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Introduction of complementary feeding in premature children

Fernanda Afonso Dourado Manuela Rebouças da Silva Barreto Kíssia Souza da Paixão Larissa Vieira Pinto Menezes Carla Steinberg About the authors

ABSTRACT

Purpose:

to describe the characteristics of complementary feeding introduced to preterm children.

Methods:

an exploratory, descriptive, cross-sectional, quantitative research. Data collection took place in February 2020 and between May and July 2021 in an outpatient follow-up clinic for high-risk newborns. To participate in the research, children had to have food introduced at least 30 days before and be 24 months corrected gestational age, at the most. The research instrument, developed by the researchers, was applied to the children’s parents/guardians on the day of routine visits. The information they did not know was verified in the patient's institutional medical record.

Results:

the sample comprised 29 mothers/babies, 55.2% (16) of whom were males, with a mean gestational age of 13 months. Most mothers introduced complementary feeding at 6 months corrected gestational age; 25% of them introduced it late and 17.9%, early. Almost 100% of the babies received fruits and/or vegetables as their first foods.

Conclusion:

more than half of the preterm children’s mothers started complementary feeding at the recommended time with adequate consistencies and utensils.

Keywords:
Infant Nutrition; Infant, Premature; Child Nutrition

RESUMO

Objetivo:

descrever as características da introdução da alimentação complementar em crianças nascidas pré-termo.

Métodos:

trata-se de uma pesquisa de caráter exploratório, descritiva, transversal, quantitativa. A coleta ocorreu em fevereiro de 2020 e entre os meses de maio e julho de 2021 em um ambulatório de seguimento de recém-nascidos de alto risco. Para participar da pesquisa as crianças tinham que ter iniciado a introdução alimentar há pelo menos 30 dias e ter no máximo 24 meses de idade gestacional corrigida. O instrumento de pesquisa, desenvolvido pelas pesquisadoras, foi aplicado com o responsável pela criança no dia das consultas de rotina, o que o acompanhante não soube responder foi averiguado no prontuário institucional do paciente.

Resultados:

a amostra foi composta por 29 díades, sendo 55,2% (16) do sexo masculino, e média de idade corrigida de 13 meses. A maioria das mães introduziu a alimentação complementar aos seis meses de idade corrigida. 25% delas introduziram tardiamente e 17,9% precocemente. Quase 100% dos bebês receberam frutas e/ou verduras como primeiros alimentos.

Conclusão:

mais da metade das mães iniciaram a alimentação complementar no tempo recomendado com consistência e utensilio adequados.

Descritores:
Nutrição do Lactente; Recém-Nascido; Prematuro; Nutrição da Criança

Introduction

Complementary feeding (CF) encompasses every food and liquid other than breast milk given to children after 6 months old11. BRASIL. Ministério da Saúde. Cadernos de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2 ed. Brasília, DF, 2015.. After this age, breast milk is no longer enough to provide for their nutritional needs, which is why it is important to introduce CF while maintaining breastfeeding, if possible, up to 2 years old or more22. Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Nutrologia. Manual de Alimentação: orientações para alimentação do lactente ao adolescente, na escola, na gestante, na prevenção de doenças e segurança alimentar. 4ª ed. São Paulo: SBP; 2018. [accessed 2021 Aug 19]. Available at: https://edisciplinas.usp.br/mod/resource/view.php?id=3160985&forceview=1.
https://edisciplinas.usp.br/mod/resource...
. Introducing high-quality CF, in due time, is essential to child growth and development33. BRASIL. Ministério da Saúde Cadernos de Atenção Básica. Guia alimentar para crianças brasileiras menores de 2 anos. Brasília, DF, 2019..

Preterm birth is the main cause of death in the first year of life in Brazil, and this preterm population is more likely to have neurological disorders and developmental changes44. Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Neonatologia. Monitoramento do crescimento de RN pré-termos. 2017 [accessed 2019 May 25]. Available at: https://www.sbp.com.br/fileadmin/user_upload/2017/03/NeonatologiaMonitoramento-do-cresc-do-RN-pt-270117.pdf.
https://www.sbp.com.br/fileadmin/user_up...
. Moreover, prematurity is an obstacle to exclusive breastfeeding (EBF) up to 6 months old55. Vasconcelos TC, Barbosa DJ, Gomes MP. Fatores que interferem no aleitamento materno exclusivo durante os primeiros seis meses de vida do bebê. Rev. Pró-UniverSUS. 2020;11(1):80- 7., due to biological, psychological, sociocultural, and other hindrances66. Moraes AS, Aguiar RS. Dificuldades com a amamentação de recém-nascidos prematuros após a alta hospitalar: uma revisão integrativa. Rev. JRG de estudos acadêmicos. 2021;4(8):252-63..

It is understood that when treating prematurity, CF must be introduced to preterm children according to their neurological maturity. Hence, the corrected gestational age (CGA) is used as a parameter77. Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento de Científico de Neonatologia. Seguimento ambulatorial do prematuro de risco. 1ª edição. 2012. [accessed 2019 Nov 3]. Available at: https://www.sbp.com.br/fileadmin/user_upload/pdfs/seguimento_prematuro_ok.pdf.
https://www.sbp.com.br/fileadmin/user_up...
. Preterm newborns may have greater feeding transition difficulties than full-term children; therefore, these children must be included early in a specialized support network to ensure their development88. Pagliaro CL, Buhler KEB, Ibidi SM, Limongi SCO. Dietary transition difficulties in preterm infants: critical literature review. Jornal de Pediatria. 2016;92(1):7-14..

The scarcity of references on CF in preterm children reveals the need for further research in this field. Feeding is essential to these children’s growth and nutrition, as they belong to the risk group for developmental changes. Thus, knowing this population better contributes to the clinical team practice and facilitates family care for these babies. This study aimed at describing the characteristics related to the introduction of CF to preterm children.

Methods

This study was approved by the Research Ethics Committee of the Climério de Oliveira Maternity Hospital, Brazil, under CAAE 26733119.1.0000.5543 and evaluation report no. 3.768.089. This study is an integral part of an umbrella project named “Complementary feeding in preterm children” and was conducted in the prematurity follow-up outpatient center at the Climério de Oliveira Maternity Hospital of the Federal University of Bahia (UFBA).

The sample was selected by convenience, encompassing preterm children followed up at the said outpatient center, who had been introduced to CF at least 30 days before, and whose CGA was 24 months at the most on the data collection day. All children had to be in exclusive oral feeding. The researchers established a minimum 30-day period to obtain more consistent and homogeneous responses, considering that CF is gradually introduced.

The exclusion criteria were as follows: children with neurological, cardiac, or respiratory diseases, craniofacial or aerodigestive malformations, or any other clinical situation that directly interfered with safe swallowing and effective oral feeding.

This is exploratory, descriptive, cross-sectional, and quantitative research.

Data Collection

The researchers involved in the project and the speech-language-hearing therapists who work in the said outpatient center collected data in February 2020 and between May and July 2021, due to the COVID-19 pandemic.

The children’s parents/guardians were invited to participate in the study and were informed of the research objectives and methodology. Those who agreed to participate signed an informed consent form. They were individually interviewed once in their routine visits.

The collection instrument was a semi-structured form developed and applied by the researchers. This investigation used prematurity classification, maternal sociodemographic data, breastfeeding duration, artificial nipple use, and CF introduction data.

The information the parents/guardians did not know was collected by consulting the patients’ institutional medical records.

Data Analysis

The data bank was created in Microsoft® Excel 2010. Descriptive analysis was conducted, with mean, standard deviation, and absolute and relative frequencies.

Results

The sample comprised 29 children, of whom 55.2% (16) were males. The sample’s prematurity classification data regarding gestational age (GA), weight, and classification with the percentile curve at birth are shown in Table 1.

Table 1:
Prematurity classification data regarding gestational age, weight, and classification, according to the percentage curve at birth

Maternal data regarding their age and educational attainment are described in Table 2.

Table 2:
Data on sample mothers

Concerning breastfeeding history, 58.6% (17) of the children were discharged from the hospital in EBF - which was achieved by 31% (9) of them by 6 months CGA.

Table 3 described information on the CF introduction. One mother did not know when it was introduced.

Table 3:
Information on the introduction of complementary feeding

Fruits and/or vegetables were the first foods offered to babies, mentioned by 28 mothers. The types of foods initially offered are described in Table 4. Food consistencies used in the CF introduction are presented in detail in Table 5.

Table 4:
Foods introduced in complementary feeding

Table 5:
Food consistencies introduced in complementary feeding

Discussion

In the sample of premature babies followed up at the outpatient center of a Child-Friendly Hospital, more than half the babies had CF introduced by 6 months CGA. There is yet no consensus in the literature on the ideal moment to introduce CF to premature babies11. BRASIL. Ministério da Saúde. Cadernos de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2 ed. Brasília, DF, 2015.,99. Baldassare ME, Di Mauro A, Pedico A, Rizzo V, Capozza M, Meneghin F. Tempo de desmame em bebês prematuros: uma auditoria de pediatras da atenção primária italiana. Nutrients. 2018;10(5):616.,1010. Liotto N, Cresi F, Beghetti I, Roggero P, Menis C, Corvaglia L et al. Alimentação complementar em bebês prematuros: uma revisão sistemática. Nutrients. 2020;12(6):1843.. Some authors describe that premature babies exposed to CF by 4 months old were hospitalized more often than those introduced to it by 6 months CGA1111. Gupta S, Agarwal R, Aggarwal KC, Chellani H, Duggal A, Arya S. Alimentação complementar aos 4 versus 6 meses de idade para bebês prematuros nascidos com menos de 34 semanas de gestação: um estudo randomizado, aberto e multicêntrico. Lancet Glob. Health. 2017;5(5):e501.. However, another study verified that early CF introduction had benefits for this population’s growth and nutrition1212. Foote KD, Marriott L. Weaning of infants. Arch Dis Child. 2003;88:488-92..

Delaying CF introduction may have negative impacts on babies, such as growth deficits and a lack of micronutrients, energy, and proteins11. BRASIL. Ministério da Saúde. Cadernos de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2 ed. Brasília, DF, 2015.. On the other hand, this population was born before 33 weeks’ GA, often with extremely low weight; hence, the late introduction may be due to neurological immaturity, oral-motor conditions, neuropsychomotor development, or other difficulties preventing CF introduction. The GA at birth influences global motor and oral motor sensory development. The lower the GA at birth, the greater the risks of developmental delay in the oral motor sensory system and consequently in the functions it performs1313. Castro AG, Lima MC, Aquino RR, Eeickmann SH. Desenvolvimento do sistema sensório motor oral e motor global em lactentes pré-termo. Pró-Fono Rev. Atual. Cientif. 2007;19(1):29-38..

Before introducing CF to preterm children, two aspects must be considered: the baby’s CGA and signs of readiness11. BRASIL. Ministério da Saúde. Cadernos de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2 ed. Brasília, DF, 2015.. In other words, these children’s global and oral motor maturity and organization must be assessed. The following motor development parameters must be analyzed before introducing CF: holding their head and neck up; sitting up without support; having reduced tongue protrusion reflex; manipulating objects, and so forth1414. Perilo TVC. Tratado do especialista em cuidado materno-infantil com enfoque em amamentação. Belo Horizonte. Mame bem. Editora METHA. 2019.. A cohort of children followed up at outpatient centers until 2 years old verified that most premature children had adequate milestones and the expected neuropsychomotor development for their age1515. Jesus LMR, Basso CSD, Castuglioni L, Monserrat AL, Arroyo MAS. Speech-language-hearing follow-up of preterm children: feeding and neuropsychomotor performance. Rev. CEFAC. 2020;22(4):e15119..

According to a study, more than 95% of preterm babies had already received solid foods by 6 months CGA1616. Cleary J, Dalton SMC, Harman A, Wright I. Prática atual na introdução de alimentos sólidos para bebês prematuros. Public Health Nutr. 2019;23(1):94-101.. Another study conducted in Rio Grande do Sul showed that premature babies received pureed foods at the ideal moment (by 6 months old) but liquids and solid foods before the recommended time1717. Brusco TR, Delgado SE. Characterization of the feeding development of preterm infants between three and twelve months. Rev. CEFAC. 2014;16(3):917-28..

As for breastfeeding - a topic closely related to CF -, more than half of the mothers/babies were discharged from the hospital in EBF, and more than half of these maintained EBF until the baby was 6 months old. Interrupting breastfeeding and consequently introducing CF to these babies before the recommended time is associated with countless biological, psychological, sociocultural, and other factors66. Moraes AS, Aguiar RS. Dificuldades com a amamentação de recém-nascidos prematuros após a alta hospitalar: uma revisão integrativa. Rev. JRG de estudos acadêmicos. 2021;4(8):252-63.. The most common motives are the sensation of insufficient milk, the belief in the benefits of tea, and the need for water1818. Lima KMS, Santos JMJ, Oliveira NTB, Machado GCC, Leite AML. Possíveis motivações para o desmame precoce entre mães adolescentes. 2º Congresso Internacional de Enfermagem. 12º de setembro de 2019;1(1). Available at: https://eventos.set.edu.br/cie/article/view/11367 .
https://eventos.set.edu.br/cie/article/v...
. A study verified a 68.6% prevalence of breastfeeding by 6 months in Brazil1919. Scochi CGS, Ferreira FY, Góes FSN, Fujinaga CI, Ferecini GM, Leite AM. Alimentação láctea e prevalência do aleitamento materno em prematuros durante internação em um hospital amigo da criança de Ribeirão Preto-SP, Brasil. Ciência, Cuidado e Saúde. 2008;7(2):145-54.. This number drops substantially in the preterm population; other authors described a 22% prevalence of EBF by 6 months in premature babies, of which 33.3% were in mixed breastfeeding2020. Czechowski AE, Fujinaga CI. Seguimento ambulatorial de um grupo de prematuros e a prevalência do aleitamento na alta hospitalar e ao sexto mês de vida: contribuições da fonoaudiologia. Rev. Soc Bras de Fonoaudiol. 2010;15(4):527-7.. These numbers are below those found in this study.

This study probably found higher EBF percentages because the mothers/babies were followed up in an outpatient center and received guidance from the multiprofessional team. Almost all participants reported they had been instructed by both nutritionists and pediatricians at the outpatient center regarding CF introduction. Less than 1/4 of the sample had other foods introduced to their diets before 6 months CGA. Some authors found CF introduction to be associated with low maternal educational attainment and male babies1616. Cleary J, Dalton SMC, Harman A, Wright I. Prática atual na introdução de alimentos sólidos para bebês prematuros. Public Health Nutr. 2019;23(1):94-101.. In this regard, 79.2% of the mothers had a high school degree or incomplete higher education, which may have also contributed to the favorable EBF rates in the present study. Early weaning is associated with low educational attainment in the country and the early introduction of other types of milk or infant formulas2121. Alvarenga SC, Castro DS, Leite FMC, Brandão MAG, Zandonade E, Primo CC. Fatores que influenciam o desmame precoce. Rev. Aquichan. 2017;17(1):93-103.. However, other authors have reported many mothers with at least a high school degree who weaned early2222. Brandt GP, Britto AMA, Leite CCP, Marin LG. Fatores associados ao aleitamento materno exclusivo em maternidade hospitalar de referência no parto humanizado. Rev Bras Ginecol Obstet. 2021;43(2):91-6..

The literature demonstrates the importance of a plan involving mothers/babies and the multidisciplinary team on different healthcare levels to effectively promote and follow up breastfeeding after hospital discharge since discontinuing it too early is rather common1818. Lima KMS, Santos JMJ, Oliveira NTB, Machado GCC, Leite AML. Possíveis motivações para o desmame precoce entre mães adolescentes. 2º Congresso Internacional de Enfermagem. 12º de setembro de 2019;1(1). Available at: https://eventos.set.edu.br/cie/article/view/11367 .
https://eventos.set.edu.br/cie/article/v...
. The present study encompassed mothers/babies followed up at an outpatient center of a Child-Friendly Hospital, which may have been decisive to the quite positive breastfeeding rates.

The type of milk given to babies may be associated with feeding difficulties when CF is introduced. Some researchers addressed this issue and reported that food refusal occurred mainly in preterm newborns who were receiving formula2323. Menezes LVP, Steinberg C, Nóbrega AC. Complementary feeding in infants born prematurely. CoDAS. 2018;30(6):e20170157..

Regarding recommended consistencies and utensils, CF should be introduced by offering babies crushed or grated fruits and at least one main meal, with cereals or tubers, proteins, legumes, and vegetables. A spoon must be used, and the quantities must be gradually increased over time22. Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Nutrologia. Manual de Alimentação: orientações para alimentação do lactente ao adolescente, na escola, na gestante, na prevenção de doenças e segurança alimentar. 4ª ed. São Paulo: SBP; 2018. [accessed 2021 Aug 19]. Available at: https://edisciplinas.usp.br/mod/resource/view.php?id=3160985&forceview=1.
https://edisciplinas.usp.br/mod/resource...
. Most mothers in this sample gave their babies crushed fruits or vegetables with a spoon, as recommended by the Brazilian Society of Pediatrics and the Ministry of Health. Research conducted in Salvador, Brazil, revealed that all premature children who had CF introduced with liquidized foods had defensive behaviors, arching their bodies during the CF introduction process2424. Steinberg C, Menezes LVP, Nóbrega AC. Oral motor disorder and feeding difficulty during the introduction of complementary feeding in preterm infants. CoDAS. 2021;33(1):e20190070..

This study did not find any indications of poor eating habits. No mother reported giving their babies processed foods, with high levels of sugar, sodium, caffeine, and so forth. These foods are associated with the development of chronic diseases such as diabetes, obesity, and cardiovascular diseases22. Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Nutrologia. Manual de Alimentação: orientações para alimentação do lactente ao adolescente, na escola, na gestante, na prevenção de doenças e segurança alimentar. 4ª ed. São Paulo: SBP; 2018. [accessed 2021 Aug 19]. Available at: https://edisciplinas.usp.br/mod/resource/view.php?id=3160985&forceview=1.
https://edisciplinas.usp.br/mod/resource...
. A study conducted in Italy with late premature babies, with 34 to 36 weeks’ GA, showed that the first foods that more than half of them received had low nutritional values, although they needed foods rich in protein and energy to ensure this population’s adequate growth2525. Gianni ML, Bezze E, Colombo L, Rossetti C, Pesenti N, Roggero P et al. Práticas de alimentação complementar em uma coorte de bebês prematuros atrasados na Itália. Nutrients. 2018;10(12):1861.. In Belém, Brazil, children from 4 months CGA also received nonnutritive foods, with high levels of sugar, such as soft drinks, sandwich cookies, coffee, crackers, and chocolate milk2626. Marques RFSV, Sarni ROS, Santos FPC, Brito DMP. Práticas inadequadas da alimentação complementar em lactentes, residentes em Belém-PA. 2013. [accessed 2021 Nov 29]. Available at: http://files.bvs.br/upload/S/0101-5907/2013/v27n2/a3675.pdf.
http://files.bvs.br/upload/S/0101-5907/2...
.

The limitations of the study include the few participants, due to difficulties collecting data during the COVID-19 pandemic, and a possible information bias, with incomplete data on artificial nipple use - which the researcher could not discuss.

Conclusion

More than half of the premature children’s mothers, in this study, introduced CF at the recommended time, with adequate consistencies and utensils. Moreover, breastfeeding by 6 months CGA was considered successful. This is a vulnerable group that needs multiprofessional follow-up after hospital discharge to encourage breastfeeding and promote safe and healthy CF introduction.

REFERENCES

  • 1
    BRASIL. Ministério da Saúde. Cadernos de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2 ed. Brasília, DF, 2015.
  • 2
    Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Nutrologia. Manual de Alimentação: orientações para alimentação do lactente ao adolescente, na escola, na gestante, na prevenção de doenças e segurança alimentar. 4ª ed. São Paulo: SBP; 2018. [accessed 2021 Aug 19]. Available at: https://edisciplinas.usp.br/mod/resource/view.php?id=3160985&forceview=1
    » https://edisciplinas.usp.br/mod/resource/view.php?id=3160985&forceview=1
  • 3
    BRASIL. Ministério da Saúde Cadernos de Atenção Básica. Guia alimentar para crianças brasileiras menores de 2 anos. Brasília, DF, 2019.
  • 4
    Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento Científico de Neonatologia. Monitoramento do crescimento de RN pré-termos. 2017 [accessed 2019 May 25]. Available at: https://www.sbp.com.br/fileadmin/user_upload/2017/03/NeonatologiaMonitoramento-do-cresc-do-RN-pt-270117.pdf
    » https://www.sbp.com.br/fileadmin/user_upload/2017/03/NeonatologiaMonitoramento-do-cresc-do-RN-pt-270117.pdf
  • 5
    Vasconcelos TC, Barbosa DJ, Gomes MP. Fatores que interferem no aleitamento materno exclusivo durante os primeiros seis meses de vida do bebê. Rev. Pró-UniverSUS. 2020;11(1):80- 7.
  • 6
    Moraes AS, Aguiar RS. Dificuldades com a amamentação de recém-nascidos prematuros após a alta hospitalar: uma revisão integrativa. Rev. JRG de estudos acadêmicos. 2021;4(8):252-63.
  • 7
    Sociedade Brasileira de Pediatria [homepage on the internet]. Departamento de Científico de Neonatologia. Seguimento ambulatorial do prematuro de risco. 1ª edição. 2012. [accessed 2019 Nov 3]. Available at: https://www.sbp.com.br/fileadmin/user_upload/pdfs/seguimento_prematuro_ok.pdf
    » https://www.sbp.com.br/fileadmin/user_upload/pdfs/seguimento_prematuro_ok.pdf
  • 8
    Pagliaro CL, Buhler KEB, Ibidi SM, Limongi SCO. Dietary transition difficulties in preterm infants: critical literature review. Jornal de Pediatria. 2016;92(1):7-14.
  • 9
    Baldassare ME, Di Mauro A, Pedico A, Rizzo V, Capozza M, Meneghin F. Tempo de desmame em bebês prematuros: uma auditoria de pediatras da atenção primária italiana. Nutrients. 2018;10(5):616.
  • 10
    Liotto N, Cresi F, Beghetti I, Roggero P, Menis C, Corvaglia L et al. Alimentação complementar em bebês prematuros: uma revisão sistemática. Nutrients. 2020;12(6):1843.
  • 11
    Gupta S, Agarwal R, Aggarwal KC, Chellani H, Duggal A, Arya S. Alimentação complementar aos 4 versus 6 meses de idade para bebês prematuros nascidos com menos de 34 semanas de gestação: um estudo randomizado, aberto e multicêntrico. Lancet Glob. Health. 2017;5(5):e501.
  • 12
    Foote KD, Marriott L. Weaning of infants. Arch Dis Child. 2003;88:488-92.
  • 13
    Castro AG, Lima MC, Aquino RR, Eeickmann SH. Desenvolvimento do sistema sensório motor oral e motor global em lactentes pré-termo. Pró-Fono Rev. Atual. Cientif. 2007;19(1):29-38.
  • 14
    Perilo TVC. Tratado do especialista em cuidado materno-infantil com enfoque em amamentação. Belo Horizonte. Mame bem. Editora METHA. 2019.
  • 15
    Jesus LMR, Basso CSD, Castuglioni L, Monserrat AL, Arroyo MAS. Speech-language-hearing follow-up of preterm children: feeding and neuropsychomotor performance. Rev. CEFAC. 2020;22(4):e15119.
  • 16
    Cleary J, Dalton SMC, Harman A, Wright I. Prática atual na introdução de alimentos sólidos para bebês prematuros. Public Health Nutr. 2019;23(1):94-101.
  • 17
    Brusco TR, Delgado SE. Characterization of the feeding development of preterm infants between three and twelve months. Rev. CEFAC. 2014;16(3):917-28.
  • 18
    Lima KMS, Santos JMJ, Oliveira NTB, Machado GCC, Leite AML. Possíveis motivações para o desmame precoce entre mães adolescentes. 2º Congresso Internacional de Enfermagem. 12º de setembro de 2019;1(1). Available at: https://eventos.set.edu.br/cie/article/view/11367 .
    » https://eventos.set.edu.br/cie/article/view/11367
  • 19
    Scochi CGS, Ferreira FY, Góes FSN, Fujinaga CI, Ferecini GM, Leite AM. Alimentação láctea e prevalência do aleitamento materno em prematuros durante internação em um hospital amigo da criança de Ribeirão Preto-SP, Brasil. Ciência, Cuidado e Saúde. 2008;7(2):145-54.
  • 20
    Czechowski AE, Fujinaga CI. Seguimento ambulatorial de um grupo de prematuros e a prevalência do aleitamento na alta hospitalar e ao sexto mês de vida: contribuições da fonoaudiologia. Rev. Soc Bras de Fonoaudiol. 2010;15(4):527-7.
  • 21
    Alvarenga SC, Castro DS, Leite FMC, Brandão MAG, Zandonade E, Primo CC. Fatores que influenciam o desmame precoce. Rev. Aquichan. 2017;17(1):93-103.
  • 22
    Brandt GP, Britto AMA, Leite CCP, Marin LG. Fatores associados ao aleitamento materno exclusivo em maternidade hospitalar de referência no parto humanizado. Rev Bras Ginecol Obstet. 2021;43(2):91-6.
  • 23
    Menezes LVP, Steinberg C, Nóbrega AC. Complementary feeding in infants born prematurely. CoDAS. 2018;30(6):e20170157.
  • 24
    Steinberg C, Menezes LVP, Nóbrega AC. Oral motor disorder and feeding difficulty during the introduction of complementary feeding in preterm infants. CoDAS. 2021;33(1):e20190070.
  • 25
    Gianni ML, Bezze E, Colombo L, Rossetti C, Pesenti N, Roggero P et al. Práticas de alimentação complementar em uma coorte de bebês prematuros atrasados na Itália. Nutrients. 2018;10(12):1861.
  • 26
    Marques RFSV, Sarni ROS, Santos FPC, Brito DMP. Práticas inadequadas da alimentação complementar em lactentes, residentes em Belém-PA. 2013. [accessed 2021 Nov 29]. Available at: http://files.bvs.br/upload/S/0101-5907/2013/v27n2/a3675.pdf
    » http://files.bvs.br/upload/S/0101-5907/2013/v27n2/a3675.pdf

Publication Dates

  • Publication in this collection
    21 Nov 2022
  • Date of issue
    2022

History

  • Received
    06 July 2022
  • Accepted
    04 Oct 2022
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