BREASTFEEDING KNOWLEDGE AND PRACTICE OF HEALTH PROFESSIONALS IN PUBLIC HEALTH CARE SERVICES

This study evaluated breastfeeding knowledge and practice of professionals who care for infants at health care services in a city in the interior of São Paulo, Brazil. This epidemiological study was carried out with a population of 89 nurses and physicians. Their answers to a structured questionnaire were analyzed in total and by place of work through the test for difference between proportions (Chi-square) with the level of significance at p<0.05. Data analysis was performed according to the Ministry of Health recommendations. The significant differences found for knowledge and practice, according to place of work, were restricted to certain aspects. Results of average scores were slightly better for professionals from the basic care units. Regular and poor performance were found in different studied aspects regardless of place of work, which suggest that potential educational interventions in this subject should include professionals at all levels of health care.


INTRODUCTION
Breastfeeding is essential ton infants' health and quality of life, presenting advantages to infants and the other subjects involved with this practice (1) .
Despite the current tendency to increase the period of breastfeeding, in Brazil this practice is far from what has been recommended: exclusive breastfeeding (EB) in children's first six months of life and complemented by other foods until two years of age or more (1) . .
On the other hand, receiving effective, professional or lay support during breastfeeding is associated with its success.Several international and Brazilian studies have shown this positive influence (3-  5)   .A study carried out in Botucatu, SP, Brazil between 1995 and 2004 pointed to this relationship.It showed that the best results in the average duration of EB (increase of 82%) and breastfeeding (increase of 50.9%) in the period were related to the creation of the Human Milk Bank, to the implementation of Family Health Units and the increased number of health professionals involved with breastfeeding in the city (6) .
We proposed this study considering the importance of breastfeeding, its still limited duration and the influence of health professionals in its prevalence.The study's general objective was to evaluate the knowledge and practice related to breastfeeding for professionals who care for infants in the public health service in Botucatu, in the interior of São Paulo, Brazil.We also sought to identify potential differences, according to professionals' places of work: hospital facility or primary care service, aiming at developing educational interventions.

METHOD
This descriptive study in the field of health  (7) , adapted to meet the needs of this research and submitted to three experts in the area: two nurses and one nutritionist.These experts developed the answer sheet according to the Ministry of Health recommendations (8) .
To ensure anonymity during data collection, questionnaires were sent to the head nurses in the basic care units with no identification.After each professional filled out his/her own questionnaire, they put it in a sealed white envelope and returned it to the respective nurses.The researcher handed on the questionnaires to the participant professionals in the hospital facilities and they also returned questionnaires in a sealed white envelop to the researcher herself.
Variables related to the characterization of To analyze knowledge about breastfeeding, the following were investigated: knowledge about the

RESULTS
A brief characterization of the studied subjects revealed that the majority were nurses (61.8%), female (82%), between 25 and 35 years of age (44.9%), with up to 10 years since graduation (55.1%) and up to five years working in their current service (43.8%).
A little more than a third (34.8%) of the studied population knew three or more steps for breastfeeding success and the most cited step was: provide no artificial nipples to breastfeeding infants (Step 9) and the least mentioned: show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants (Step 5).
In regard to other studied variables addressing knowledge, there were generally good results in relation to the composition of breast milk and reasons to discontinue breastfeeding.For the remaining variables, one or more questions presented results that can be considered good, with the exception of proper latch on, whose results were below 80% and therefore were classified as average or poor.
The majority of the interviewees correctly indicated the duration of breastfeeding and EB: 92.1% and 83.1% respectively (Table 1).

Continue... Table 1 -Continuation
In regard to practices related to breastfeeding, good results were observed among the professionals in the question that advises against pacifiers (85.4%) and among those who work in basic care units on the question about their orientation regarding the advantages of breastfeeding (98%).
Average results were found in another question asked to all professionals: advise the maintenance of EB when the mother has a job (77.5%) and in all questions asked to professionals working in the hospital facilities (Table 2).A statistically significant difference was found in the health professionals' knowledge regarding breastfeeding according to place of work on the issue of the frequency of feedings, only on the question that proposed that full term newborns should breastfeed every three hours.There was also significant difference when factors related to low milk production where considered and the most significant reason reported to immediately offer formulas was the absence of the letdown reflex on the 3 rd day postpartum.Professionals from the hospital facilities presented lower scores in all these situations (Table 3).The minimum and maximum scores varied little.Considering the average scores, the basic care units presented a slightly better result than hospital facilities but with no statistically significant difference.
The average scores revealed a regular performance in both cases, (Table 5).

DISCUSSION
The In regard to knowledge, we verified that almost half of the professionals were not able to report any of the Ten Step to Breastfeeding Success.
Considering that this subject is familiar to workers from hospital facilities (1) , we can affirm that the percentage of deficient knowledge was high.In a previous study, carried out in the same city, approximately 70% of professionals from maternity care facilities reported knowledge of the Ten Steps (9) .
Step 9 was the most cited and refers to the improper use of pacifiers and artificial nipples as they may lead to less frequent feedings, diminished stimulation and withdrawal of breast milk, leading to lower milk production and consequent weaning (10) .
The physiology of lactation shows, among other aspects, the importance of periodic sucking for milk production.Therefore, in the event mother and child should be temporarily separated, actions should be implemented to maintain lactation, though Step  Regarding questions related to low levels of milk production, the professionals' performance was good when questions addressed the supply of other liquids and foods.However, their performance was regular when questions addressed less important aspects such as those related to milking in excess, feeding babies during the night or short feedings and maternal nutrition.These aspects are relevant because according to the Ministry of Health, among the main causes of hypogalactia are the offering of other foods and drinks, short, hurried and non-frequent feedings and discontinuing feedings at night (8) .
A slight slowdown in weight gain is not a reason to immediately offer formula, since this can sometimes be observed in healthy breastfeeding babies (11) , though the performance of professionals was only regular on this question.
In the analysis of knowledge about hygiene and breast trauma, the results were good and regular.
The breastfeeding clinical management requires proper breast hygiene to avoid complications such as breast trauma and mastitis.In a study carried out in Botucatu, SP, Brazil, the report about difficulties with breastfeeding was associated with the discontinuing of EB in infants younger than four months (12) .
Despite the high frequency of correct answers to questions about the duration of breastfeeding and EB, the obtained results were considered unsatisfactory because of the relevance of this knowledge to the practice and especially because official and scientific recommendations have been established and widely and continually disseminated for several years (1) .
The analysis of practices related to breastfeeding revealed good performance of professionals in the question about advising against the use of pacifiers.Even though government initiatives control, discourage and even prohibit publicity and use of rubber nipples in maternities, its use is still very frequent among Brazilian children.
This fact might be related to representations people hold in relation to pacifiers, among others, that it symbolizes the child and soothes the baby, facilitating the mothers' work (13) .
Although all participants agreed that the mothers' professional occupation is not a reason to offering formula, professionals presented a regular response to the newborn's stimuli, the body position of mother/child and proper sucking (14) .
The analysis by place of work of knowledge and practices scores regarding breastfeeding evidenced significant differences, especially concerning: knowledge related to the frequency of feedings of full term babies; supply of liquids to babies as a factor related to low milk production; absence of letdown reflex on the 3 rd day postpartum justifying the supply of formulas; and when questions addressed practices about providing orientation to mothers to avoid the use of pacifiers.The performance of basic care units was better than that observed in hospital facilities in all cases.
study included professionals working in public health services, both in hospitals and basic care units in Botucatu, SP, Brazil, and allowed us to obtain a broad perspective of their knowledge a n d p r a c t i c e i n b r e a s t f e e d i n g .A d h e r e n c e o f professionals was high since only 4.7% of losses occurred due to the absence of professionals who were on vacation or leave.However, biases due to q u e s t i o n n a i r e ' s s e l f -a p p l i c a t i o n c a n n o t b e discarded.We highlight that the use of a detailed instrument that was previously validated was important because the obtained results can help in the planning of future educational actions in the city.
performance regarding orientation about how to maintain breastfeeding in such situations.The evaluation of practices of professionals working in the basic health service was good in relation to questions addressing the advantages of breastfeeding and regular in relation to questions addressing the need to observe feedings and care for breast trauma.Observing feedings and being attentive to the maternal posture and to the newborn's latch on can provide important support to health professionals about the risks of early weaning.In regard to trauma, even taking into account that the results of knowledge were good for the majority of questions, in practice, only 71.4% of the professionals addressed this subject in the majority of consultations.There still are professionals who test babies' sucking capacity with glucose serum among those who work in hospital facilities despite evidence indicating that it compromises breastfeeding.There are also those who prescribe formula for newborns with no problems whatsoever and only half of professionals allow mothers to initiate early breastfeeding in the majority of deliveries.A study aiming to categorize the group of mothers/newborns with a special need to have support to experience a successful breastfeeding beginning and also verify care practices associated with breastfeeding, indicates that the use of formulas and glucose serum was associated with the worst scores when it evaluated the following:

Table 1 -
Expected answers and frequency of correct answers concerning breastfeeding knowledge of health professionals who care for infants.Botucatu,

Table 2 -
Expected answers and frequency of

Table 3 -
Frequency of correct answers to questions related to breastfeeding knowledge of professionals who care for infants according to the level of health care: hospital (n=40) and basic care (n=49).Botucatu, SP,

Table 4 -
Frequency of correct answers related to breastfeeding practices of professionals who care for infants, according to the level of care: hospital (n=40) and basic care (n=49).Botucatu, SP, Brazil 2007