ABSTRACT

OBJECTIVES: to identify the sociodemographic, obstetric, and breastfeeding factors associated with early weaning in a human milk bank.
METHODS: data from maternal and child evaluation forms of women assisted at the human milk bank of the Federal University of Maranhão university hospital in 2016, 2017 and 2018 were compiled.
RESULTS: of the 1,276 forms evaluated, 1,275 (99.9%) had information about early weaning (outcome variable), which was identified in 30.6% of assisted pairs. The frequency of early weaning was higher among mothers who had already breastfed (169-31%) [p=0.0235, OR=4.03; CI95%=1.21-13.46] and among mothers who had "household" occupation (204-36%) [p<0.0001, OR=1.58, CI95%=1.24-2.00]. The other independent variables evaluated did not show significant association (p>0.05).
CONCLUSIONS: among the evaluated characteristics, only maternal occupation and previous breastfeeding experience were associated with early weaning.

Keywords: Breastfeeding, Weaning, Patient care continuity, Milk Bank, Health promotion

RESUMO

OBJETIVOS: avaliar a associação de variáveis sociodemográficas, obstétricas e de aleitamento materno com o desmame precoce em um banco de leite humano.
MÉTODOS: foram compilados dados das fichas de avaliação materno-infantil de mulheres atendidas no banco de leite humano do hospital universitário da Universidade Federal do Maranhão em 2016, 2017 e 2018.
RESULTADOS: das 1.276 fichas avaliadas, 1.275 (99,9%) tinham informações sobre desmame precoce (variável de desfecho), que foi identificado em 30,6% dos pares atendidos. A frequência de desmame precoce foi maior entre as mães que já amamentaram (169-31%) [p=0,0235, OR=4,03; IC95%=1,21-13,46] e entre aquelas que tinham ocupação "do lar" (204-36%) [p<0,0001, OR:1,58, IC95%=1,24-2,00]. As demais variáveis independentes avaliadas não apresentaram associação significativa (p>0,05).
CONCLUSÕES: entre as características avaliadas, apenas a ocupação da mãe e a experiência previa de amamentação associaram-se ao desmame precoce.

Palavras-chave: Aleitamento materno, Desmame, Continuidade da assistência ao paciente, Bancos de leite, Promoção da saúde

Introduction

Breastfeeding is a wise natural strategy for bonding, affection, protection and nutrition for the child, generating great impact on the promotion of integral health of the mother-child binomial and, consequently, reducing child and maternal morbidity and mortality.¹ In the history of science, there has never been so much knowledge available about the complex importance of breastfeeding for mothers and infants, which allows stating that breastfeeding can change the course of human life.² Breastfeeding is much more than nourishing the child, it is a process that involves deep interaction between mother and child, with repercussions on the nutritional status of the infant,³ on the ability to defend against infectious diseases,⁴ on cognitive and emotional development and on long-term health,⁵ on the prevention of otitis media⁶ and dental caries,⁷ in addition to having positive implications for the physical and mental health of the mother.¹

Early weaning is defined when the interruption of exclusive breastfeeding (EBF) is identified before the infant reaches the sixth month of life, with the introduction of other foods to complement breast milk.⁸

In the United States of America, four out of five live births (83.2%) start breastfeeding; however, only 25% of these are exclusively breastfed during the first six months of life, which is far below the at least 50% suggested by the World Health Organization (WHO).⁹ In the European Union, there are marked differences between countries with regard to EBF practices, corresponding to an average of 13% EBF up to six months of life, with lower prevalences in Greece (0.7%), Finland (1%) and the United Kingdom (1%); and higher in Slovakia (49.3%), Hungary (43.9%) and Georgia (54.8%).¹⁰ In low- and middle-income countries, only 37% of children under six months old are exclusively breastfed. With few exceptions, breastfeeding duration is shorter in high-income countries than in low- and middle-income ones.²

According to the National Child Food and Nutrition Study (ENANI),¹¹ the prevalence of EBF in Brazil is 45.7%, and 38% for the Northeastern region. In Brazil, this prevalence characterizes early weaning as an important public health problem.² It may occur because, among other factors, many mothers are unaware and/or have difficulties using the correct breastfeeding technique, leading to difficulties in sucking, nipple trauma and pain, emptying the breast with consequent reduction in milk production, culminating in the introduction of other foods earlier.¹² There are also reports of early weaning due to insufficient milk and the return to work/study,¹³ little encouragement from health professionals, in addition to "maternal knowledge deficit", "food beliefs and taboos", "use of pacifiers or bottles" and "influence of family members and friends" are classified as factors that are often not clearly seen by mothers, but which lead to early weaning.¹⁴

In order to maintain breastfeeding, the mother needs to receive support and help centered on her difficulties, with relevant information to provide peace of mind and make her feel more confident and good about herself and her child during breastfeeding.¹⁵ Thus, the importance of guidelines relevant to the breastfeeding process should still occur in the maternity ward, preventing early weaning and strengthening the affective bond of the mother-child binomial,¹⁶ with the support frombreastfeeding specialists, such as the team that makes up the human milk bank (HMB) of maternity wards.¹⁷

In addition, HMBs are sources of guidance regarding breast preparation for donation or breastfeeding, correct posture and grip, collection, sorting, classification, processing and distribution of lactic production by the donor lactating mother.¹⁸

The human milk bank of the maternal and child unit of the Federal University of Maranhão university hospital (BLH-HUUFMA) provides health services to infant and mother via the Unified Health System (SUS), on demand. Among other activities, BLH encourages EBF until the sixth month of life, guiding and helping mothers who have difficulties breastfeeding, in addition to encouraging mothers of premature infants to store their own milk during the hospitalization period in order to offer it pasteurized to her child. It also supplies pasteurized human milk to the neonatal intensive care unit of HUUFMA and, in this logic, there is an incentive to extend the breastfeeding period in lactating mothers who donate milk and have recently given birth at HUUFMA.

So far, no study characterizing the prevalence of breastfeeding and its determinants in São Luís-MA has been identified. In this context, the present study sought to evaluate the association of sociodemographic, obstetric and breastfeeding variables with the occurrence of early weaning in the HMB ofthis location.


Methods

This is an observational study of retrospective cohort type with quantitative approach carried out through the collection of data obtained from HMB registration spreadsheets of the HUUFMA maternal and child unit. The HMB was inaugurated in December 1999 and works to receiveindividuals who seek guidance and comfort about breastfeeding, in addition to providing pasteurized human milk to the neonatal intensive care unit of HUUFMA.

The study evaluated mother-infant binomials attended at the BLH-HUUFMA between January 2016 and December 2018 through the analysis of data from mother-infant registration forms of the Exclusive Breastfeeding Incentive Program. The forms are filled in at the first appointment; subsequently, the infant is monthly monitored for routine appointments until six months of life. Breastfeeding observation and the necessary corrections are performed in the first and subsequent appointments.

Forms that presented incomplete information regarding the records of evaluations of maternal body posture and newborn sucking were excluded, as well as forms with inaccurate, incorrect and pencil-marked data on spreadsheets, as they compromised data validity.

The study variables were grouped according to data referring to: a) maternal sociodemographic characteristics (age at the time of delivery, marital status, schooling, occupation, income, smoking habits and alcohol use); b) newborn characteristics (gender, breastfeeding in the delivery room, anthropometric measurements at birth); c) maternal obstetric and breastfeeding history (how many pregnancies, number of births, number of abortions, place and number of prenatal consultations, vaccination, intercurrence in pregnancy, guidance on breastfeeding during prenatal care, breastfeeding other children, receivingfamily support for breastfeeding, type of delivery); and d) breastfeeding observation regarding body posture and newborn sucking.

Categorical variables were described with absolute and relative frequencies. Quantitative variables were described as mean, standard deviation, median, minimum and maximum values. Subsequently, simple and multiple logistic regression models were used to analyze the association between independent variables and the outcome (early weaning). All variables with p<0.20 in the simple (raw) analyses were considered in the multiple regression model, and those with p≤0.05 remained in the final model, after adjustments for the other variables. The fit of the model was evaluated using the Akaike Information Criterion (AIC). Using regression models, crude and adjusted odds ratios with 95% confidence intervals were estimated. Analyses were performed using the R software, with 5%significance level.

The study project was submitted to the Ethics Research Committee (CEP) of HUUFMA, obtaining the respective opinion consubstantiated according to CAAE: 29667120.9.0000.5086.


Results

Between 2016 and 2018, 1,276 binomials (mothers-infant) were monitored, among which 1,275 (99.9%) mother-infant registration forms were included in the study as they met the inclusion and exclusion criteria defined in the study.

In Table 1, the maternal sociodemographic characteristics of evaluated forms are described. It was observed that, on average, mothers were 27.4 (6.9) years old, and the majority were in a consensual union, had "domestic" occupation, complete high school and received from one to three minimum wages. Regarding previous breastfeeding experience, most were primiparous, but of those who were not primiparous, most received family support to breastfeed their previous child.

 



Table 2 presents the characteristics of newborns monitored during the study period, in which it was observed that the average birth weight was 3,216.6 (501.4) kilos and that most were breastfed in the delivery room.

 



In the descriptive analyses of the characteristics of maternal obstetric and breastfeeding history, it was observed that 1,268 (99.4%) mothers received prenatal care, with 568 (44.6%) receiving prenatal care at the HUUFMA's maternal and child unit. Still on the breastfeeding history, 635 (49.8%) and 1,065 (83.5%) of mothers reported they had received guidance on breastfeeding during prenatal care and in the maternity ward,respectively. As for obstetric history, it was observed that 654 (51.3%) deliveries were vaginal; and, on average, mothers had 7.2 prenatal consultations, ranging from zero to 20 (Table 3).

 



In the descriptive analysis of the breastfeeding observation regarding body posture and newborn sucking, it was observed that 390 (30.6%) newborns were weaned early. As for posture and grip, the most frequently observed distributions of posture variables were 901 (70.7%) observations of "slow and deep sucking, episodes and pauses", 916 (71.8%) "swallowing could be heard", 935 (73.3%) "round cheeks" and 1,002 (78.6%) "chin touching the breast". The least frequent postures were 553 (43.4%) "head and body aligned" and 600 (47.1%) "infant close, facing the breast" (Table 4).

 



From the results of simple and multiple logistic regression models used to analyze the association between independent variables and the outcome (early weaning), it was observed that the frequency of early weaning was higher among mothers who had already breastfed (169- 31%) [p=0.0235, OR=4.03; CI95%=1.21-13.46] and among mothers who were housewives (204-36%) [p=<0.0001, OR=1.58, CI95%=1.24-2.00]. The other independent variables evaluated did not present significant association (p>0.05) (Table 5).

 



Discussion

The frequency of early weaning found in the present study shows that the proportion of exclusively breastfed children (69.4%) is above the perspectives of breastfeeding for the 21^stcentury in low- and middle-income countries,² and weaning was only associated to maternal characteristics and antecedents among binomials monitored at HMB.

According to ENANI,¹¹ the prevalence of EBF in Brazil, in 2019, was 45.7%, with prevalence of 38% for the Northeastern region. In the present study, this value was significantly higher, probably because it was carried out in an important HMB which, through the Exclusive Breastfeeding Incentive Program, encourages exclusive breastfeeding up to the sixth month of life and seeks to extend the breastfeeding period in lactating mothers who are milk donors and who have recently given birth. The mother-infant binomial is monthly evaluated during the six months of EBF, with clinical evaluation, physical examination and breastfeeding observation during this period.

In this context, it could be inferred that the average EBF time in children was positively influenced in the population attended at BLH-HUUFMA. The Maternal and Child Unit of HUUFMA is a highly complex maternity hospital, a reference in the state of Maranhão, and BLH-HUUFMA is certified with a gold standard of excellence according to the Global Network of Human Milk Banks (RBLH-Fiocruz), in addition to offering important guidance that are valued and constitute one of the pillars of support of the Baby Friendly Hospital Initiative (BFHI).

Although the literature shows that early weaning may be associated with problems with the puerperal breast,¹⁶ the binomial position and the sucking adequacy during breastfeeding,^9,20,21 in this study, no significant association was observed between breastfeeding characteristics and the occurrence of early weaning. The close monitoringof the binomial during the six months, in addition to helping maternal difficulties, may have contributed to this important finding, either by the prompt correction of breastfeeding complications or by the actions developed that had a positive impact on the maintenance of breastfeeding and, consequently, in promoting maternal and child health.²²

Although prevalence of EBF higher than that recommended by WHO has been observed, it would be interesting to understand the reasons that lead to early weaning so that new interventions can be carried out in order to reduce this incidence. However, the reasons for early weaning is not part of the Clinical-Assistance Protocol of the Exclusive Breastfeeding Incentive Program, and, therefore, there is lack of specific data in this regard, representing a limitation of the present study. In addition, the current protocol has a passive perspective on the issue of guidance and education on breastfeeding, as it only guides mothers who seek the milk bank service; therefore, new approaches with a perspective of active search for these mothers, especially in prenatal care, can help to improve these limitations, since, as seen in this study, only 49% of mothers received breastfeeding guidelines during prenatal care.

As for maternal obstetric and breastfeeding history, only previous breastfeeding experience was associated with early weaning. Although primiparous women usually report greater breastfeeding difficulty in the postpartum period, which indicates deficiencies in the mother's guidance regarding breast preparation during pregnancy and early intervention in the postpartum period,²³ the finding of the present study highlights the efforts of the HMB team in the sense that they encouraged primiparous women to overcome these difficulties by maintaining EBF. In contrast, the knowledge that mothers who had more than one child stated that, despite not offering powdered milk, porridge or cornstarch to the first child, they did so to the others.²⁴ In addition, this study points to an important aspect to be taken into account by the team in approaches to experienced mothers in order to encourage them to maintain EBF despite the difficulties found.

The relationship between type of delivery, prenatal care and EBF is clear in literature, with strong evidence that vaginal delivery favors²⁵ and prolongs it,²⁶ and positively influences the early initiation of breastfeeding in the first hour of life.²⁷ Adequate prenatal care also favors EBF.²⁵ In this study, 51.3% of deliveries were vaginal, and 99% of mothers received prenatal care; however, these findings were not associated with early weaning, probably due to the already discussed positive impact of the actions developed at the HMB in promoting maternal and child health.²²

Among the sociodemographic factors evaluated, early weaning was significantly higher among housewives than among women with formal job, self-employed or students. Accordingly, Taveiro et al.,²⁸ pointed out that returning to work was not a determining factor for early weaning and discontinuing EBF. Other studies have also shown that there is higher prevalence of breastfeeding among working mothers,^29,30 pointing out that employment is not the main cause of weaning and that most workers use leave to breastfeed. In addition, other techniques are used to maintain breastfeeding when returning to work, such as, for example, the periodic breast milk collection during the working day,³⁰ which does not occur with "housewife" mothers who are submitted to an uninterrupted routine of care for the newborn and the house, often without adequate support.

Among evaluated characteristics, only mother's occupation and previous breastfeeding experience were associated with early weaning. The findings of the present study strengthen the importance of the HMB in supporting, protecting and encouraging EBF, given that many variables that could influence early weaning were nullified by the management and correct guidelines for breastfeeding by the established care protocol. Despite this, knowing the variables that influence early weaning under these controlled conditions of EBF management can lead to the rethinking of practices and approaches to mothers at home and those who have already breastfed other children, which, in this study, proved to be susceptible to early weaning.


References

1. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança: nutrição infantil: aleitamento materno e alimentação complementar. 2^nd ed. Brasília (DF): Ministério da Saúde; 2015. [access in 2021 jan 14]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/saude_crianca_aleitamento_materno_cab23.pdf

2. Victória CG, Barros AJD, França GVA, Bahl R, Rollins NC, Horton S, et al. Amamentação no século 21: epidemiologia, mecanismos, e efeitos ao longo da vida. Epidemiol Serv Saúde. 2016; 25 (1): 1-24.

3. Horta BL, Mola CL, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type-2 diabetes: systematic review and meta-analysis. Acta Paediatr. 2015; 104 (467): 30-7.

4. Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec; 104 (467): 3-13.

5. Horta BL, Mola CL, Victora CG. Breastfeeding and intelligence: systematic review and meta-analysis. Acta Paediatr. 2015 Dec; 104 (467): 14-9.

6. Bowatte G, Tham R, Allen KJ, Tan DJ, Lau M, Dai X, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec; 104 (467): 85-95.

7. Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau MX, Dai X, et al. Breastfeeding and the risk of dental caries: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec; 104 (467): 62-84.

8. Muniz MD. Benefícios do aleitamento materno para a puérpera e o neonato: a atuação da Equipe de Saúde da Família. Formiga /Minas Gerais. Braz J Health Rev. 2010; 4 (1): 1343-55.

9. Centers for Disease Control and Prevention (CDC). Breastfeeding Report Card [online]. United States: CDC; 2018. [access in 2021 jan 14]. Available from: ww.cdc.gov.breastfeeding

10. BagciBosi AT, Eriksen KG, Sobko T, Wijnhoven TM, Breda J. Breastfeeding practices and policies in WHO European Region Member States. Public Health Nutr. 2016 Mar; 19 (4): 753-64.

11. Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019): resultados preliminares-indicadores de aleitamento materno no Brasil. UFRJ: Rio de Janeiro; 2020. [access in 2021 jan 14]. Available from: https://enani.nutricao.ufrj.br/wp-content/uploads/2020/08/Relatorio-preliminar-AM-Site.pdf

12. Barbosa GEF, Silva VB, Pereira JM, Soares MS, Medeiros Filho RA, Pereira LB, et al. Dificuldades iniciais com a técnica da amamentação e fatores associados a problemas com a mama em puérperas. Rev Paul Pediatr. 2017; 35 (3): 265-72.

13. Pinto KCLR, Silva LFC, Ribeiro PS, Dias ERS, Silva BV. Prevalência do desmame precoce e suas principais causas. Braz J Health Rev. 2020; 3 (1): 717-28.

14. Lima APC, Nascimento DS, Martins MMF. A prática do aleitamento materno e os fatores que levam ao desmame precoce: uma revisão integrativa. J Health Biol Sci. 2018; 6 (2): 189-96.

15. Vieira AC, Costa AR, Gomes PG. Boas práticas em aleitamento materno: aplicação do formulário de observação e avaliação da mamada. Rev Soc Bras Enferm Ped. 2015 Jul; 15 (1): 13-20.

16. Barbosa GEF, Pereira JM, Soares MS, Pereira LB, Pinho L, Caldeira AP. Dificuldades iniciais com a técnica da mamada e impacto na duração do aleitamento materno exclusivo Rev Bras Saúde Matern. Infant. 2018; 18 (3): 527-37.

17. Morais TCEV, Souza TO, Vieira GO, Bessa Júnior J, De Jesus GM. Técnica de amamentar e a incidência de traumas mamilares em puérperas atendidas em um hospital municipal: estudo de intervenção Rev Bras Saúde Matern. Infant. 2020; 20 (3): 705-14.

18. Marchiori GRS, Alves VH, Rodrigues DP, Santos MV, Riker Branco MBL, Gabriel AD. Saberes sobre processo de enfermagem no banco de leite humano. Texto Contexto Enferm. 2018; 27 (2): e0390016.

19. Rocci E, Fernandes RAQ. Dificuldades no aleitamento materno e influência no desmame precoce. Rev Bras Enf. 2014; 67 (1): 22-7.

20. Coca KP, Gamba MA, Silva RS, Abrão ACFV. A posição de amamentar determina o aparecimento do trauma mamilar? Esc Enferm USP. 2009; 43 (2): 446-52.

21. Nascimento CS, Lemos JGSM, Valente AL, Mello PRB, De Luccia G. Dificuldades iniciais da amamentação na população atendida no ambulatório de amamentação do hospital universitário Júlio Muller. Rev Coorte. 2017; 7 (1): 18-31.

22. Fonseca RMS, Milagres LC, Franceschini SCC, Henriques BD. O papel do banco de leite humano na promoção da saúde materno infantil: uma revisão sistemática. Ciênc Saúde Colet. 2021 Jan; 26 (1): 309-18.

23. Fialho FA, Lopes AM, Dias IMAV, Salvador M. Fatores associados ao desmame precoce do aleitamento materno. Rev Cuid. 2014; 5 (1): 670-8.

24. Oliveira JS, Joventino ES, Dodt RCM, Veras JEGLF, Ximenes LB. Fatores associados ao desmame precoce entre multíparas. Rev Rene. 2010; 11 (4): 95-102.

25. Duarte J, Nelas P, Coutinho E, Chaves C, Amaral O, Dionísio Rui. Influência das características obstétricas e maternas na prevalência do aleitamento materno. Int J Dev Educ Psychol. 2019; 4 (1): 357-66.

26. Lanzaro C, Santos P, Guerra A, Pinto Hespanhol A, Esteves MJ. Prevalência do aleitamento materno: comparação entre uma população urbana e uma população rural do norte de Portugal. Act Pediatr Portuguesa. 2015; 46 (2): 101-8.

27. Mugadza G, Zvinavashe M, Felicity, Gumbo Z, Stray-Pedersen B, Haruzivishe C. Earley breastfeed initiation (EBFI) [online]. Int J Nurs Midwifery. 2016; 8 (10): 81-5.

28. Taveiro E, Vianna E, Pandolfi M. Adesão ao Aleitamento Materno Exclusivo em Bebês de 0 a 6 Meses Nascidos em um Hospital e Maternidade do Município de São Paulo. Rev. BrasCiênc Saúde. 2020; 24 (1): 71-82.

29. Ribeiro KV, Florentino CLV, Mariano DCA, Peres PLP, Rodrigues BMRD. A amamentação e o trabalho informal: a vivência de mães trabalhadoras. Rev Pró-Univer SUS. 2017; 8 (2): 3-9.

30. Steurer LM. Maternity Leave Length and Workplace Policies' Impact on the Sustainment of Breastfeeding: Global Perspectives. Public Health Nurs. 2017 May; 34 (3): 286-94.

Received on January 14, 2022
Final version presented on September 22, 2022
Approved on October 4, 2022

Associated Editor: Lygia Vanderlei

Authors' contribution: Conceição FOVA: study design, data collection, analysis and interpretation, review of the manuscript. Zanin L, Neto APA, and Pinheiro FS: data interpretation and manuscript review. Flório FM: study conception and design, analysis and interpretation of data, review of the manuscript. The authors approved the final version of the article and declare that there is no conflict of interest.