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Public Policy

Along the milky way

Guidance from health agents triples level of exclusive breastfeeding of babies

Pediatrician Sonia Bechara Coutinho breastfed her three children for a short time. She was hired by the Federal University of Pernambuco (UFPE) in 1978, soon after the birth of Renata, her oldest, and had no right to maternity leave. When the other two were born, she also did not manage to breastfeed them exclusively for more than a couple of weeks, because of the work at the hospital and at the university. But the brief experience of this gesture, a symbol of maternity perpetuated in the renaissance canvases of Madonnas with their bambini, did not reduce her motivation for investigating the benefits of maternal breastfeeding for the newborn. Nor did it allay her quest for ways of increasing the very low proportion – a mere 14% – of Brazilian women that offer their children just their mother’s milk for the first 6 months of life, as the World Health Organization (WHO) recommends.

After almost three decades of searching, Sonia arrived at a simple and cheap formula for stimulating breastfeeding: guidance by community health agents on home visits to the mothers of the newborn. The model is similar to the one adopted by the program for fighting malnutrition and infant mortality of the Pastoral da Criança [Children’s Ministry], a social organization linked to the Catholic Church. The UFPE’s program was implanted on an experimental basis over two years in four municipalities (Palmares, Joaquim Nabuco, Catende and Água Preta) from the Zona da Mata, in the hinterland of the state of Pernambuco, one of the poorest regions of the country. There, of each group of a thousand children, 77 die before completing 5 years of life. The program proved to be a success: it raised from 13% to 45% the proportion of women that exclusively breastfeed their children until the sixth month of life, according to an article published recently in the Lancet magazine.

The publishing of these results represents more than international recognition of the program: it is the consecration of the model for fighting infant malnutrition that the Pastoral da Criança has been using in the country for almost 20 years. In the 3,921 municipalities in which it acts, on average 76% of the mothers exclusively breastfeed their children until their fourth month in life, a far higher level than the average for the country. “The main difference is that in the Pastoral the work is done by volunteers”, says Nelson Arns Neumann, the assistant national coordinator of the Pastoral da Criança and son of its founder, the sanitarian doctor Zilda Arns Neumann.

The figures from the Pastoral and from the team from UFPE also prove that saving the lives of the newborn does not call for any hefty budget: the essential thing is to publicize the importance of exclusive maternal breastfeeding until the sixth month of the baby’s life. Sonia trained the health professionals from three maternity hospitals to give the first guidance on breastfeeding soon after the birth. As the mothers stay only two or three days as in-patients, Sonia also prepared five women living in the region to act as community agents and to visit periodically the 175 women who had been selected to come into the study.

In the ten visits made to each one of the mothers, the agents showed notions of breastfeeding that are included in a 40-page primer drawn up by the team from UFPE. Six months later, after almost 2 thousand visits, 45% of the mothers were continuing to feed their children just with the mother’s milk. In the control group, made up of 175 women from the region who had had a baby in the same period, but who did not receive educative visits, this proportion was only 13%.

“Without the support of Salvina, the community health agent who visited me, perhaps I wouldn’t have had the patience to breastfeed my daughter for a year and nine months”, says saleswoman Girlaine Patrícia Félix Lins, who took part in the study in 2001, when her daughter Ranyele was born.

Having concluded the work in Palmares, the team from UFPE obtained funding of about R$ 100 thousand from the United Nations Children’s Fund (Unicef) and from Rede Globo’s Criança Esperança [Child Hope] program, to train community agents from two of the six health districts of Recife. From then until now, 692 health agents have now received qualification for giving guidance on maternal breastfeeding. A preliminary survey done with 200 families is impressive: the level of exclusive breastfeeding until the 6th month of life reached 32% – a level four times higher than that previously seen (8%).

“This is a cheap way of saving lives”, says Sonia Coutinho, from UFPE. Training each agent comes out on average at R$ 150 and could easily be expanded to other towns, resorting to the network of 204 thousand community agents of the Ministry of Health’s Family Health Program, spread over 94% of the Brazilian municipalities. In a study published in 2003 in the Lancet, Gareth Jones, from Unicef, estimates that there would be a 13% reduction in infant mortality in the world if nine mothers of each group of ten were to give their children only their mother’s milk until the fifth month of life. In absolute figures, it means preventing the deaths of 1.3 million children a year under 5 years in age from infectious diseases like diarrheas and pneumonias.

Although the benefits of excusive maternal breastfeeding are known – both for the child, which develops the organism’s defenses better and runs less risk of becoming obese, and for the mother, who shows a lower probability of developing breast cancer -, what is necessary is to take this knowledge to the communities and to poor families, according to Nelson Arns Neumann, from the Pastoral da Criança. Furthermore, beliefs deep-rooted in the population have to be combated, like the one that maternal milk is weak or that infusions help to clean the baby’s intestines. In reality, the use of contaminated water in the preparation of infusions and fruit juices is one of the main causes of infections in the newborn.

Three surveys made by the Brazilian Institute of Geography and Statistics (IBGE) show that the situation in the country falls short of the ideal: 60% of the mothers breastfeed during the first month of life, but only 14% of them offer their children maternal milk exclusively until the sixth month.

Behind these percentages there is more than misinformation. In the first half of last century, the advertising campaigns of the dairy industry exalted the facilities brought about by powdered milk, such as the more active participation of the husbands in feeding and the possibility of women leaving the feeding of their children to the cares of nursemaid. Until the 1970’s, the pediatricians themselves did not think, and even today many do not think, that exclusive maternal breastfeeding during the first half year of life to be necessary. Often influenced by campaigns of the food industry, they would recommend women to supplement their children’s diet with a few kinds of powdered milk even before being six months old, a measure that today is seen as reprehensible.

Concern with the increase in infant mortality amongst the newborn led the WHO to draw up, in 1981, the International Code of Marketing of Breastmilk Substitutes, and Brazil to create the Brazilian Standard for the Marketing of Food for Suckling Children, in 1988. The objective was to inhibit advertising regarded as unethical, such as the distribution of free samples to physicians and nutritionists, besides granting material or financial stimuli to health professionals. But they are not always successful. In a survey with 90 health professionals from 30 Brazilian cities, Marina Ferreira Rea and Tereza Setsuko Toma, from the São Paulo Health Institute, found that this unethical behavior still prevailed.

Another factor helps one to understand the lack of stimulus for breastfeeding. “The first international recommendation for exclusive breastfeeding based on scientific studies, the Innocenti Declaration, arose in 1990”, Marina explains. One of the works that provided a basis for this recommendation was carried out in Pelotas, in Rio Grande do Sul, by epidemiologist César Victora, from the Federal University of Pelotas. As the coordinator of the biggest and longest study following up a population carried out in the developing countries – since 1982, his team has been evaluating the health of 6 thousand persons  -, Victora identified evidence that maternal breastfeeding protects the babies. Children that were being given other kinds of milk showed a risk four times greater of dying as a consequence of diarrhea and 1.6 times greater of death from pneumonia, compared with those just breastfed, according to results published in 1987 in the Lancet.

The mechanism by which maternal milk prevents the occurrence of diarrheas has been investigated in the last few years at the University of São Paulo (USP) by the teams of pediatrician Magda Carneiro-Sampaio and microbiologist Luiz Rachid Trabulsi, who died in May 2005. Both the milk produced in the first few days after the childbirth – the colostrum – and the mature milk are rich in immunoglobulin A, an antibody that prevents the Escherichia coli bacterium, one of the main causers of diarrhea, from adhering to the walls of the intestine and proliferating there. From a protein used by E. coli to adhere to the cells of the intestine – intimin -, the researchers developed an oral antidiarrheal vaccine that is now to be found at its initial stage of testing on humans.

In collaboration with researchers from the State University of Londrina and from  USP, Marly Vannuchi, Carlos Augusto Monteiro and Marina Rea compared the number of women who were exclusively breastfeeding their children before and after the implantation of the Children’s Friend Hospital Initiative in three maternity hospitals of Londrina, in Paraná. The title of Children’s Friend Hospital is granted to maternity hospitals that follow the ten pro-maternal breastfeeding steps.

While in hospital, the proportion of mothers who were exclusively breastfeeding their babies went up from 2% in 1994, before the implantation of the program, to 42% in 1998. At least half of the mothers gave their children maternal milk only during 45 days in 1998, while this same proportion of women were breastfeeding for only 12 days four years before. In Palmares, Neusa Marques, from UFPE, had observed even more unsatisfactory results before the beginning of the program of visiting the mothers of the newborn. Of the 364 women interviewed, not one had given maternal milk exclusively to her baby after leaving the hospital.  Made public in 2001, in Pediatrics, this work also shows that in the first week at home 80% of the women offered water or tea to the newborn, and 56% allowed the use of a pacifier.

“The training offered to the professionals of the maternity hospital is important, but it does not suffice”, comments Sonia Coutinho. “To maintain exclusive breastfeeding for longer, there has to be an investment in support at home.” And this support must not be restricted to guidance on how to hold the baby or when to feed it. “There also has to be a willingness to listen to the mothers’ doubts and fears”, says psychoanalyst Regina Orth de Aragão, president of the Brazilian Association for Studies about Babies. After the childbirth come the doubts. “Many mothers have a fear of not managing to breastfeed”, says Regina. “If they do not manage, they can feel guilty or think they are not good mothers”, adds pediatrician and psychiatrist Wagner Ranña, a professor from the Children’s Institute of the Faculty of Medicine at USP and of the Sedes Sapientae Institute.

Double the sugar
What is certain is that maternal milk is the best food for the newborn from the biochemical and physiological point of view. Human milk contains vitamins, minerals and proteins at adequate levels for completely meeting the nutritional needs of the child until the sixth month of life. In its composition, there is almost double the sugar and half the proteins of cow’s milk, besides an enzyme called lipase, which helps to digest the fats. It is the antibodies that the baby consumes by means of the maternal milk that give it immunological protection, while its defense system has not yet matured.

In partnership with the team of Ana Maria Segall Corrêa, from the State University of Campinas (Unicamp), Marina Rea analyzed the quantity of calories ingested by 118 children of less than 1 year old under four diets: the first group was given only maternal milk; the second would be taking maternal milk, water and infusions; the third was drinking maternal milk, other kinds of milk, water, infusions, fruit juices and solid foods; and the fourth was consuming just other kinds of milk, water, infusions, fruit juices and other foods. They found that only the babies fed exclusively with maternal milk were receiving the quantity of calories recommended by the WHO for developing countries. The others were ingesting from 30% to 50% more calories than suggested, increasing the risk of developing obesity and chronic-degenerative diseases in the course of their lives.

This calorie consumption profile is probably responsible for the difference in growth between the children who were given only maternal milk until the age of six months and those fed with powdered milk since birth. Amongst the children born in Pelotas, Victora found, in 1993, that those that were fed only with maternal milk grew and gained weight more quickly until around the third month. From then onwards, despite being healthy, they start developing at a slower pace.

As this pattern of growth is different from those children that are bottle-fed, until a very short time ago it used to be believed that maternal milk was insufficient for the development of the newborn – today, differently, it is believed that bottle-fed babies grow more quickly because they consume more calories than recommended. At the moment, Victora is working on the production of a new infant growth curve that should be disclosed this year by the WHO and become a new standard for pediatricians from all over the world.

The initial slower growth brought about by maternal milk does not, however, make unviable its recommendation for the newborn, even for the premature. The reason is not known, but the composition of maternal milk appears to produce benefic effects on development that last all through life. Victora’s team recently compared the performance at school 6 thousand children born in Pelotas in Pelotas em 1982 – about 60% of them had been fed with maternal milk and 30% were bottle-fed. Published in November in Acta Pediatrica, the results show that those who are given only maternal milk until the age of six months reach their 18th year with almost one year more of studies than the other adolescents, regardless of the socioeconomic level of the family or the level of schooling of their parents.