated and non-graduated professionals were included. Thus, we do not believe that this factor has negatively influenced our results, as some professionals included in the samples of the selected studies did not graduate from universities, but receive specific training for breastfeeding and breast milk 23,27 . However, most of the studies included in our review have a sample of graduated professionals.
Another factor that influenced the level of knowledge of professionals was personal experi-ence. However, this personal experience should be interpreted with caution, as demonstrated by Szucs et al. 17 , who affirmed that personal experience of health professionals referring to breastfeeding may be related to recommendations contrary to the evidence-based recommendations. In addition, Xian et al. 14 , highlighted that health professionals who were parents of children up to two years old had more knowledge about breastfeeding than professionals who did not have children. Also, Svendby et al. 36 reported that female professionals had more knowledge than male professionals.
When comparing the knowledge of different professionals, one study related that the knowledge of doctors was lower than those of nutritionists, midwives and nurses 18 . However, in another evaluation 40 , they did not show scores that were statistically different from those of nutritionists or nurses. Although they reported being able to manage medical problems such as mastitis, doctors reported delegating the responsibility of providing practical breastfeeding support to lactation consultants 22 and midwives 43 . Therefore, there is a need to improve multiprofessional work and communication between the groups involved with breastfeeding, highlighting that they should receive mutual learning 43 .
Considering the breastfeeding time, the WHO recommends exclusive breastfeeding for the first six months of life, followed by breastfeeding associated with adequate complementary food for up to two years or more 48 . It is known that exclusive breastfeeding is the best source of protection and nutrition for the baby up to the sixth month of life, with no other type of food or liquid necessary 49 . However, our results show that knowledge about exclusive breastfeeding for up to six months is not satisfactory 22,26,31,[34][35][36] . It has been shown that doctors and nurses recommended that mothers give liquids and solid foods to babies under six months of age 31 .
Even though the WHO recommendation is not current 48 , our results demonstrate that there is a lack of knowledge among professionals regarding the duration of breastfeeding. Levinienė et al. 31 reported that the most of general practitioners and nurses did not know that breastfeeding with complementary foods should be continued until two years of age or older. In addition, more recent studies have cited that general practitioners have demonstrated negative opinions about breastfeeding up to twenty-four months 22 and almost half have recommended that children be breastfed up to twelve months 36 . It is worth mentioning that one of the studies 22 was carried out in Australia where the national health and medical research council recognizes the continuation of breastfeeding for at least twelve months, which can cause confusion regarding the professionals' guidelines and is not according to the guidelines established by the WHO.
A review of the previous literature evaluating studies with nursing mothers highlighted the factors that make breastfeeding difficult and cause early weaning, which could be: the perception of weak or insufficient milk, use of a pacifier, return to work or school, nipple fissure and pain, lack of encouragement from health professionals for exclusive breastfeeding, precarious knowledge of mothers about the importance of breastfeeding, low level of education of the mother and increasing the child's age 49 . In our results, we observed that many professionals reported at least one of these situations as a factor for not indicating or not encouraging breastfeeding 30,32,37,40,41 . However, these studies were carried out more than ten years ago and what makes us believe that a change in the knowledge regarding factors such as weak milk, nipple fissure and returning to work or school is happening. Despite this, the lack of maternal knowledge and the lack of encouragement from health professionals reported by mothers demonstrates their direct influence on the success of breastfeeding, as observed by Sims et al. 44 .
Our results demonstrated a conflict of knowledge related to weaning and beginning of deciduous dentition. McLaughlin et al. 21 and Pereda et al. 39 reported that doctors and nurses do not recommend weaning when the rash starts. However, Holtzman and Usherwood 22 reported that a doctor stated he recommends that mothers wean if the baby bites while breastfeeding. The American Academy of Pediatric Dentistry (AAPD) recommends that children should be taken to the pediatric dentist at no later than your child's first birthday or when the time of the eruption of the first tooth 50 . This is an opportune time for the dentist to provide guidance on the benefits of breastfeeding, the correct weaning protocol and appropriate oral hygiene guidelines. It is known that oral health is an integral part of the general health and that child's general health care cannot be achieved if oral care is not included 51 . Despite that, none of the selected studies evaluated the knowledge of dentists about breastfeeding and weaning. That is, after the systematic search in each electronic base, none of the studies included dentists as part of the sample. Thus, it represents a warning sign for dentists, which suggests that they are not considered by many to be professionals who work directly with such themes in their clinical practices.
An important habit reported in our results and the dentist's technical competence is the use of pacifiers. The use of pacifiers can cause a decrease in the frequency of feedings, reduced stimulation, and withdrawal of breast milk, which leads to less milk production, and consequently to weaning 52 . In addition, non-nutritive sucking habits, such as the use of pacifiers, can negatively affect the orofacial system. Scientific evidence has shown an association between the use of pacifiers and the presence of anterior open bite and posterior cross bite. So-called orthodontic pacifiers reduce the prevalence of open bite when compared to non-orthodontic pacifiers; however, it is not possible to state that orthodontic pacifiers show a positive effect on crossbite 53 . In our results, opinions about the use of pacifiers were contradictory, Levinienė et al. 31 , Silvestre et al. 29 and Fonseca-Machado et al. 42 agree that pacifiers should not be recommended as it can negatively affect breastfeeding. However, more than a half of the nurses assessed by McLaughlim et al. 21 did not know that pacifiers can cause confusion in babies who are starting the breastfeeding. In addition, Szucs, Miracle and Rosenman 17 reported that some professionals advise the early use of pacifiers. These counterpoints once again demonstrate the importance of including all health professionals, involving dentists, in child health promotion programs and research on breastfeeding and weaning.
As previously highlighted, breastfeeding plays an important role in child health. In this sense, it has an extremely importance for the development of a normal dental occlusion. Studies have shown a lower proportion of malocclusion in primary dentition in children breastfed up to 12 months 54 or more 55 , regardless the sociodemographic factors. Another advantage of natural breastfeeding clarified in the recent years is that breast milk alone does not cause a decrease in the biofilm pH, suggesting that breastfeeding alone may not contribute to early childhood caries 56 . In addition, a systematic review suggests that children breastfed exclusively for up to 12 months compared to those breastfed for less time were protected from tooth decay 57 . Thus, we emphasize the importance of pediatric dentistry in the care of newborns, so that risk assessments of early childhood caries should be carried out, as well as the diagnosis and early intervention of malocclusions.
Health education can be considered a process that induces behavioral change related to health, not only individual, but also collective 58 . Given the importance of the dentist highlighted here earlier, the rapprochement between pregnant women/infants and a multiprofessional health team including dentists appears to be a fundamental challenge for the beginning of a promising oral health promotion cycle for women and babies. It is essential to rethink the formation of an interprofessional prenatal work team 59 . In this context, the dentist may be part of this team, being responsible for the development of oral health education actions, where women can become aware of their important role in the acquisition of positive oral health habits and their maintenance, acting as an information multiplying agent 60 . In addition, dentists in a pre-natal team would welcome and support breastfeeding, highlighting its importance for the development of the stomatognathic system 7 .
The need and lack of specific training on breastfeeding were reported by the authors 23,25 and observed in our study. We believe that this factor may have influenced the low level of knowledge of professionals, especially regarding the time and management of practical problems that may occur during the breastfeeding period. Thus, the importance of implementing breastfeeding promotion programs during the training of health professionals and effective policies to promote child health is highlighted. In addition, we emphasize the inclusion of the dentist in this context as a fundamental part of promoting the child's comprehensive health.

conclusion
This scope review shows that health professionals with different formations are aware of the benefits of breastfeeding for the mother and the baby. However, these issues have conflicting knowledge about the exclusive breastfeeding time and the duration of breastfeeding. Moreover, despite the knowledge of the main reasons that may lead to early weaning, many professionals are trapped in barriers to promote breastfeeding. collaborations MLD conduct the review, drafted, and wrote down the manuscript. Also searched the databases, evaluated the articles, collected the data and approved the version to be published; KRD carried out searches in the databases, evaluated the articles and approved the version to be published; DMTPF, a librarian experienced in systematic searches, guided the search strategy and approved the version to be published; AFG idealized the study design, critically reviewed the manuscript and approved the version to be published.