Artigo Original
The demand for assistance from the nursing
staff in a human milk bank and its motivations
A procura por assistência da equipe de enfermagem em um
banco de leite humano e suas motivações
Cristiane Taís Antunes Neles Soares1, Maria Celestina Bonzanini Grazziotin2,
Adriana Maria Wan Stadnik3, Eduardo Borba Neves4
Abstract
A practice with a big impact on reducing child and maternal mortality, breast-feeding should be encouraged to promote
physical, mental, and emotional health to the child and mother. From this consideration, the central purpose of this study was
to investigate the reasons for women to seek assistance from nursing staff of a milk bank. The central objective is to seek
explanations for the complaints of mothers and it suggests ways to promote this practice among women, based on the idea
that the process of information, education, health promotion, and human interaction are part of the work of nursing staff. This is
a retrospective study, exploratory-descriptive, quantitative, and qualitative analysis performed by individual medical records
of women seen from January to December, 2009. We have identified 14 different categories of complaints in 380 consultations examined. The main reasons pointed out were: relief milking, mastitis, milk bank guidance and breast-feeding, breast
engorgement, and to get wrongly. It is suggested that beyond the technical issues of how to make, professional guidance
promotes human health, and the involvement of the nursing staff can be fundamental in the establishment and maintenance
of the practice of exclusive breast-feeding.
Keywords: milk, human; breast feeding; gift giving.
Resumo
Prática de grande impacto na redução da mortalidade infantil e materna, o aleitamento materno deve ser estimulado para
promoção da saúde física, mental e psíquica da criança e da nutriz. Partindo-se dessa consideração, o objetivo central
deste estudo foi verificar as razões que levaram mulheres a buscar a assistência da equipe de enfermagem de um banco de
leite. O referencial adotado, além de procurar explicações para as queixas das nutrizes, sugere formas de promoção dessa
prática entre as mulheres, partindo da ideia de que o processo de informação, educação, promoção da saúde e interação
humana fazem parte do trabalho da equipe de enfermagem. Trata-se de uma pesquisa retrospectiva, exploratório-descritiva,
quantiqualitativa, realizada pela análise das fichas de atendimento individual das mulheres atendidas de janeiro a dezembro
de 2009. Foram identificadas 14 diferentes categorias de queixas em 380 atendimentos analisados. Os principais motivos
levantados foram: ordenha de alívio, mastite, orientação sobre banco de leite e amamentação, ingurgitamento mamário e
pega errada. Sugere-se que, para além das questões técnicas de como fazer, haja orientação profissional em sentido à
promoção da saúde humana, e o envolvimento da equipe de enfermagem pode ser fundamental para o estabelecimento e
para a manutenção da prática do aleitamento materno exclusivo.
Palavras-chave: leite humano; aleitamento materno; doações.
Trabalho realizado na Universidade Tecnológica Federal do Paraná – Curitiba (PR), Brasil.
1
Enfermeira da Unidade de Saúde Augusta da Prefeitura Municipal de Curitiba – Curitiba (PR), Brasil.
2
Professora do Centro Universitário Campos de Andrade – Curitiba (PR), Brasil.
3
Professora do Departamento Acadêmico de Educação Física, campus Curitiba, Universidade Tecnológica Federal do Paraná (UTFPR) – Curitiba (PR), Brasil.
4
Professor do Programa de Pós-graduação em Engenharia Biomédica, campus Curitiba, UTFPR – Curitiba (PR), Brasil.
Endereço para correspondência: Eduardo Borba Neves – Rua Marquês do Paraná, 418 – apartamento 104 – Água Verde – CEP 80620-210 – Curitiba (PR),
Brasil – E-mail: [email protected].
Fonte de financiamento: nenhuma.
Conflito de interesses: nada a declarar.
Cad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33 327
Cristiane Taís Antunes Neles Soares, Maria Celestina Bonzanini Grazziotin, Adriana Maria Wan Stadnik, Eduardo Borba Neves
INTRODUCTION
Breast-feeding is a practice of great impact on reducing
infant and on maternal mortality and it should be encouraged
to promote the physical, mental, and emotional child and
mother health. Although scientifically proven its superiority over artificial formulas, exclusive maternal breast-feeding
(EMB) in Brazil is far from the levels agreed by the World
Health Organization (WHO) and the Ministry of Health
(MOH), and the trend to early weaning is still evident. The
WHO together with the United Nation Children’s Fund
(UNICEF) and the MOH recommend EMB for about six
months and maintenance of supplemented breast-feeding
by two years or more1,2. According to data from the Second
Survey of the Prevalence of Breast-feeding3, the average days
of EMB in state capitals in Brazil are only 54 days.
The same authors, Venâcio and Monteiro4, in another
study, compared national estimates of the frequency of
breast-feeding (regardless of the receipt of other foods) and
they observed an increasing trend of breast-feeding in Brazil between 1974 and 1989 – especially because in previous
decades breast-feeding was declining in the country –, with
its increasing median duration from 2.5 to 5.5 months. Importantly, this tendency was mainly seen in urban areas in
South-Central region of the country and among women of
higher income and education, highlighting the importance
and need for education, with more than just schooling, the
really crucial is access to information – that in our reality is
usually easier to those who have access to school education.
Breast-feeding strengthens the affective bond between
mother and son; provides nutrients and important immune
substances for growth and development of children. It also
provides benefits to the mother, family, and society from the
standpoint of biological, psychosocial, and environmental
fields5,6.
During the prenatal, pregnant women should be counseled on the benefits of breast-feeding for mother and baby.
Education and preparation in this period are the key element
to a successful breast-feeding, which should be initiated soon
after birth, in the first hours after childbirth, and breast milk
should be offered on free demand. While breast-feeding is
a natural process, unlike what happens to other mammals,
human breast-feeding is not an instinctive act – mother and
baby need support to learn how to and to breastfeed7.
Thus, remembering that learning is directly related to the
educational process, it becomes essential, which is highlighted
by the WHO as one of the criteria for a person to be considered healthy, the health knowledge and access to medical care,
in other words, health education and opportunity to have and
use infrastructure – human and material resources in health8.
328 Cad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33
At the same time, we believe that in addition to education,
there is need for adequate preparation for new social role as
mothers, or mother again.
Bear in mind that education is not a solitary act, it is a
society demand and, according to Ferreira9, it is the engine
of social transformation of individual predispositions, and it
ensures the adaptation of the individual belonging to a particular society and its social groups living together.
Health professionals have an important role in programs
of health education in prenatal care and the postpartum/
breast-feeding. To perform these functions, technical expertise, clinical skills, listening, supporting, and helping women
to make decisions on breast-feeding management are needed,
because the mothers need to be assisted and supported in
fulfilling their new role in society, women’s mother7,10.
One of the strategies of the National Breastfeeding Policy
for reducing child mortality, promoting, protecting, and supporting breast-feeding is the human milk bank (HMB), which
are specialized centers necessarily tied to a hospital of maternal/child health11. Mello et al.12 suggest that deep and lasting
changes will happen only if the healthy public policy operates
accordingly.
The HMB first appeared in Brazil in 1943, in the National
Institute of Pediatrics, now called Instituto Fernandes Figueira. From 1943 to 1985, the HMB had as its main objective
the collection and distribution of human milk to meet only
the special cases, such as prematurity, nutritional disorders,
and allergies to heterologous proteins, and it did not follow
clinical priorities nor worried with stimulating (for giving
encouragement) to the return to breast-feeding. Only since
1985, with the rupture of the original paradigm, there was a
real expansion in the number of HMBs11,13. Currently there
are approximately 199 HMB registered in the Brazilian Network of Human Milk Banks Network (HMB-BR), 28 in the
Southern region and 8 in the state of Paraná, all following the
laws (Board Resolution – RDC/ANVISA No. 171, September
2006), which regulate the operation11,14,15.
The actions performed by nurses in promoting and encouraging breast-feeding in milk banks go beyond technical
skills, because it must provide its customers the full nursing care in relation to physical, emotional, social, spiritual,
and cultural wellness. “You must keep up expanding their
technical, scientific and cultural benefit of customers, community and development of the profession, promoting and/or
facilitating technical development, scientific and cultural staff
under his guidance and supervision”, article 18 and 19 of the
Ethics Codes for Professional Nursing16.
According to Mello et al.12, professional skills in the areas
of health are no longer unique and autonomous, in that the
Nursing staff in a human milk bank
variety in competency intersects and articulates. For Fujimori
et al.17, who conducted a research on breast-feeding, it is necessary that health professionals know the aspects that hinder
or facilitate the establishment and maintenance of breastfeeding to guide actions.
Another example of the importance of health professionals’ education is seen in a survey developed by the MOH on
breast-feeding, in the State capitals and Federal District3, it
was found that the introduction of water, tea, juice, milk,
and other supplementary foods in infant feeding generally
occurred early, during which the researchers considered
the fundamental role of health professionals to reduce this
picture.
Despite efforts made towards education and promotion
of breast-feeding in Primary Care, Baby Friendly Hospitals
(in supporting the ten steps to successful breast-feeding) and
national initiatives, for example, the Breast-feeding Network
Brazil program, HMB are being sought by many mothers,
not only to make a donation, but as a source of help to solve
their difficulties in breast-feeding. Currently, milk banks are
no longer just a local collection and distribution to promote,
protect and support breast-feeding11,15.
The creation of HMB is now a global incentive and has
shown that human milk, milked and fed to the baby when
he/she is momentarily unable to receive it directly by sucking the breast has shortened the period of hospitalization of
premature infants, showing a good gain of weight and a more
rapid improvement of clinical frame11,18,19.
In the view of this and the dissemination of the activities
by HMB, through the media, aiming to raise donated breast
milk, many mothers with babies to term, without too much
milk for donation, had been looking for the HMB to receive
help practice of breast-feeding and to answer their questions.
Thus, this study aims at identifying the reasons for women to
seek assistance from the nursing team in a HMB in Curitiba
city, trying to understand also the role of health education
actions.
After evaluating the records of each call made and to
survey the main complaints, it will be possible to know,
within the researched reality, which aspects of breast-feeding,
scientific knowledge and pedagogical training are needed to
be trained or improved. Therefore, we hope to offer a quality service and to have results and a positive impact on the
prevalence of exclusive breast-feeding in the first six months
of life, which are the goals proposed by the WHO and MOH,
seeking to offer a collaboration from the standpoint of a study
beyond its descriptive and quantitative aspect. This is focused
in checking the reality and transforming it, when it is possible,
through the presentation of the results of research.
METHODOLOGY
This is a retrospective field, exploratory-descriptive, quantitative and qualitative study, carried out in the HMB of the
Clinical Hospital of Paraná, one of the reference centers in
breast-feeding, which serves the customers of Curitiba, the
areas nearby, and other metropolitan cities in the State of
Paraná. In the present study, the medical records of individual
nursing of pregnant and lactating women, who attended the
milk bank at the hospital, were selected and analyzed, from
January to December, 2009.
The individual medical records, standardized by the medical department, contained only the fields for the source of the
patient (internal or external at the hospital), age and central
complaint. For this study, all patients were selected from pregnant and lactating women outside, for a total sample of 380
attendances. The research project was submitted to the Ethics
Committee on Research of the Clinics Hospital of Paraná,
with protocol approval No 2278.172/2010-07.
Reasons that lead women to seek a hmb
The HMB at the Clinics Hospital of Paraná was initiated
in 1978 and became a reference in the State. This unit carries
out health promotion, protection, and support of breastfeeding and performs collection activities of human milk,
collecting on average 200 L of human milk per month20. In the
Milk Bank, the steps of selecting, sorting, processing, quality
controlling, and distributing donated milk are carried out to
meet the nutritional needs of preterm infants in hospital, to
provide them a better quality of life and to reduce the infant
mortality21,22.
The sample consisted of pregnant and lactating women
aged from 14 to 42 years, who sought care in the milk bank
at the Clinics Hospital of Curitiba, in 2009, obtaining a mean
age of 28.14 years-old. This study identified 14 different categories of complaints from a total of 380 visits made in 2009.
All women who sought the assistance of the nursing staff
were treated for aspects of guidance to health and the practice
maneuvers required for relief of main complaint by nursing
team, when necessary. Table 1 shows the frequency distribution of the main complaints.
Relief milking
In this study it was found that from the total attendance
of 380 women, 22.1% sought assistance for carrying out relief
milking, so this is the complaint that stood out with greater frequency. This happens due to a normal physiological response,
because the rapid influx of milk, swelling, vascular congestion, and lymphedema of the breast tissues, the physiological
process of milk letdown, the breasts may become painful, hot,
Cad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33 329
Cristiane Taís Antunes Neles Soares, Maria Celestina Bonzanini Grazziotin, Adriana Maria Wan Stadnik, Eduardo Borba Neves
Table 1. Frequency distribution of the main complaints of women who sought the milk bank in Curitiba, Paraná, in 2009
Main complaint
Relief milking
Mastitis – Pain (signs of inflammation)
Guidance on the human milk bank and breast-feeding
Breast engorgement
Takes the breast in a wrong way
Orientation about donation
Inhibition of lactation
Low production of human milk
Nipple injury
Milking-son to return to work
Twinning
Flat or inverted nipples
Lactose intolerance
Re-lactation
Total
and heavy. However, even with these characteristics, a nurse
targeted is capable of performing milking without difficulty to
hand press, but if this practice is not carried out effectively, it
will result in stasis of milk flow leading to complications, such
as breast engorgement23.
Importantly, when the baby cannot enter the nipple in the
mouth because the breast is too full, there is an excess of milk,
the baby is unable to drain both breasts at each feeding, and
their infants are unable to breast-feed (premature, weak or
sick), or breast-feeding women present conditions that would
contraindicate it, the mothers should be advised to do the
relief milking23.
Mastitis
The frequency of reported mastitis complaints by women
seen at HMB was 21.6%, with one of the highest rates. Mastitis
is characterized by an inflammation of one or more segments
of the breast (the most commonly affected is the upper left
quadrant), which may progress or not for a bacterial infection. Preventive measures are the same used in the breast
engorgement24. The puerperal mastitis is an acute infection
in the breast that affects from 2 to 6% of the breast-feeding
mothers, especially new ones23.
Mastitis usually occurs in the second and third weeks after
birth and rarely after the 12th week. The accumulated milk,
inflammatory response and tissue damage, such as cracks, allow entry of bacteria (the most common being Staphylococcus
aureus and albus, Escherichia coli and Streptococcus), favoring
the onset of infection. The flavor of milk is altered, becoming
saltier due to increased levels of sodium and decreased levels
of lactose, which can cause rejection of milk by infants. Maternal fatigue is also a risk factor for mastitis2. The breast with
330 Cad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33
Frequency
84
82
44
40
32
31
17
16
16
10
5
1
1
1
380
Percent
22,1
21,6
11,6
10,5
8,4
8,2
4,5
4,2
4,2
2,6
1,3
0,3
0,3
0,3
100
Cumulative percent
22,1
43,7
82,4
54,2
62,6
70,8
91,1
86,6
95,3
97,9
99,2
99,5
99,7
100
----
mastitis have heat, swelling, pain, hypersensitivity, increased
volume, induration, pus may develop into an abscess, fever,
malaise and chills25.
Guidance on breast-feeding and HMB
Of the 380 women who sought assistance from the milk
bank, 11.6% had doubts about the management of breastfeeding and would like guidance and clarification on the
criteria needed to become donors. According to ANVISA11,
healthy women who have lactic secretion superior to the requirements of their child and who are willing to donate the
surplus of their own free will are considered donors. According to Dias26, in a study conducted at University Hospital in
Maringá city in 2006, 14.6% of women had not received any
information from professionals about breast-feeding.
It is considered a fundamental educational work to promote human health, and it is composed with excellence part
of daily professional.
Going forward, in relation to breast-feeding, according
to Fujimori et al.17, even though health professionals are
maintained in the EMB to provide guidance in the first six
months of the baby, information is not enough, it is necessary
involvement.
It was found that everyday situations are specific to each
woman and depends on their experiences, with particular
need for quick service at the time of crises, which are more
common in the first days and weeks after delivery. Furthermore, more experienced people, usually family members,
have great influence on behavior related to breast-feeding,
especially for being with these women in their day-to-day.
It is understood that not enough women want to breastfeed and to have technical knowledge about it, so that the
Nursing staff in a human milk bank
practice is necessary to establish support within their peculiarities.
According to Tardif e Lessard27, the profession of nursing,
as many others in this line, is one of the most recognized professions as “social interaction”, which demand improvement
of human relations and the ways to dealing with the other that
is always a human being, in constant transformation and, usually, in care situation.
By this point of view, to understand and to get involved
with the patient is part of the profession and should be highly
valued.
Breast engorgement
From the population studied, 10.5% sought by the HMB
complained of breast engorgement. Breast engorgement is
characterized by congestion of the breast28 and can promote
the voltage of the areola and nipple flattening, damaging the
handle by the baby. It can be caused by a clogged duct, accumulation of milk and non-removing of dead cells by the
breast29. The predisposing factors are inadequate emptying
of the breasts and the inhibition of milk letdown reflex30.
The woman is at increased volume of the breasts, sensitivity
to touch, redness, pain, and may or may not have fever and
chills, and the milk does not flow easily. In prevention, Giugliani7 recommended to start breast-feeding as soon as possible,
on free demand, using the correct techniques.
According to a study conducted at the HMB from the
University Hospital of Londrina city, in 2005, from donated
breast milk, 65% had sought treatment at HMB by problems
related to breast-feeding, especially, breast engorgement, and
from this assistance becoming a donor31.
Breast engorgement (the fourth most frequently complaint in this study) is related to difficulties with the handling of the breasts during the lactation period, often due
to lack of guidance from professionals during prenatal care
in the hospital soon after birth, whose care would help prevent it. By knowing that this change is related to excessive
milk in the breast, the mother who has the problem should
become a donor of milk to HMB, if properly supported and
assisted.
Takes the breast in a wrong way
It was noted that 8.4% of women were receiving care for
incorrect way to maneuver the breasts. Breast-feeding should
not be a painful process, though most women feel a slight pain
or discount at the beginning of it, which is considered normal.
Nipple damage by improper positioning and way of touching
are one of the most common causes of pain in breast-feeding.
Very sore and hut nipples, though very common, they are
not normal. Therefore, to solve these problems, women
that are breast-feeding need support and guidance since its
initiation, because if these complaints are not resolved and/
or minimized, they could cause complications and result in
abandonment of breast-feeding24.
Guidance for donation
According to the survey, only 8.2% of pregnant women
and nursing mothers looked for the milk bank to resolve their
doubts concerning the donation of breast milk. According to
Felipe e Almeida18, in a survey conducted in the Public Maternity Hospital of the City of Rio de Janeiro in 2003, only
a percentage of 26.9% of mothers had been counseled on
donated breast milk for the HMB.
A study conducted in the milk bank at the University
Hospital of Londrina city, in 2005, showed that from the
donors interviewed 37.4% received clarification and information about donation and existence of HMB by health
professionals31.
Other complaints
The search for nipple injury complaints showed a level of
4.2% (Table 1) and it is known that this complaint is directly
related to management and may be incorrect. The percentage of complaints for flat or inverted nipples was 0.3%, as
shown in Table 1, and it is known that the type of nipple,
from the perspective of anatomy, has little influence on the
establishment and success of breast-feeding and it assumes a
secondary role in the determination of nipple trauma. Clearly,
the most common cause of pain during breast-feeding is the
nipple trauma by inadequate positioning and wrong way to
get the breasts.
The demand for assistance to inhibit lactation was 4.5%.
Inhibition of lactation or ablactation is a technique usually
adopted when it is necessary to stop milk production. It is
recommended for lactating women after death of baby or
neonatal to suppress lactation, to prevent vertical transmission of HIV and Hepatitis C, and when the infant has some
pathology that would contraindicate breast-feeding, such as
galactosemia32. The procedure for lactation inhibition is simple, it is made by milking of relief, if there is any excess milk,
apply cold compresses for about ten minutes, bandage up the
breast and guide to use tight bra and liquid restriction. The
use of drug to inhibit lactation is used only in special cases,
with medical prescription32,33.
The average age of women presented was of 28.14 years.
However, mothers who sought care for complaints of lactation inhibition obtained a significant increase, their average
age was of 32.15 years and it may also be related to the physiCad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33 331
Cristiane Taís Antunes Neles Soares, Maria Celestina Bonzanini Grazziotin, Adriana Maria Wan Stadnik, Eduardo Borba Neves
ological weaning, when the child is already in the ideal age
and the woman stops to produce milk, which prevents leaks.
For complaints of low milk production, there was a 4.2%
percentage. According to studies by Giugliani24 and Lana33,
diseases, such as breast engorgement, nipple trauma, mastitis
and low milk production, are important factors that may predispose to complications of lactation.
The demand for assistance from the milk bank for milk
to son, from returning to work had a frequency of 2.3 and
1.3% for twins. The percentage of mothers seeking care for
re-lactation was 0.3% and for guidance on lactose intolerance,
0.3%. These attendance figures are considered as natural since
it is known that health education, and in this case of new
mothers, is an ongoing process and should be performed by
professionals trained in the techniques of breast-feeding, in
order that these women have better chances of overcoming
problems and have higher rates of success in breast-feeding.
FINAL CONSIDERATIONS
This study revealed that the main reasons leading women
to seek the HMB – in order of visit frequency –, were: relief
milking, mastitis and guidance, both on breast-feeding, and
on donation, triggering the importance of work and educational information on health promotion. These situations are
susceptible of clarification in clinical prenatal and/or postpartum, which would provide information and involvement
beyond the technical and scientific knowledge.
Regarding other complaints, like child milking in order
to be able to return to work, it is obviously a social issue, only
raised but not discussed in this paper, which deserves further
studies. For flat or inverted nipples, lactose intolerance and
re-lactation were found to each of these complaints just a service, considering they should be cited, but in this study they
are not considered essential.
Once there are guidance and information, most questions
tends to improve the quality of the experience of breast-feeding.
It is essential that professionals who assist breast-feeding mothers appreciate not only the physical events and physiological,
but also psychological factors arising during breast-feeding. It
is up to health professionals, from primary to the hospital level,
to listen to complaints and problems reported by women, respect their individuality and inspire confidence so that they can
together solve the problems presented during breast-feeding.
It should be reminded that not enough women want to
breast-feed and have technical knowledge about it, so that the
practice established is necessary to support within their peculiarities and that all health professionals must comply with
this educational and informative role.
Information collected in this study is useful for planning
strategies at all levels of care. It is recommended continuous
education to help promoting, protecting, and supporting
breast-feeding in order, objectively, that the health professional knows the problems that can arise from breast-feeding
and offer reliable guidance for the mother and baby to help
them solve their problems.
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Recebido em: 23/02/2011
Aprovado em: 21/07/2011
Cad. Saúde Colet., 2011, Rio de Janeiro, 19 (3): 327-33 333