Clinical management of breastfeeding : knowledge of nurses

Objective: Discuss the knowledge of nurses in the clinical management of breastfeeding, so the benefits of breastfeeding on the health of women and children. Method: A descriptive, exploratory qualitative study conducted in public hospitals of Niterói with fifty-nine nurses working in obstetrics center, rooming and ward pregnant. Data were collected through semi-structured interviews and analyzed according to the construction of thematic categories. Results: Knowledge of nurses about the clinical management of breastfeeding, the result of an assistance expertise based on attitudes to support lactation involving women-nursing mother, the newborn and family. Conclusion: The technical and scientific knowledge it becomes very important because the strategies to promote breastfeeding in the clinical management of breastfeeding.


INTRODUCTION
Breastfeeding has different meanings, according to different cultures; Therefore, its care becomes a habit related to social determinants and cultural manifestations, and suffer influence of the same ideas and values shown in the woman's socialization process 1 .So, the following questions emerge: what is breastfeeding?What is the significance of lactation?Breastfeeding means to breastfeed, raise by the breast, lactate, feed, nourish.Lactation is a synonymous of breastfeeding, from the point of view of its definition, which has the same functional connotation of breastfeeding or raising the child with the milk it produces.Therefore, the meaning of both words isn't restricted purely to the biological aspect of the action; Instead, it goes beyond, in order to translate the emotions surrounding the woman's relationship with her child, family and the world around them 2 .
In a survey conducted by the Ministry of Health (MOH) in all state capitals and the Federal District, with total information about 34 366 children, it was found that the average time of breastfeeding as increased in the capitals and the Federal District, from 296 days in 1999 to 342 days in 2008.During the same period and places, the median duration of exclusive breastfeeding time reached 51.1 days (1.8 months), while the practice of breastfeeding was supplemented by other foods in 341.6 days (11.2 months) 3 .
The Ministry of Health recommends exclusive breastfeeding in children during their six months old, and to be supplemented by two years old.In this sense, there is a guarantee of full growth and healthy development of infants, and the nutritional values of breastmilk protection, and promote the emotional bonds between mother and child, contributing to the woman-mother's recover postpartum [4][5][6] .
In the last thirty years, Brazil has created actions to promote, protect and support breastfeeding, in order to increase the exclusive and complementary breastfeeding rates in the country and inhibit early weaning.These facts result from public policies such as the National Program to Encourage Breastfeeding (NPEB), created in 1981, which has been critical to the practice of breastfeeding 7 .
From this perspective, the National Policy of Breastfeeding (NPB) is organized according to the following strategies: Promotion of Breastfeeding in Basic Care -Breastfeed Brazil network; Baby Friendly Hospital Initiative (BFHI) and Kangaroo Care in hospital care; Brazilian Network of Human Milk Banks; Legal protection through the Brazilian Standard for Marketing of Baby Food (BSMBF); Actions of social mobilization through campaigns and partnerships; Monitoring of actions and breastfeeding practices and, in recent years, Friendly Breastfeed initiative at Basic units (FBIBU) 8,9 .
The clinical management of breastfeeding is understood as the actions and supportive care for the establishment of breastfeeding, milk production, treatment and prevention of diseases.This management approach results from the breastfeeding process, according to clinical competences and technical skills of the professionals involved 10 .Thus, it is possible to understand that management is not limited to guidance on breastfeeding, but encompasses a set of techniques that involves the understanding of physiology, anatomy, psychology and communication techniques.
Regarding the work of nurses in the context of the National Policy of Breastfeeding, they must be prepared to prevent, recognize and resolve difficulties in nurturing and child interaction, especially when it comes to breastfeeding, such as the helping identify obstacles to their successful practice.Therefore, it's mandatory to keep the eyes open at those needs of nurturing, during lactation in hospital stay, so that they can be identified early and resolved, avoiding early weaning or the beginning of the mains supplement while only exclusive breastfeeding is important.Thus, the clinical management of breastfeeding becomes necessary to deepen the practice of breastfeeding and, likewise, intervene directly by the nursing mother for her to be able to provide a healthy feeding to the newborn 11 .
In this context, the study aims at: Discussing the knowledge of nurses in the clinical management of breastfeeding, in the seek for the benefits of breastfeeding on the health of women and children.

METHOD
It is a descriptive, exploratory study with a qualitative approach, since we haven't aimed at quantifying data, but identify events that reflect on the knowledge of nurses in the clinical management of breastfeeding 12 .
The investigation was held after its consideration and approval by the Ethics Committee of the Medical School of the Universidad Federal Fluminense (UFF) and was approved under protocol number 190/2011, as foreseen in Resolution N. 196/96 of the National Health Council (CNS).
Study participants were fifty-nine nurses from public hospitals in the city of Niterói, based on the following inclusion criteria: working in group accommodation units, obstetric center, infirmary for pregnant women and neonatal unit in the Institutions previously mentioned.All they signed a consent form conditioned on their voluntary participation in the research, ensuring their anonymity and the confidentiality of information by use of an alpha-numeric code (E 1 ...E 59 ), which has met the requirements of Resolution CNS-196/96 already cited.
It was used as data collection technique an the individual semi-structured interview, based on a script composed by discursive and multiple-choice questions about the clinical management of the breastfeeding process of nursing mother 12 .The 32 questions were designed so that they could demonstrate the nurses' knowledge: what they understand as for the clinical management of breastfeeding, their importance to the mother and the baby, as they guide and show how to handle and better position for breastfeeding, as well as their knowledge in the management of major breastfeeding disorders, among others.The interviews took place in the period of June 2012 to Clinical management of breastfeeding Azevedo ARR, Alves VH, Souza RMP, Rodrigues DP, Branco MBLR, Cruz AFN June 2013, where they were initially recorded in a digital device with authorization of the participants.Later, the interviews were transcribed by the researchers and submitted to the respondents for validation of their testimony, prior to completion of the analysis of the collected material.
To analyze the data, we opted for the formulation of 12 thematic categories, verifying the registration units in which they arose from, thus enabling built them and enabling the discussion and the establishment of the view to achieving the objectives proposed in the study.From the methodological perspective, the following categories emerged: 1) the clinical management of breastfeeding from the perspective of nurses working in public hospitals; 2) The strategies used by nurses in the clinical management of breastfeeding.

The clinical management of breastfeeding from the perspective of nurses in public hospitals
The psychological, physiological, emotional and financial benefits of breastfeeding for the nursing mother were demonstrated in the statements of the participants.The factors mentioned by nurses consist of great importance, as currently these are less stressed because of the studies mainly focused on the benefits for the child.the importance is... she is feeling happy to be feeding her child and then many questions about health issues, the diminishment of postpartum bleeding, the fast gaining of weight, the body issue which is important to women, the reduction of breast cancer, which is something she isn't aware at that time.(E9)

She loses weight faster, increases the bond between mother and child, at no cost, the cost is zero, it is easier, it is more practical, it is more efficient, it's better in many different ways. Besides collaborating with the growth, and health. (E19)
Knowing the benefits of breastfeeding for the newborn is necessary for effective care.This information will be crucial for the counseling of the mother and family about the importance of the lactating practice.It is important to be up-to-date and to have scientific basis and thus provide current and correct information.

She has less food complications, and is less likely to have food allergy, diarrhea, I think she will develop better her speaking... the face muscles. (E6) It's all good. The mother's milk besides feeding him, it will give the baby with all the antibodies and the needs for all the vitamins and proteins. The milk changes as the baby ages, to fulfill all needs he will present throughout his life. (E13)
In the clinical management of breastfeeding, it is necessary that the nurse have technical and scientific knowledge of anatomy and physiology of lactation, suction, emotional and psychological factors that might interfere, and communication techniques, to guide them about proper positioning, manual extraction of breast milk and alternative forms of supplying of breast milk, other than through feeding bottles.
This baby has to be facing her, belly to belly, the baby has to be with his little head on the curve of her arm, looking at her.And then he will catch it.He has to pick up the biggest part of her areola so that he can, in fact, catch the breaks and feed himself well.(E4) I see it this way: the professional needs to have the knowledge of breast anatomy, the physiology part of the breast.They need to have the knowledge of the anatomical and physiological parts, the breastfeeding technique, the catching, the baby movements to catch the breasts, the positioning by the mother's breast.They need to be able to identify the breast, if it's turgid, flaccid, if the nipple is flat or half-plane, if it is reversed.They need to have the knowledge about the breasts… For the mother to have a good catch, it is necessary that she is well seated, reclining, with her back reclined.(E31) And it goes from us trying to teach this woman how the physiology of breastfeeding works, so she can understand it in a practical way.The we have to be adapting this guidance to the physiology particularities, and its functioning for the production of milk until it gets to the baby and from there we need to support them(...) not only guide, but also support the woman at the time of breastfeeding [..

.]. (E37)
Provide a quiet, comfortable place where the mother can perform manual extraction and even breastfeeding, facilitates the process of breastfeeding and conveys the confidence that the nurse is available to help her.
I even think that this room here was very convenient, because we already did the milking, massaging, all there in the infirmary.and everyone now and then someone would come in, the local wasn't convenient.I think this point is interesting because the person feels more at ease even to talk while she is helping us, it's the time she's here, free, expressing herself, because sometimes you do not know what's behind the difficulty she is going thought, that is whether breastfeeding or not.(E5) In first place, the mother's positioning has to be at a comfortable place so she can be able to hold the baby firmly.So she can feel well, so it isn't a painful moment for her who has just gone through childbirth.(E15)

Clinical management of breastfeeding
Azevedo ARR, Alves VH, Souza RMP, Rodrigues DP, Branco MBLR, Cruz AFN The study participants realize the importance of the nurses' performance in counseling about breastfeeding, and know that the information provided will be important even after hospitalization.This fact is explicit in their testimonies: It is indispensable in the area I work.You have to know, because it's the time when I will encourage this mother, I will ensure the best kind of feeding for that child.(E1) We see it as a simple act of ours, guidance, sometimes, just by hearing the handling, the aid itself, that breastfeeding becomes a success... stimulating, guiding, helping, aiding.And so on.Facilitating this mother to breastfeed more easily.(E4) The incorrect catch of the baby generates stress for the nursing mother and the baby, contributing to inefficient feedings, discouragement from the mother to continue breastfeeding and onset of breast complications.

What if he just gets the nipple, besides the possibility of cracking, he still does a good breastfeeding. (E4)
They hold the baby by their back and not the little head, between the head and the neck... in order to facilitate the handle of the little baby, and the little baby just failing to suck, then he get anxious, stressed, she starts crying and it`s difficult enough to handle.(E12) Given the exposed, it can be inferred that what has been expressed by the nurses with regard to the clinical management of breastfeeding, is a result of a technical assistance knowledge based on attitudes and practices to support breastfeeding involving the nursing mother, the newborn and the family, in order to ensure the safety of breastfeeding success.

The strategies used by nurses in the clinical management of breastfeeding
It is essential to have the domain of communication techniques so there is not only efficient exchange of information, but also empathy and trust between the professionals and the nursing mother, aspects that were indicated in the statements as strategies they use to provide good clinical management:

It is empathy, active listening... listening more than talking, giving back, that communication in which we do not use verbal communication, but looks, expressions, touches, positioning close to her. (E40) It's no use to guide them and realize the person is not listening to you! You have to have that empathy with them. It is the most complicated part of the orientation process, in my opinion. (E43)
Being available for the nursing mother when you notice that she is feeling some difficulty and being around when she needs are strategies used by professionals, and are also indispensable for the creation of her confidence in the care they receive.
I think it's the greatest strategy for the support and for the clinical management of breastfeeding, that is, patience and availability to be there next to that woman supporting and guiding her for breastfeeding.(E11) Verbal communication is one of the strategies most used by nurses as for the clinical management.Educating in health is a practice that accompanies the nurse: knowing how to articulate, listen, understand what this woman knows, see her as a subject, convey information and allow her to reflect and decide for what is best.

So this is the strategy I use, I come, talk to her, introduce myself and ask if she needs help, and how is the infant's relationship with her, and how the child's feeding is. (E3) Education. You have always to be informed. You can not just put the child by the mother's breast and say: It is good for children and good for you ...And show her that the moment she is breastfeeding, she will feel some cramping because her uterus is returning to its place. And that's important. The point is showing her that she has turgid breasts, and that she has to work to prevent this from happening, because this can affect breastfeeding. (E11)
Many nurses mention to be more successful when, beyond the verbal guidance, they use visual accessories.Showing "how it should be done", help in understanding what the professional wants to convey as a guide.

Guidance. Not only guide, you have to mime it, right, sometimes you only talk and don't do it, you have to talk and do. Make them, for example, pick up the baby, put her/him by the breast, articulate, you understand? Move along with her, bring her, "come here", "sit here", picks up a chair and stuff. And sometimes you're just talking, talking, talking and she can not do it, you have to sit down and put the baby's clothes on and off. And so you're able to make it happen. (E4)
The lack of illustrative materials such as brochures, pamphlets and audiovisual supplies, to assist these professionals in the clinical management of breastfeeding, is reported out in statements, making them use other strategies when they are acting in the units:

Here, the demonstration itself, how could I perform the milking, how breastfeeding is, it is practical, there's not audio visual strategy. (E5)
This same point of observing, of always guiding them, there isn't any other strategy at the time.There are no dolls or fake breasts, or anything.These lectures that happen are our observation, our support, the experiences of a mother to another one, we talk, we talk, discuss.We know they talk to each other all day, in the afternoon we bring up a topic and and make them exchange experiences stances among themselves.They already are in the infirmary, we get in there and promote all this discussion.(E13) The use of illustrative material greatly facilitate nurses to advise mother.By the way, the professionals working in units that have these resources, verbalize what are the most used:

I've already used one of those fake breast that have the alveolus to explain. I've taken the flip-chart from the Ministry as well. Recently we created a folder based on the Ministry's one. I've already gathered the mothers in the hallway of the accommodations, I was talking, guiding… I also show a mother who is breastfeeding correctly so the others can also see that they can, that they are able to breastfeed. (E10)
But usually there are folders, posters, fake breasts, devices, right?Which facilitates our works.It helps us better expose things for them.Using folders, devices, posters are strategies for sure.(E24) Thus, the clinical management of breastfeeding becomes necessary to change the reality for the promotion, protection and support of breastfeeding, and when done with the help of visually explanatory material, can contribute in a decisive way so that there's not early weaning.

DISCUSSION
The knowledge of physiological, biological, psychological, emotional and financial benefits of breastfeeding for the nursing mother, were demonstrated in the testimonies of nurses.These benefits constitute, in their physiological nature, the release of the hormone oxytocin which promotes uterine contraction, and it prevents a decrease in bleeding and also contributes for the uterine involution to occur more rapidly 13 .As for the biological benefits, human milk contains sufficient water; more adequate protein and fat for children, and vitamins in sufficient quantities, eliminating the use of vitamin supplements, thus protecting against allergies and infections, especially diarrhea, favoring the growth and development of children 14 .
In addition, there is the psychological and emotional benefits that the nursing mother-fetus relationship promotes in the woman's and the young kid's lives, which constitute imbricated value in the act of breastfeeding.It is inferred that this value corresponds to the experience of a living being, for the man is a valuable being that engaged in their existence.And as breastfeeding permeates this bond, it can be deduced that such affection is directly linked to sentimental value, because the nursing mother and child relationship is a unique experience, existing only in human beings, and come from the relationship that breastfeeding provides 3 .As for the financial benefits, milk brings with it a capable own value to supply all the needs of the fetus, making it unnecessary to buy food for him, which saves money for the nursing mother.Plus the fact that breastfeeding means preserving the health of the child, which is equal to any other important benefit.
The knowledge of the advantages of breastfeeding for the newborn becomes necessary for effective performance of nursing professionals in the clinical management of breastfeeding; it sets up an important practice, especially in counseling nursing mothers and family and answering questions about breastfeeding and its benefits in child health, and the prevention of food complications, food allergies 14 , and also in the development of facial muscles to ensure that the baby's speech will be better in the future 12 .In addition, there is the immunology protection function, through colostrum, acting against microorganisms since the first feeds 3,10,11,15 .
In the clinical management of breastfeeding, it is necessary technical and scientific knowledge by nurses in favor of interventions in complications and counseling for nursing mothers about breastfeeding practices, such as proper hold and position and also the manual extraction of milk.Thus, the knowledge about the anatomy and the physiology of the breast is a typical practice for the members of the nursing staff, who must have solid knowledge to interfere when necessary along with the nursing mother.This way, the clinical management of breastfeeding, the nurses must act directly towards the care of the breasts, watching both their hygiene as the time of feedings, making use of a simple and objective communication for the encouragement and support of breastfeeding 10,11,15 .
Regarding the position of the child during the act of breastfeeding, one should be facing the nursing mother, belly to belly; the lower lip of the newborn born should touch the nipple, and one must open their mouth naturally in search for food.In child's mouth should be placed the nipple and as much of the areola as possible.During breastfeeding, the child's lips are curled out in "fish mouth", occurring closure between the mouth and the mother's breast 4,8,10,11,15 .Thus, the nurses' knowledge on the correct positioning and catching must act directly in order to correct the erroneous practice in order to prevent future complications caused by breastfeeding.
The quiet and comfortable setting allows a better practice and facilitates manual breast milk extraction, to prevent interference and external interrupts, which also promotes the support and promotion of breastfeeding 16 , as well as counseling directed to nursing mothers about breastfeeding.That is because this is a Clinical management of breastfeeding Azevedo ARR, Alves VH, Souza RMP, Rodrigues DP, Branco MBLR, Cruz AFN way nurses can act and listen to the mothers they are caring for, trying to understand her and their expertise offers help to provide planning, decision-making and strengthening to deal with pressures, therefore increasing their self-confidence and self-esteem.So it is important that breastfeeding counseling is performed whenever possible during the prenatal home visits in the immediate postpartum period concurrently with the first feeding, during their stay in rooming at the time of hospital discharge and subsequent consultations for the promotion of breastfeeding 17,18 .
The orientation of the health care provider allows it to act by the nursing mother straight in the problems caused by breastfeeding, especially cracked nipples, breast engorgement and mastitis that, as a rule, are caused by the position and inadequate holding 3,10,11,14 .Thus, it is the nurse's duty to promote the correction of these problems as part of the effective care for the clinical management of breastfeeding.
The domain of communication techniques in the relationship with the nursing mother becomes indispensable, and it's one of the strategies used by nurses in the clinical management of breastfeeding.So, the active listening, the watchful eye, the tone and empathy favor the exchange in communication, leading to a more comprehensive and effective for the practice of breastfeeding.During counseling, the nurse acts as a link between the theoretical-scientific content and the practice that will be experienced by the mother, explaining the importance, the benefits of breastfeeding, demystifying beliefs and prejudices 10,11,17,18 .Another point used by nurses as strategy for the clinical management of breastfeeding is the creation of trust, i.e., offering their support as he needs to be close when the nursing mother needs their guidance and counseling for proper practice in breastfeeding.
The support for breastfeeding is an important practice of nurses for clinical management of breastfeeding, and favors the creation of the nursing-mother confidence, as their actions and guidance favor breastfeeding.In this sense, when the nurse answers questions and aids through difficulties, when they ask the nursing mothers to simulate the breastfeeding technique, and when they voice the importance of breastfeeding advantages, he gets the confidence of the 17 nursing mother and contributes to their confidence and self-esteem in regards to the practice of breastfeeding 18 .
Verbal communication is also a strategy used by nurses in this management.The verbal communication the one that uses words, and it's used by nurses to collect information, guide, enlighten and register.In fact, verbal communication composed the the technique for the promotion and support of breastfeeding.And by teaching them, nurses use both verbal communication and the demonstration, so that the message is understood 14 .In this context, verbal communication sets out the information about the care of breastfeeding, such as the advantages and benefits for the nursing mother and the newborn, but also alert to proper positioning and holding during breastfeeding.
In addition to verbal communication, nurses use visual aids for the promotion of breastfeeding and its better understanding.The nonverbal communication is the transmission of messages without using words that help the nurse to judge the reliability of verbal messages.In addition, non-verbal manifestations add meaning to what is being said in the verbal communication.So, by maintaining eye contact with the nursing mother, the nurse shows interest in the dialog, which may facilitate the more natural and detailed statement of guidance.So, in a certain way, they should have a heightened sensitivity to recognize the expressions people's eyes and, likewise show an affectionate or firm look, according to the moment, to encourage the support for breastfeeding 10 .
However, the shortage of audiovisual resources, folders and pamphlets, in the health units, is expressed as an obstacle to this strategy related to the clinical management of the breastfeeding.The use of these resources would be facilitators in counseling breastfeeding mothers by nurses, who should, therefore, make use of technologies in the context of promoting breastfeeding.It's important to mention that the inclusion of materials and audiovisual resources in health institutions must be effective and widespread, and for sure contributes to the promotion of population's health 10,11,16,17 .
It seems, therefore, that counseling, communication and information are nursing strategies in the clinical management of the breastfeeding.Besides that, the performance of these professionals is of great importance to the support and promotion of breastfeeding, allowing anyone to perform direct interventions in complications, doubts and fear of nursing mothers, thereby inhibiting early weaning.

CONCLUSION
Breastfeeding is not a simple process: it involves social, biological, psychological and cultural issues.Initially, one should respect the maternal wishes and decisions, however, it is the nurses' responsibility to guide them in order to ensure the best breastfeeding to the newborn.Thus, the clinical management of breastfeeding should be started even prenatally, during which the woman will already be able to understand the physiology of lactation, the benefits for herself and the baby during the breastfeeding, the intervals between feedings, the signs of hypoglycemia, allowing them to get on motherhood with this knowledge.If the guidance begins early, the interventions tend to decrease when breastfeeding is initiated.
The nurses, in this study, have technical and scientific knowledge regarding the clinical management of breastfeeding; so they make use of counseling about the benefits of breastfeeding for the nursing mother and her son, focusing on the positioning and appropriate holding during feedings, favoring it and the promotion and support of breastfeeding.They also use strategies such as verbal and non-verbal communication to demonstrate to nursing mothers, with the use of materials and audiovisual resources, important techniques for the promotion and support of breastfeeding.