FACTORS ASSOCI ATED W I TH EXCLUSI VE BREASTFEEDI NG I N
CHI LDREN UNDER FOUR MONTHS OLD I N BOTUCATU-SP, BRAZI L
Mar ia Ant oniet a de Bar r os Leit e Car v alhaes1 Cr ist ina Mar ia Gar cia de Lim a Par ada1 Mar ilene Plácido da Cost a2
Car valhaes MABL, Parada CMGL, Cost a MP. Fact or s associat ed w it h exclusiv e br east feeding in childr en under four m ont hs old in Bot ucat u- SP, Brazil. Rev Lat ino- am Enfer m agem 2007 j aneir o- fever eir o; 15( 1) : 62- 9.
Th is st u dy aim ed t o iden t ify fact or s associat ed w it h ex clu siv e br east feedin g ( AME) an d t h e r eason s m ot hers present ed t o int roduce com plem ent ary feeding in t he first four m ont hs of life. A t ot al of 380 m ot hers ( 92. 2% ) of childr en under four m ont hs old v accinat ed in a Mult i- v accinat ion Cam paign w er e int er v iew ed. To ident ify fact ors associat ed t o AME, univariat e and m ult iple logist ic regressions analyses were perform ed. Thirt y-eight per cent of t he childr en w er e on AME; 3 3 . 4 % consum ed cow m ilk ; 2 9 . 2 % t ea; and 2 2 . 4 % w at er . The m ot hers j ust ified int roduct ion of cow m ilk by fact ors relat ed t o quant it y/ qualit y of m at ernal m ilk and “ necessit y” of t he child. The use of a pacifier ( odds rat io= 2.63; CI 95% = 1.7- 4.06) and difficult y t o breast feed ( odds rat io= 1.57; CI 95% = 1.02- 2.41) w er e associat ed w it h t he absence of AME. The populat ional at t r ibut able r isk per cent age for t he use of a pacifier was est im at ed at 46.8 % . Thus, m odifiable risk fact ors were associat ed wit h AME int errupt ion.
DESCRI PTORS: br east feeding; hum an m ilk ; w eaning; r isk fact or s
FACTORES ASOCI ADOS A LA SI TUACI ÓN DE LACTANCI A MATERNA
EXCLUSI VA EN NI ÑOS MENORES DE 4 MESES EN BOTUCATU- SP
El obj et iv o f u e iden t if icar f act or es asociados a la lact an cia m at er n a ex clu siv a ( AME) y los m ot iv os pr esent ados por las m adr es par a la int r oducción de alim ent os com plem ent ar es en los pr im er os 4 m eses de vida. Se les ent revist aron a 380 m adres ( 92,2% ) de niños m enores de 4 m eses vacunados en una Cam paña de Mult iv acunación. Par a ident ificación de los fact or es asociados a la sit uación del niño con r elación al AME, se r ealizar on análisis de r egr esión logíst icas univ ar iadas y m últ iplas. En AME est aba el 3 8 , 0 % de los niños; el 33,4% consum ía leche de vaca; el 29,2% t é y el 22,4% agua. Las m adres j ust ificaron la int roducción de leche de v aca por fact or es r elat iv os con la cant idad/ calidad de la leche m at er na y “ necesidad” del niño. El uso de chupet e ( odds rat io= 2,63; I C95% = 1,7- 4,06) y relat o de dificult ad con la lact ancia ( odds rat io= 1,57; I C95% = 1,02-2,41) se asociaron a la ausencia de AME. El riesgo at ribuible poblacional asociado al uso de chupet e fue 46,8% . Así, fact or es m odificables fuer on ident ificados com o de r iesgo par a int er r upción de AME.
DESCRI PTORES: lact ancia m at er na; leche hum ana; dest et e; fact or es de r iesgo
FATORES ASSOCI ADOS À SI TUAÇÃO DO ALEI TAMENTO MATERNO
EXCLUSI VO EM CRI ANÇAS MENORES DE 4 MESES, EM BOTUCATU- SP
Ob j et iv ou - se id en t if icar f at or es associad os ao aleit am en t o m at er n o ex clu siv o ( AME) e os m ot iv os apr esen t ados pelas m ães par a a in t r odu ção de alim en t ação com plem en t ar n os pr im eir os 4 m eses de v ida. Fo r am en t r ev i st ad as 3 8 0 m ães ( 9 2 , 2 % ) d e cr i an ças m en o r es d e 4 m eses v aci n ad as em Cam p an h a d e Mult ivacinação. Para ident ificação dos fat ores associados à sit uação da criança em relação ao AME, realizaram -se an áli-ses d e r eg r essão log íst ica u n iv ar iad as e m ú lt ip las. Em AME, est av am 3 8 , 0 % d as cr ian ças; 3 3 , 4 % consum iram leit e de vaca; 29,2% , chás, e 22,4% , água. As m ães j ust ificaram a int rodução de leit e de vaca por fat or es r elat iv os à quant idade/ qualidade do leit e m at er no e “ necessidade” da cr iança. Uso de chupet a ( odds r at io= 2 , 6 3 ; I C9 5 % = 1 , 7 4 , 0 6 ) e r elat o de dificu ldade com a am am en t ação ( odds r at io= 1 , 5 7 ; I C9 5 % = 1 , 0 2 -2,41) associaram - se à ausência de AME. O risco at ribuível populacional associado ao uso de chupet a est im ado foi 46, 8% . Assim , fat or es m odificáv eis for am ident ificados com o de r isco par a int er r upção do AME.
DESCRI TORES: aleit am ent o m at er no; leit e hum ano; desm am e; fat or es de r isco
1
Ph D, Assi st an t Pr o f esso r, São Pau l o St at e Un i v er si t y Jú l i o d e Mesq u i t a Fi l h o at Bo t u cat u Med i cal Sch o o l , e- m ai l : car v al h a@f m b . u n esp . b r, cpar ada@fm b. unesp. br ; 2 RN
I NTRODUCTI ON
T
h er e is a u n iv er sal con sen su s ab ou t t h e fundam ent al im port ance of breast feeding for children’sa d e q u a t e g r o w t h a n d d e v e l o p m e n t a n d f o r t h e i r
p h y si ca l a n d m e n t a l h e a l t h . No a r t i f i ci a l f e e d i n g
f or m u la is cap ab le of q u alit at iv ely r ep lacin g b r east
m i l k , i t s sp eci f i c n u t r i en t s an d p r o t ect i o n ag ai n st
diseases ( 1).
I n r ecent decades, br east feeding pr om ot ion,
p r o t e c t i o n a n d s u p p o r t a c t i o n s h a v e b e e n
im plem ent ed as a st r at egy t o r educe child m or t alit y
a n d i m p r o v e c h i l d r e n ’ s h e a l t h . A s a r e s u l t ,
b r e a s t f e e d i n g r a t i o s h a v e e v o l v e d f a v o r a b l y.
Nevert heless, inadequat e pract ices, such as t he early
in t r odu ct ion of w at er, t eas, ot h er t y pes of m ilk an d
sem i- solid foods st ill cont inue, so t hat t he prevalence
of exclusive br east feeding r em ains far fr om desir able
levels ( 2- 4).
I n Bot ucat u- SP, where t his st udy was carried
ou t , on ly 1 9 . 1 % of ch ildr en u n der f ou r m on t h s old
r eceiv ed ex clu siv e b r east f eed in g ( EB) in 1 9 9 5( 3 ), a
proport ion t hat increased t o 22.6% in 1999( 4). Am ong
i n f a n t s u n d e r si x m o n t h s o l d , o n l y 1 3 . 0 % w e r e
ex clu siv ely br east fed, in cr easin g t o 1 6 . 5 % in 1 9 9 9 .
The sit uat ion in Bot ucat u is sim ilar t o t hat obser v ed
in ot her cit ies in São Paulo St at e: a st udy carried out
in 84 cit ies in 1998 evidenced prevalence rat es of EB
in in f an t s u n der f ou r m on t h s old ov er 2 0 % in on ly
32% of t hem ( 2).
St udies t o m onit or br east feeding levels have
been r ealized all ov er Br azil since t he m iddle of t he
1990’s, and analyses of det erm ining fact ors have been
pu blish ed. Socioecon om ic an d dem ogr aph ic f act or s,
as w ell as fact or s r elat ed t o healt h ser v ice pr act ices
a n d p r o f e s s i o n a l s h a v e b e e n a p p o i n t e d a s
d et er m i n an t f o r f eed i n g p r act i ces d u r i n g t h e f i r st
m ont hs of life( 2,5). However, t he large variat ion in even
geogr aphically close Br azilian cit ies’ EB r at es point s
t owards t he influence of t he local cont ext . Hence, st udy
r esult s about causes of EB abandonm ent in one sit e
c a n n o t b e g e n e r a l i z e d t o o t h e r s . Th i s j u s t i f i e s
r esear ch aim ed at u n der st an din g t h ese ph en om en a
in specific locat ions, as t hese r esult s ar e needed t o
bet t er define act ions aim ed at m odifying EB rat es and
assessin g in t er v en t ion s.
The aim of t his st udy w as t o ident ify fact ors
associat ed w it h t he absence of EB in childr en under
four m ont hs old in Bot ucat u- SP in 2004 and t he m ot ives
t h eir m ot h er s p r esen t ed t o in t r od u ce n on - n u t r it iv e
fluids, ot her t y pes of m ilk and com plem ent ar y foods
in t heir childr en’s feeding.
We decided t o st udy t he EB sit uat ion in infant s
under four m ont hs old, due t o t he fact t hat , unt il 2001,
t he ideal durat ion of exclusive breast feeding - four or
six m ont hs - was a source of polem ics ( 1).
METHOD
St udy Ty pe and Dat a Collect ion
We car r ied out a cr oss- sect ional st udy. Dat a
w er e ob t ain ed f r om t h e Nat ion al Mu lt i- v accin at ion
cam paign, an ev ent t hat at t ends a lar ge par t of t he
popu lat ion an d h as been w idely u sed in Br azil ov er
t h e last t en y ear s for epidem iological st u dies abou t
child healt h ( 2- 3).
Children under four m ont hs old were included,
who part icipat ed in t he first phase of t he 2004 Mult
i-v accin at ion Cam paign in Bot u cat u - SP, t oget h er w it h
t h eir m ot h er. Th is ch oice aim ed t o g u ar an t ee d at a
r eliabilit y, av oiding infor m ant s w ho w er e not fam iliar
wit h t he child’s feeding hist ory. I n t ot al, 412 children
under four m ont hs old cam e t o t he vaccinat ion unit s
during t his cam paign, and 380 m ot hers ( 92.2% ) were
int er v iew ed. This st udy is par t of t he “ Br east feeding
and Cit ies” proj ect , developed in various cit ies in São
Pau lo St at e in 2 0 0 4 , u n der t h e coor din at ion of t h e
St a t e Hea l t h Secr et a r y ’ s Hea l t h I n st i t u t e, a d d i n g
specific quest ions about t he abandonm ent of EB. The
au t h or s or g an ized d at a collect ion , su p er v ised an d
t r ained t he int er v iew er s and analy zed dat a.
EB Sit uat ion and Feeding Pr act ices
We adopt ed t he “st at us quo” m et hod, t hat is,
we exam ined t he food t he child consum ed on t he day
befor e t he int er v iew , w it hout r et r ospect iv e quest ions
a b o u t t h e m o m e n t w h e n d i f f e r e n t f o o d s w e r e
in t r od u ced . I n it ially, t h e m ot h er s an sw er ed sim p le
q u est ion s ( y es- n o) ab ou t w at er con su m p t ion ( p u r e
an d w it h su gar ) , t eas, fr u it j u ices, fr u it s ( pieces or
pu lp) , cow m ilk pow der, ot h er t y pes of cow ’s m ilk ,
ot her t y pes of m ilk , por r idge ( w it h m ilk ) , m ush and
v eget able soup w it h or w it hout m eat and beans and
h om em ad e f ood .
We also ex am ined t he r easons t he m ot her s
alleged for having int roduced non- nut rit ive fluids and
in f lu en ce of p r of ession als, r elat iv es an d f r ien d s t o
adopt t h ese pr act ices an d t h e h elp t h ey r eceiv ed if
t hey had difficult ies t o st ar t br east feeding.
I n depen den t Var iables
The r esear ch v ar iables w er e select ed on t he
basis of lit er at ur e, because t hey ar e supposed t o be
f act or s cap ab le of in f lu en cin g ( y es- n o) t h e ch ild ’s
EB sit u at ion . Th ese f act or s w er e gr ou ped in block s
a c c o r d i n g t o h y p o t h e s e s a b o u t t h e o r d e r o f
p r e ce d e n ce i n w h i ch t h e y i n f l u e n ce t h e t y p e o f
b r e a s t f e e d i n g t h e c h i l d r e c e i v e s ( Fi g u r e 1 ) .
Socioecon om ic an d dem ogr aph ic fact or s ( edu cat ion ,
w or k - m at er nit y leav e and t he m ot her ’s w or k st at us
now aday s or dur ing pr egnancy - and m at er nal age)
w er e con sid er ed as t h e m ost d ist al d et er m in an t s,
w h i c h c a n a f f e c t a l l o t h e r l o w e r - r a n k f a c t o r s .
Obst et r ic and healt h car e- r elat ed fact or ( par it y, bir t h
p lace an d t y p e an d b ir t h w eig h t ) w er e con sid er ed
int er m ediar y fact or s t hat , in t ur n, can influence car e
pr act ices ( pacifier and bot t le use) and t he occur r ence
o f d i f f i c u l t i e s t o s t a r t b r e a s t f e e d i n g ( b r e a s t
engor gem ent , nipple cr ack s, m ast it is, nipple absence
or ot h er s) . Th e lat t er ar e pr ox im al det er m in an t s of
t he EB sit uat ion.
5QEKQGEQPQOKECPF&GOQITCRJKE(CEVQTU
x
/CVGTPCN GFWECVKQP NGXGN RTKOCT[ RTKOCT[ VQ KPEQORNGVG
UGEQPFCT[UGEQPFCT[CPF
x
/CVGTPCNCIG [GCTU
x
%WTTGPVLQD;GU0Q
x
9QTMFWTKPIRTGIPCPE[;GU0Q
x
/CVGTPKV[NGCXG;GU0Q
1DUVGVTKECPF*GCNVJ5GTXKEG4GNCVGF(CEVQTU
x
2CTKV[2TKOKRCTKV[;GU0Q
x
2NCEG
QH
DKTVJ
7PKXGTUKV[
*QURKVCN
*QURKVCN575
2TKXCVG#UUQEKCVGF*QURKVCN
x
$KTVJYGKIJV I
x
&GNKXGT[V[RG
%CTGRTCEVKEGUCPFDTGCUVHGGFKPIFKHHKEWNVKGU
x
$TGCUVHGGFKPIFKHHKEWNVKGU;GU0Q
x
2CEKHKGT;GU0Q
x
$QVVNG;GU0Q
'ZENWUKXG$TGCUVHGGFKPI;GU0Q
Figure 1 - Theoret ical m odel of EB sit uat ion det erm inant s in children under 4 m ont hs old
Depen den t Var iable
The dependent variable under st udy w as t he
ch ild ’s EB sit u at ion ( y es- n o) , d ef in ed as ex clu siv e
breast m ilk consum pt ion on t he day before t he st udy,
i n l i n e w i t h Wo r l d H e a l t h Or g a n i z a t i o n
r ecom m en d at ion s( 1 ).
Dat a An aly sis
Quest ionnair es w er e check ed and coded and
a dat abase was creat ed in Epi I nfo 6.0 soft ware, using
r e so u r ce s t h a t o n l y p e r m i t t e d t h e e n t r y o f d a t a
e st a b l i sh e d d u r i n g co d i n g . Fi l e co n si st e n cy w a s
dist r ibu t ion s in associat ed qu est ion s, cor r ect in g t h e
iden t if ied er r or s.
I nit ially, we verified which part of t he children
r eceiv ed each of t he food it em s under analy sis and
t h e p r ev alen ce of ch ild r en r eceiv in g EB. Nex t , w e
car r ied out a descr ipt iv e analy sis of t he r easons t he
m ot hers alleged for int roducing fluids or foods in t he
child’s feeding and t he or ient at ions t hey r eceiv ed t o
adopt t hese pr act ices.
To ident ify fact ors associat ed w it h t he child’s
EB sit uat ion, we perform ed logist ic regression analyses,
a d o p t i n g r e c o m m e n d e d p r o c e d u r e s f o r r a n k e d
an aly ses( 6 ). I n or d er t o id en t if y p ossib le con f u sion
fact ors of t he associat ions under st udy, variables t hat
present ed an associat ion wit h t he dependent variables
of less t h an 2 0 % in t h e u n iv ar iat e an aly ses w er e
i n cl u d ed i n t h e m u l t i v ar i at e an al y si s. I n i t i al l y, w e
included variables from t he first block ( socioeconom ic
and dem ogr aphic fact or s) . Var iables associat ed w it h
EB ( p< 0.20) were m aint ained in t he m odel as pot ent ial
co n f u si o n f a ct o r s f o r t h e o t h er b l o ck s. Th e sa m e
happened wit h fact ors from t he second block in relat ion
t o t h e t h i r d . Af t e r t h e a d j u st e d a n a l y se s, a 5 %
significance lev el w as adopt ed t o consider a fact as
associat ed wit h t he EB sit uat ion.
RESULTS
Thirt y- eight percent of t he children under four
m onths old were receiving EB and 85.0% were breastfed.
Cow’s m ilk or ot her t ypes of m ilk were consum ed by
33.4% , teas by 29.2% and water by 22.4% on the day
before t he research. Fruit , fruit j uice, porridge, m ush,
so u p a n d h o m e m a d e f o o d w e r e co n su m e d l e ss
frequent ly. These dat a are displayed in Table 1.
Table 1 - Fr equency of childr en under 4 m ont hs old
w h o con su m ed m at er n al m ilk , n on - n u t r it iv e f lu id s,
ot h er t y p es of m ilk an d solid or sem i- solid f ood s.
Bot ucat u/ SP, 2 0 0 4
Ta b l e 2 s h o w s t h e m o t i v e s t h e m o t h e r s
alleged for int r oducing non- nut r it iv e fluids and ot her
t y p es of m ilk in t o t h eir ch ild r en ’s f eed in g an d t h e
p r o f essi o n al s o r p er so n s w h o ad v i sed t h em w h en
int roducing t hese pract ices. I n t he case of wat er and
t ea, t he m ost fr equent m ot iv e w as consider ing t hat
t he child needed t his ( 34.1% and 38.7% respect ively) ,
t hat is, t hat t hese fluids w er e needed t o sat isfy t he
child’s “ need”, i.e. t hirst . The second m ost m ent ioned
m ot ive for t ea consum pt ion was cram ps. The m ot hers
m ainly j ust ified t he consum pt ion of ot her t ypes of m ilk
by reasons relat ed t o breast m ilk quant it y ( inexist ent ,
insufficient ) or qualit y ( weak) , as well as by at t endance
t o t he child’s “ need”, in t his case hunger.
B e t w e e n 7 0 % a n d 8 0 % o f t h e m o t h e r s
af f i r m ed t h at n o b o d y i n f l u en ced t h ei r d eci si o n t o
int roduce non- nut rit ive fluids or com plem ent ary foods
i n t o t h e i r ch i l d r e n ’ s f e e d i n g , a ssu m i n g t h e so l e
r esponsibilit y for t hese pr act ices. A sm all par t of t he
m ot hers m ent ioned it w as t he physician w ho advised
t h em t o in t r od u ce w at er ( 1 4 . 1 % ) or t eas ( 9 . 0 % ) ,
followed by relat ives ( 11.8% and 9.9% , respect ively) .
The offering of cow’s m ilk t o t he child m ainly happened
on t he physician’s advice ( 22.8% ) , wit h lit t le reference
t o r elat iv es ( 4. 7% ) .
Table 2 - Main m ot ives alleged by m ot hers t o int roduce
ot h er t y pes of m ilk an d n on - n u t r it iv e flu ids t o feed
t heir child under 4 m ont hs old and r efer r ed adv isor s
of t hese pract ices. Bot ucat u/ SP, 2004
Ta b l e 3 sh o w s t h e ch i l d r e n ’s d i st r i b u t i o n
according t o EB- relat ed fact ors from t he first , second
an d t h ir d b lock , as w ell as u n iv ar iat e an d m u lt ip le
l o g i st i c r e g r e ssi o n a n a l y si s r e su l t s. No n e o f t h e
s d o o f / s d i u l
F Yes No Noinformation
º
N % Nº % Nº %
k li m l a n r e t a
M 323 85,0 57 15,0 0 0 k li m r e h t
O 127 33,4 251 66,1 2 0,5 s
a e
T 111 29,2 256 67,4 13 3,4 r
e t a
W 85 22,4 292 76,8 3 0,8 h s u m d n a e g d i r r o
P 26 6,8 352 92,7 2 0,5 e c i u j t i u r
F 21 5,5 357 94,0 2 0,5 t
i u r
F 15 3,9 362 95,3 3 0,8 p
u o
S 9 2,4 367 96,6 4 1,0 d o o f e d a m e m o
H 2 0,5 367 96,6 11 2,9
s e v i t o M r e t a W ) 5 8 = n
( (nT=e1a1s1) O(tnh=er12m7)lik º
N % Nº % Nº %
) r e g n u h /t s r i h t ( t i d e d e e n d li h c e h
T 29 34.1 43 38.7 21 16.5 s p m a r c h t i w t n a f n
I - - 19 17.1 - -k li m e lt t il , k li m k a e w , p u d e i r d k li
M 10 11.8 5 4.5 48 37.8 n o it a c i d e m e t u li
D 5 5.9 1 0.9 - -k li m r e d w o p r o h s u m g n i k a
M 3 3.5 - - -
-t s a e r b d e t c e f n i , d e g r o g n e , d e k c a r
C - - - - 6 4.7
d e k r o w r e h t o
M - - - - 5 3.9
e c i o h c s 'r e h t o
M - - - - 3 2.4
r e h t o m e h t y b e k a t n i n o it a c i d e m r o n o it a z il a ti p s o
H - - - - 3 2.4
s r e s i v d A n a i c i s y h
P 12 14.1 10 9.0 29 22.8 e
s r u
N 1 1.2 1 0.9 1 0.8 s e v it a l e
R 10 11.8 11 9.9 6 4.7 s
r e h t
socioecon om ic, d em og r ap h ic, ob st et r ic an d h ealt h
-s e r v i c e r e l a t e d v a r i a b l e -s r e v e a l e d a -s i g n i f i c a n t
associat ion w it h t he child’s EB- sit uat ion in univ ar iat e
an aly ses. We fou n d an inv er se r elat ion bet w een EB
an d p acif ier u se ( p < 0 . 0 0 1 ) an d b et w een EB an d
cur r ent or ear lier br east feeding difficult ies ( p= 0.018)
Cu r r en t m at er n al j ob, m at er n al age an d pr im ipar it y
w er e ident ified as pot ent ial confusion fact or s for t he
effect of t hese pr ox im al v ar iables.
The adj ust ed analy ses show n in Table 3 did
not exert any significant effect on t he risk associat ed
w it h pacifier use. The adj ust ed odds r at io r em ained
sim ilar and quit e significant ( 2. 63; CI 95% = 1. 70
-4 . 0 6 ) . Th e associat ion bet w een h av in g ex per ien ced
or exper iencing br east feeding difficult ies and t he r isk
of not receiving EB also cont inued ( odds rat io = 1.57;
CI 95% = 1.02 - 2.41) , alt hough at a lower st at ist ical
sign if ican ce lev el.
s e i r o g e t a C / s e l b a i r a V g n i d e e f t s a e r B e v i s u l c x E R O s s o r
G CI95% p AdjOuRsted CI95% p
s e
Y No
N % N %
n o i t a c u d E -1 k c o l B
>secondary 59 41.0 92 40.0 1 - 0.784 - -y r a m i r
p 34 23.6 49 21.3 0.924 (0.54-1.60) - -y r a m i r p
< 51 35.4 89 38.7 1.119 (0.70-1.80) -
-b o j t n e r r u C o
N 140 95.9 215 91.9 1 - 0.132* - -s
e
Y 6 4.1 19 8.1 2.062 (0.80-5.30) -
-y c n a n g e r p g n i r u d k r o W o
N 76 52.1 126 53.8 1 - 0.737 - -s
e
Y 70 47.9 108 46.2 1.075 (0.71-1.63) -
-e v a e L y t i n r e t a
M 0.305
s e
Y 46 31.5 61 26.1 1 - -
-o
N 22 15.1 48 20.5 1.645 (0.87-3.10) - -y l p p a t o n s e o
D 78 53.4 125 53.4 1.208 (0.75-1.95) -
-e g a l a n r e t a M s r a e y 5 3 -| 0
2 107 73.3 169 72.2 1 - 0.188* - -+ d n a s r a e y 5
3 17 11.6 17 7.3 0.633 (0.31-1.30) - -s r a e y 0 2
< 22 15.1 48 20.5 1.381 (0.78-2.41) -
-y t i r a p i m i r P -2 k c o l B o
N 88 60.3 123 52.6 1 - 0.142* - -s
e
Y 58 39.7 111 47.4 1.369 (0.9-2.10) -
-l a t i p s o H h t r i B l a t i p s o H y t i s r e v i n
U 42 28.8 83 35.5 1 - 0.505 - -l a t i p s o H l a n o i g e
R 72 49.3 106 45.3 0.745 (0.46-1.21) - -. H e t a v i r P / . c o s s
A 25 17.1 32 13.7 0.648 (0.34-1.23) - -s
r e h t
O 7 4.8 13 5.6 0.902 (0.35-2.53) -
-e p y T y r e v il e D l a m r o
N 94 64.4 147 62.8 1 - 0.758 - -n o it c e s n a e r a s e
C 52 35.6 87 37.2 1.070 (0.70-1.65) -
-t h g i e W h t r i B
>2500g 135 92.5 215 91.9 1 - 0.837 - -g
0 0 5 2
< 11 7.5 19 8.1 1.085 (0.50-2.35) -
-g n i d e e f t s a e r b t r a t s y t l u c i f f i D -3 k c o l B o
N 75 53.6 94 40.9 1 - 0.018 1 - 0.041 s
e
Y 65 46.4 137 59.1 1.669 (1.09-2.60) 1.57** (1.02-2.41)
r e i f i c a P f o e s
U -
-o
N 89 61. 86 36.8 1 - 0.000 1 - 0.001 s
e
Y 57 39.0 148 63.2 2.687 (1.76-4.11) 2.63** (1.70-4.06)
Tab le 3 - Dist r ib u t ion of ch ild r en an d r esu lt s of log ist ic r eg r ession an aly ses accor d in g t o b lock 1 , 2 an d 3
var iables. Bot ucat u/ SP, 2 0 0 4
* select ed as pot ent ial confusion fact ors of subsequent blocks
* * analysis adj ust ed for current m at ernal j ob ( Yes, No) ; prim iparit y ( Yes, No) ; m at ernal age ( < 20 years, 20 t o 35 years; > = 35 years)
Table 4 evidences t hat 55.5% of t he m ot hers
m ent ioned br east pr oblem s, m ainly : nipple t r aum as
( 2 9 . 0 % ) an d b r east en g or g em en t ( 1 9 . 5 % ) . Healt h
pr of ession als an d t h e ch ild’s m at er n al gr an dm ot h er
w e r e i n d i c a t e d a s t h e m a i n h e l p e r s i n c a s e o f
24.2% , respect iv ely. I t st ands out t hat 23.2% of t he
m ot hers m ent ioned nobody helped t hem t o overcom e
t h ese p r ob lem s an d t h e sm all r ole of h u sb an d s or
par t ner s in t his suppor t m ode: 5.2% .
Table 4 - Dist r ibu t ion of m ot h er s of ch ildr en u n der
f o u r m o n t h s o l d a cco r d i n g t o cu r r e n t o r e a r l i e r
br east feeding difficult ies and per son or pr ofessionals
w ho helped t o solve t hem . Bot ucat u/ SP, 2004
sit uat ion: higher r isk of ear ly w eaning in childr en on
ar t ificial pacifier use t han in childr en using pacifier s
int er m it t ent ly or even occasionally, w hich suggest s a
causal r elat ion( 7).
Two hypot heses have been put up t o explain
t he process t hrough which using a pacifier negat ively
influences EB: it s use could lead t o lower breast feeding
frequency, t hus decreasing breast st im ulat ion and t he
consum pt ion of t he produced m ilk and, consequent ly,
m ilk pr odu ct ion . Mor eov er, t h e m ot h er s’ per cept ion
t hat t he child is hungry or t hat m ilk product ion is low
m akes t hem int roduce ot her fluids or t ypes of m ilk in
t he infant s’ feeding( 7). A recent st udy found t hat 73.1%
of childr en using a pacifier no longer r eceived EB by
t he end of t he second m ont h of life( 8).
Th e s e c o n d h y p o t h e s i s r e f e r s t o t h e
phenom enon called “ nipple confusion”, caused by t he
baby ’s ear ly cont act w it h ar t ificial nipples( 9).
No m at t er t he m echanism t hrough which t he
pacifier affect s exclusive breast feeding, m odifying t his
si t u a t i o n r ep r esen t s a co n si d er a b l e ch a l l en g e f o r
h ealt h pr of ession als in t h e cit y u n der an aly sis. Th e
popu lat ion at t r ibu t able r isk associat ed w it h pacif ier
use w as high: 46.8% , consider ing t he adj ust ed odds
r at io of 2 . 6 3 and t he fact t hat 5 4 % of t he childr en
under four m ont hs older w er e using a pacifier.
Pacif ier s t en d t o b e in clu d ed in t h e b ab y ’s
t r ousseau. This is a cult ur ally dissem inat ed pr act ice,
which at t ends t o t he m ot her’s need t o calm and com fort
t he child as well as t o represent her sym bolically. Healt h
p r o f e ssi o n a l s’ a p p r o a ch e s w h e n d i sco u r a g i n g ( o r
p r o h i b i t i n g ) i t s u se n e e d t o b e r e v i e w e d , a s t h e
argum ent s t hey adopt ( risk of im pairing breast feeding,
of fut ur e dent al pr oblem s and cont am inat ion) do not
reach t he essence of m ot hers’ m ot ivat ion( 10).
The fact t hat pr ev ent able pr oblem s of w
ell-k n ow n t r eat m en t , su ch as n ipple cr acell-k s an d br east
engor gem ent , w er e ident ified as r isk fact or s for t he
int er r upt ion of EB in childr en under four m ont hs old
ev id en ces f ailu r es in car e r ou t in es at local h ealt h
ser v ices and in t he suppor t sy st em for br east feeding
m ot her s, especially dur ing t he babies’ fir st w eek s of
life. Alt h ou gh t h e r isk associat ed w it h t h is fact or is
not very high ( 1.6) , t he populat ion at t ribut able risk is
considerable ( 26.9% ) , as 55.0% of t he m ot hers under
st u d y m e n t i o n e d t h e y h a d o r a r e h a v i n g b r e a st
p r ob lem s.
I t should be em phasized t hat t he m ot hers did
not frequent ly allege pacifier use and t he presence of
n ipple t r au m as or ot h er br east - r elat ed pr oblem s as
s e i t l u c i f f i
D No %
e n o
N 169 44.5
s a m u a r t e l p p i
N 110 29.0
t n e m e g r o g n e t s a e r
B 74 19.5
g n i d e e f t s a e r b e li h w n i a
P 4 1.0
e l p p i n d e t r e v n i r o t a l
F 4 1.0
s it it s a
M 3 0.8
s m e l b o r p r e h t
O 16 4.2
s r e p l e H y d o b o
N 49 23.2
s l a n o i s s e f o r p h tl a e
H 69 32.7
r e h t o m d n a r g l a n r e t a
M 51 24.2
s r o b h g i e n d n a s d n e i r f , s e v it a l e r r e h t
O 19 9.0
r e n t r a p r o d n a b s u
H 11 5.2
n o it a m r o f n i o
N 12 5.7
DI SCUSSI ON
The sm all differ ence bet w een t he pr evalence
of EB in t he children under four m ont hs old, included
in t his st udy because t hey par t icipat ed in t he Mult
i-v acci n at i o n Cam p a i g n t o g et h er w i t h t h ei r m o t h er
( 38.0% ) , and t he rat e found in t he group of vaccinat ed
infant s under four m ont hs old ( 36.9% ) suppor t s t he
populat ional r epr esent at iv eness of t hese r esult s.
Considering t hat only lit t le m ore t han one t hird
of t he children exclusively received breast m ilk on t he
day befor e t he v accinat ion cam paign, w hile 100% of
t hem should be in t his sit uat ion, it can be affirm ed t hat
a consider able par t of childr en fr om Bot ucat u in t his
age range are exposed t o an excessive disease burden
and t o growt h and developm ent dam age( 1- 2, 5).
On l y t w o p r o x i m a l f a c t o r s s i g n i f i c a n t l y
increased t he risk of t he child not receiving EB: pacifier
use ( odds r at io = 2.63; CI 95% = 1.70 - 4.06) and
pr oblem s t o st ar t br east feeding ( odds r at io = 1. 57;
CI 95% = 1.02 - 2.41) .
The ident ificat ion of t he pacifier use habit as
an im por t an t an d sign if ican t r isk f act or t o aban don
EB in children under four m ont hs old confirm s result s
f r om ear lier st u dies in ot h er Br azilian cit ies an d in
different count ries, appoint ing t he universally negat ive
role of t his care pract ice. Lit erat ure evidences a
m ot ives for int roducing cow’s m ilk int o t heir children’s
feeding. On t he opposit e, t he m ain m at ernal allegat ions
t o j ust ify t his pract ice were t he inadequat e quant it y or
qualit y of t he m ilk t hey produced. Lit erat ure has been
indicat ing t his observat ion for decades( 11- 12). Research
on causes of EB abandonm ent in childr en under six
m on t h s old h av e f ou n d t h e f ollow in g j u st if icat ion s:
“ weak m ilk”, “ lit t le m ilk”, “ m ilk dried up” and “ m ot her’s
insecurit y in view of t he baby’s crying”( 11,13) .
I t is k n ow n t h at in cap acit y t o b r east f eed ,
a ct u a l h y p o g a l a ct i a o r m i l k p r o d u ct i o n w i t h l o w
nut rit ional value are very rare sit uat ions( 5). Therefore,
t h e m ot h er s’ allegat ion s f ou n d in t h is st u dy do n ot
st an d as “ r eal” m ot iv es f or of f er in g ot h er t y p es of
m ilk t o t he infant , but only as per ceived m ot ives.
Ninet eent h- cent ur y hy gienist s int r oduced t he
“ w eak m ilk” concept int o Brazilian cult ure due t o t he
difficult y t o explain som e m ot hers’ failure t o breast feed.
The concept was rem arkably assim ilat ed and cont inues
unt il t oday. Specialist s hav e t r ied t o under st and t he
em o t i o n a l a n d cu l t u r a l p r o cesses a sso ci a t ed w i t h
percept ions of insufficient or weak m ilk( 5).
I t sh ou ld also be h igh ligh t ed t h at t h e m ain
r eason t o offer w at er and t eas t o t he br east feeding
infant s was t he idea t hat t he child needed t hese fluids,
i.e. t hat , in a way, t hese fluids were needed t o at t end
t o one of t he childr en’s phy siological needs ( t hir st ) .
However, int roducing t eas int o infant feeding has been
ident ified as a r isk fact or for ear ly w eaning and for
diar r h ea occu r r en ce, t h u s in cr easin g m or bidit y an d
m o r t al i t y r i sk s( 1 4 ), w h i ch ar e n eg at i v e ef f ect s t h e
m ot hers do not seem t o know about .
Besides t h ir st , t h e pr esen ce of cr am ps w as
t he second m ot iv e for t ea consum pt ion t he m ot her s
m ent ioned. Ther e ex ist s no pr oof of t he t her apeut ic
effect of t he m ain infusions offer ed t o br east feeding
in f an t . On t h e op p osit e, it is k n ow n t h at t eas can
negat ively int erfere in iron and zinc absorpt ion( 15) and
t hat sugar addit ion an alm ost univ er sal pr act ice
-e x p o s -e s t h -e c h i l d t o d i g -e s t i v -e p r o b l -e m s . I t s
adm in ist r at ion t h r ou gh a bot t le, an ot h er pr act ically
u n iv er sal p r act ice, p r ed isp oses t h e ch ild t o su ct ion
m ech an ism pr oblem s du r in g br east feedin g( 9 ).
Th e se r e se a r ch r e su l t s p o i n t s t o w a r d s a
difficult road ahead t o increase t he durat ion of EB in
B o t u c a t u - SP: f a c i n g s o l i d l y e s t a b l i s h e d c u l t u r a l
pract ices in t he populat ion, such as t he use of pacifiers
and t eas. However, in order t o avoid t he inappropriat e
st art of cow’s m ilk in t he infant s’ diet , t he course seem s
t o be v ar ied and w ell- k now n: t r aining pr ogr am s for
healt h professionals, including physicians, wit h a view
t o t h e s u p p o r t a n d c l i n i c a l m a n a g e m e n t o f
b r e a st f e e d i n g d i f f i cu l t i e s a n d t h e o r g a n i za t i o n o f
efficient car e r out ines t o r each m ot her s dur ing t heir
childr en’s fir st w eek s of life.
Finally, it should be asked t o what ext ent t he
lack of an associat ion bet ween t he child’s EB sit uat ion
and socioeconom ic, dem ographic and obst et ric fact ors,
result s t hat differ from lit erat ure( 2,11) and t he init ial st udy
hy pot heses, r epr esent a w eak point in t his r esear ch.
Al t h o u g h t h e se d i v e r g i n g r e su l t s ca n n o t b e f u l l y
explained, it is believed t hat t hey do not derive from
select ion bias, giv en t he high populat ion cov er age of
t h e ev en t ( Vaccin at ion Cam paign ) du r in g w h ich t h e
m o t h e r s a n d c h i l d r e n w e r e s e l e c t e d , t h e s m a l l
proport ion of losses ( 7.2% ) and t he sim ilar prevalence
of EB in t he t ot al group of vaccinat ed children under
four m ont hs old and t hose included in t his r esear ch
( v a cci n a t e d a n d a cco m p a n i e d b y t h e i r m o t h e r s) .
Hence, in t he cit y under st udy, proxim al det erm inant s
( car e behav ior s and coping w it h init ial br east feeding
difficult ies) seem t o exert a st ronger influence on t he
EB sit u at ion in in f an t s u n der f ou r m on t h s old t h an
socioeconom ic and dem ogr aphic aspect s.
Fu r t h er st u d i es ab o u t r i sk f act o r s f o r t h e
a b sen ce o f EB a n d r ea so n s f o r t h e i n a p p r o p r i a t e
o f f e r i n g o f f l u i d s a n d o t h e r t y p e s o f m i l k t o
b r e a st f e e d i n g i n f a n t s sh o u l d i n cl u d e a sp e ct s l i k e
v alues, feelings and m at er nal r epr esent at ions about
child car e and br east feeding. The use of qualit at iv e
r e s e a r c h m e t h o d s c a n i n c r e a s e t h e s e s t u d i e s ’
ex plan at or y capacit y.
Lo n g i t u d i n a l st u d i e s o n f e e d i n g p r a ct i ce s
during t he first m ont hs of life are also useful, as t hese
can p er m it t h e id en t if icat ion of t h e m om en t w h en
m ot her s st ar t t o consider int r oducing com plem ent ar y
f o o d s a n d a sso ci a t e d ci r cu m st a n ce s, a s w e l l a s
k n ow ledge abou t t h e ch r on ology of t h e associat ion
b et w een p acif ier u se, b r east f eed in g d if f icu lt ies an d
int er r upt ion of ex clusiv e br east feeding.
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