promotion of breastfeeding on primary education: integrative ......marly javorski4, cleide maria...

ReviewArticle

Rev.Eletr.Enf.[Internet].2016[cited__/__/__];18:e1198.Availablefrom:http://dx.doi.org/10.5216/ree.v18.40682.

Promotionofbreastfeedingonprimaryeducation:integrativereview

FernandaDemuttiPimpãoMartins1,LucianaPedrosaLeal2,TatianeGomesGuedes3,

MarlyJavorski4,CleideMariaPontes5

ABSTRACT

Thisstudyaimstoanalyzetheapproachesonbreastfeedingpromotion

inprimaryeducation.ThisisanintegrativereviewcarriedoutonBVS,

PUBMED,SCOPUS,CINAHL,COCHRANEandSciELO,whichfound1,598

publications with seven of them selected for the final sample.

Categoriesidentified-Approachestoknowledge,perceptions,beliefs

and experiences of breastfeeding from children's perspective: the

interviews revealed knowledge and beliefs unfavorable to

breastfeeding;-Approachtothebreastfeedingpromotioncontentin

primaryeducation:thecontentissuperficiallyaddressedintextbooks

and educators state they do not teach it in class. The approach to

breastfeeding in primary education has been varied, although

reduced, especially in relation to educational interventions. Nurses

needtoexpandthisapproach,withactiveandplayfulmethodologies,

withaviewtoimpactingthefutureofthenextgenerations.

Descriptors: Breast Feeding; Health Promotion; Education, Primary

andSecondary;ObstetricNursing.

INTRODUCTION

Evidence reinforces the benefits of breastfeeding to reduce

infantmorbidity andmortality, alsopreventing infections anddental

malocclusioninchildrenwhoarebreastfedforlongerperiods.Theeffectsofthispracticecanextendinto

adulthood, promoting increased intelligence and decreased risk of developing obesity and diabetes. In

women'shealth,breastfeedingprotectsagainstbreastandovariancancer, type2diabetes,andprolongs

spacingbetweenpregnancies.Thesebenefitstranslateintoreducedhealthservicesexpendituresandreflect

onfamily,societyandtheenvironment,contributingtoahealthier,moreequitableandsustainableworld(1-

1Nurse,Master'sDegreeinNursing.DoctoralstudentofthePostgraduatePrograminNursing,FederalUniversityofPernambuco.Recife,PE,Brazil.E-mail:[email protected],DoctoratedegreeinNutrition.AssociateProfessoratFederalUniversityofPernambuco.Recife,PE,Brazil.E-mail:[email protected],DoctoratedegreeinNursing.AssociateProfessoratFederalUniversityofPernambuco.Recife,PE,Brazil.E-mail:[email protected],DoctoratedegreeinNursing.FullProfessoratFederalUniversityofPernambuco.Recife,PE,Brazil.E-mail:[email protected],DoctoratedegreeinNutrition.FullProfessoratFederalUniversityofPernambuco.Recife,PE,Brazil.E-mail:[email protected].

Received:04/19/2016.

Accepted:06/29/2016.

Published:12/22/2016.

Suggestedcitation:

MartinsFDP,LealLP,GuedesTG,JavorskiM,PontesCM.Promotionofbreastfeedingonprimaryeducation:integrativereview.Rev.Eletr.Enf.[Internet].2016[cited__/__/__];18:e1198.Availablefrom:http://dx.doi.org/10.5216/ree.v18.40682.

MartinsFDP,LealLP,GuedesTG,JavorskiM,PontesCM.


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2).

Globally,about80%ofchildrenreceivebreastmilkinthefirstyearoflife,butapproximatelyhalfof

themarebreastfedwithinthefirsthourafterbirth.Inmostcountries,ratesarebelow50%forbreastfeeding,

indicatingthateffortsshouldbemadetopromotebreastfeeding,especiallyatearlyinitiationandexclusive

maintenance(1-2).

Inadditiontoprogramsandpoliciestoencourage,protectandsupportbreastfeeding,strategiesto

fosterbreastfeedingpracticesneedtobeexpandedtoincludesocialmobilization,media,counseling,and

supportforbreastfeedinginthefamilyandcommunitysetting.ThesuccessfulBreastfeedingshouldnotbe

seenasasingleresponsibilityofthewoman,butacollectiveresponsibilityofsociety(2).

Theimportanceofthispracticeshouldbeemphasizedearlyon,wellbeforeprenatalcare,inorderto

facilitatetheconstructionofpositiveattitudesandbehaviorsaboutbreastfeeding(3),sincethedecisionon

the type of infant feeding generally occurs before pregnancy. In this context, the school is a favorable

scenario for actions to promote health and, therefore, should expose all students the advantages of

breastfeedingduringtheformativeyears.Educationalactivitiesaimedatstudentspromoteattitudesthat

are more favorable to breastfeeding(4) and may contribute to the motivation to breastfeed when they

becomeparents(5). Inaddition, theeducational institutionhasthepotential to integratediverseactorsof

society:women,children,adolescents,educators,familyandhealthprofessionalsinthesameplace(6).

InBrazil, theHealth inSchoolProgram, launched in2007,reinforcestheessential roleofnurses in

schooleducation,inpartnershipbetweenschoolsandbasichealthunits.Theintentionistocreatedialogic

spaces that favor learning about health, not only being restricted to the physical environment of the

institution,butalsocontemplatingtherealityofthecommunityinordertoencompassthefamilyandbring

itclosertotheschoolandhealthprofessionals(7).

however,primaryschoolteachersfeelinsecuretocarryouthealthpromotionactionsatschool,they

report difficulties in articulating partnership with health professionals in planning, implementing and

evaluatingactivities,andhighlighttheshortapproachtohealthintextbooks(8).

Insecondaryeducation,theinclusionofbreastfeedingcontentinthecurriculumisseenasimportant

fromthepointofviewofteachersandnurses(9).Forthatmatter,educationalinterventionscarriedoutwith

secondaryeducationadolescentsdemonstratepositiveeffectsinincreasingtheknowledgeofyoungpeople

about this subject.However, the studiesemphasize theneed for further research toevaluate the future

implicationsoftheseinterventionsinthepracticeofbreastfeeding(10).

Fromtheperiodbeforepregnancytopostpartum,severalsystemsinteracttoensurethesuccessof

breastfeeding, including family, professional, political, economic, and legal support for women. In this

context,theschoolhasbeencitedasanenvironmentconducivetothebreastfeedingdiscussion(9).Ingeneral,

theeducationalactivitiesaredirectedtotheadolescentpublic,consideringthepossibilityofpregnancyin

this age group. These studies lack to mention this content during childhood, especially in the school

environment.



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Therefore,knowingtheproductionofscientificknowledgeaboutthepromotionofbreastfeedingin

primaryeducationwillmakeitpossibletoidentifypossiblegapsandtodirectnewresearchthatcontributes

totheplanningof intersectoralactivitieswitharticulationbetweeneducatorsandhealthprofessionals in

favorofbreastfeeding.Thus,thisstudyaimstoanalyzetheapproachesonthepromotionofbreastfeeding

inprimaryeducation.

METHOD

This is an integrative literature review,whose purpose is to summarize the knowledge of a given

subjectaswellastoproducethemaximumofnewknowledge,whichhasnotbeenapproachedordeepened

inpreviousresearch.Tothisend,wefollowedthefivestepsproposedbyCooper(11).

Forthefirststage,thequestionofresearchwasformulated:Howisthepromotionofbreastfeedingin

primaryeducationaddressed?Inthesecondstage,datacollectionwaschosen:LatinAmericanandCaribbean

Literature(LILACS),NursingDatabase(BDENF),SpanishBibliographicIndexonHealthSciences(IBECS),U.S.

NationalLibraryofMedicine(PubMed),MedicalLiteratureAnalysisandRetrievalSystemOnline(MEDLINE),

SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), COCHRANE and the virtual

libraryoftheScientificElectronicLibraryOnline(SciELO).

WeperformedthefollowingcrossingswiththeHealthSciencesDescriptors(DeCS)andtherespective

terms of the Medical Subject Headings (MESH) with the Boolean operator "and": 1st) "Aleitamento

materno"/“Breastfeeding”,“Educaçãoemsaúde”/“Healtheducation”,“Criança”/“Child”;2nd)“Aleitamento

materno”/“Breastfeeding”, “Ensino fundamental e médio”/“Primary school”; 3rd) “Aleitamento

materno”/“Breastfeeding”, “Estudantes”/“Students”, 4th) “Aleitamento

materno”/”Breastfeeding”/”Promoçãodasaúde”/”Healthpromotion”/”Criança”/”Child”.

InPortuguese,wechosetousethedescriptor 'Ensinofundamentalemédio'becausetherewasno

descriptorthatonlyaddressedtheterm'primaryeducation'.MESHhadtheexactdescriptor'Primaryschool'.

WecarriedoutthesearchandbibliographiccollectioninthesecondhalfofOctober2015.

In the third stage, data evaluation, we considered the inclusion criteria: addressing promoting

breastfeeding in primary education; school and/or the school setting as participants; original article;

Portuguese, English and Spanish; articlewith abstract and full text, available in full or obtained through

commutation in the educational institution. It should be noted that the studies developed in secondary

educationwereincludedinthereviewonlywhentheyalsoincludedprimaryeducation.Intheattemptto

expandthesearch,notemporallimitwasestablishedfortheselectionofarticles.Theexclusioncriteriawere

dissertations,theses,guidelines,editorials,reflectivearticlesorliteraturereview/integrative/systematicand

studiesthataddressedonlythesecondaryeducationstage.Weinitiallyfound1,598studies(Table1).

Afterreadingthetitleandabstract,weexcluded1,590articles;ofthese,1,540wereinadequatetothe

themeand32wererepeatedinthedatabases,beingcountedonlyonce(Figure1).Anevaluatorperformed

thisstepindependentlyandanydoubtwasdiscussedwiththeotherauthors.Eightarticleswerepre-selected



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andsubmittedtothemethodologicalevaluationprocessusingthestandardformoftheCriticalAppraisal

SkillsProgramme(CASP)(12)adaptedtocontemplateallstudydesignspresentinthesample.Thischecklist

has10questions,foreachoneofthemcanbeassignedtheanswer/punctuation:yes(1point); inpart(0

point); not (0 point),with a scorebetween zero and ten.A score equal to or greater than six (A rating)

indicatesthatthestudyshouldbeincludedinthereview,whileascoreequaltoorlowerthanfive(ratingB)

meanslowmethodologicalaccuracy.Inthisstage,astudywasexcludedforobtainingscoresinferiortofive,

andthefinalsamplehadsevenstudies.

Table1:Publicationsaboutthepromotionofbreastfeedinginprimaryeducation.Recife,PE,Brazil,2015.Crossing/Database/Library

Breastfeeding/Healtheducation/Child

Breastfeeding/Primaryandsecondeducation

Breastfeeding/students

Breastfeeding/Healthpromotion/Child

Total

LILACS 08 01 02 16 27IBECS 0 0 0 0 0BDENF 0 0 0 1 1

MEDLINE 52 0 37 100 189SCIELO 05 01 08 27 41PUBMED 152 62 73 186 473SCOPUS 321 52 51 266 690CINAHL 07 0 07 34 48

COCHRANE 51 07 13 58 129Total 596 123 191 688 1598

Forthefourthstage,analysisandinterpretation,weadaptedtheinstrumentmadeandvalidatedby

Ursi(13) to gather and synthesize the information regarding the promotion of breastfeeding in primary

education: name of the research; authorship; publication journal; institution; year of publication; study

objectives; methodological detailing; characteristics of the sample; level of evidence; outcomes;

recommendationsandconclusions.Thethreeevaluatorsdiscussedthesynthesisandinterpretationofthe

studiesduringseveralmeetings inordertoclarifythe informationofeachresearchandtoanswertothe

objectiveofthereview.ThelevelofevidencewasidentifiedaccordingtoStillwelletal.,(14):1–Systematic

reviewsormeta-analysis, 2 –Randomized clinical trial, 3 –Clinical trialwithout randomization, 4–Case

control or cohort study, 5 – Systematic review of qualitative or descriptive studies, 6 – Qualitative or

descriptivestudiesand7–Opinionsorconsensusofexperts.

Thethreeevaluatorsdiscussedtheresultsandsubmittedthemtocontentanalysis(15),inthethematic

modality,whichincludesthestepsofpre-analysis,explorationofthematerialorencodingandtreatmentor

interpretationoftheresults.Thefirststagecomprisesfluctuatingreading,theconstitutionofcorpusandthe

formulationandreformulationofhypotheses.Inthematerialencoding,theintentionistofindmeaningful

wordsorexpressionstoguidetheconstructionofthecategories.Finally,theresultsareinterpreted.Thefifth

stage, presentation of the results, we carried out from the description of the identified categories and

discussionbasedonstudiesofthearea.



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Figure1:Flowchartofarticlesselection.

RESULTS

Thepublicationperiodvariedfrom2008to2013(16-22),fivestudiesshowedlevelofevidence6(16,19-22),

and two showed level 2(17-18). As to the language, four are publications in English(17-20) and three in

Portuguese(16,21-22).Brazilwasthepredominantresearchsite(16-18,22).

Regardingthemethodologicaldesign,fouroptedforthequantitativeapproach(16-18,20)andthreeused

thequalitativeapproach(19,21-22).Thecollectionmethodvariedfromquestionnairecontainingquestionsabout

advantages/disadvantages and paternal participation in breastfeeding(16), breastfeeding teaching(20);



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educational intervention through lecture, using visual resources and slides with images(17), with video,

followedbydiscussionofconcepts,stagingofchildren's feedingstorytelling, flyingtocolorandwritethe

historyofbreastfeeding,andapplicationofthepre/postquestionnairetest(18).Theparticipatorystorytelling

techniquewasmentionedinastudy(19),consistingofchildren'sinterpretationofanewbornfeedingnarrative

createdbythem,withtheaidofdrawingsandtext.Anotherformofdatacollectionwastheconsultationin

guidelines(21),curricularprogramsandtextbooksofprimaryeducation(22)toverifythebreastfeedingcontent.

Fromthereadingandre-readingofthearticles,twothematiccategorieswereidentifiedinrelationto

thepromotionofbreastfeedinginprimaryeducation(Figure2).

Figure2:Flowchartofcategorizationprocessofthearticles.

Inthefirstcategory,Approachestoknowledge,perceptions,beliefsandexperiencesofbreastfeeding

fromchildren'sperspective,fourarticles(16-19)wereidentified,withprimaryschoolstudentsasasample.

Thesecondcategory,Approachtothepromotionofbreastfeedinginprimaryeducation,composedof

threestudies(20-22),ischaracterizedbyinterviewswithteachersandnursesandconsultationstoguidelines,

programsandtextbooks.Itshouldbeemphasizedthatoneofthestudies(20)ofthiscategoryhadbothprimary

andsecondaryeducationstages,beingthereforeincludedinthesample.

Table 1 describes the information synthesis (authorship, databases, objectives,method) andmain

resultsextractedfromthearticlesaccordingtotheidentifiedcategories.



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Table1:Descriptionofarticlesabout'Promotionofbreastfeedinginprimaryeducation'intermsofauthorship,database,objectives,methodandmainresultsaccordingtotheidentifiedcategories.

Authorship/Databases Objectives Design/sample/location ResultsCategory1:Approachingknowledge,perceptions,beliefsandexperiencesofbreastfeedingfromchildren'sperspective.

BottaroS,GiuglianiERJ(16)Toevaluateknowledge,perceptions,beliefsandexperiencesaboutbreastfeedingin

studentsofbothsexesofPrimaryEducation.

Cross-sectional. Littleknowledgeaboutthedurationofbreastfeedingandcomplementaryfeeding;beliefs(useofteas,water,pacifiers;weakmilk,breastsizeXmilkproduction);boysdidnot

associatebreastfeedingasthefirstfunctionofthebreastandwerecontrarytothepracticeinpublic;themajoritywasbreastfedandwitnessedbreastfeeding;girlsreported

breastfeedingdollsduringchildhoodplays(41.7%)andboysparticipatelittle(16.6%).

SCOPUS

564students(5thgrade).

RioGrandedoSul,Brazil.

FujimoriM,MoraisTC,FrançaEL,ToledoOR,Honório-FrançaAC(17)

Toevaluatetheperceptionofprimaryeducationstudentsregardingbreastfeedingandtheinfluenceofeducationallecture

abouttheirknowledge.

Cross-sectional. Themajorityintendedtohavechildrenandbreastfeedthemorsupportwivesinthedecision;morethan30%ofchildrenofbothsexesreportedembarrassmentabout

breastfeedinginpublic;themajorityreceivedpriorinformationonbreastfeeding(28%inschools)andwouldliketolearnmore;interventionhadapositiveeffectonthepracticalityofbreastfeeding,useofpacifierandperiodforfoodsupplementation;boysassimilatedthe

breastfeedingadvantagesbetterthangirls.

503students(4thto8thgrade).

SCOPUS MatoGrosso,Brazil.

BottaroSM,GiuglianiERJ(18)

Toevaluatetheeffectivenessandresidualeffectofaneducationalinterventiontoimproveknowledgeandattitudesaboutbreastfeedingamongfifth-gradersofboth

sexesinBrazil.

RandomizedclinicaltrialThemajoritywasbreastfedandwitnessedbreastfeeding;41.7%ofthegirlsplayedtherole

ofbreastfeedingtheirdollsand16.6%oftheboysparticipatedinthistypeofactivity;interventionwaspositiveandhadagreaterimpactongirlsinthe9-11agegroupandwas

moreevidentinpublicschoolstudents.COCHRANE

564studentsfrompublic,privateandruralschools(298interventiongroupand253

controlgroup),5thgrade.RioGrandedoSul,Brazil.

AngellC,AlexanderJ,HuntJA(19) Toexploreawarenessofinfantfeedingin

primaryeducationchildren.

Qualitative. Lessthanhalfofthechildrenreferredtobreastfeedinginthe"Draw,writeandtell"dynamicsastothefeedingthebaby,andthosethatreferredthat,placedasasecondoptionoranextrafeedingalternative;mostofthemillustratedthemilkformulaanddetailedpracticeswithfeedingbottles,inadditiontoincludeavarietyofsolidfoods.

56children(from5to11yearsold).

PUBMED England,UnitedKingdom.

Category2:Approachingthebreastfeedingpromotioncontentinprimaryeducation.SpearHJ(20)

Toexploretheattitudesandbehaviorsofnurseeducatorsandprimaryandsecondaryeducationteachersrelatedtotheinclusion

ofbreastfeedingcontent.

Descriptive,cross-sectional. Schoolteachersrecognizedtheimportanceofincludingthecontentofthebreastfeedingbenefitsintheschoolcurriculumatthethirdandsecondeducationlevel;mostofthemstatedtheydidnotaddressthiscontentinclass;thejustificationsfornotdeliveringthiscontentare:itisnotpartoftheschoolcurriculum,lackoftimeandinstrumentalization;

about15%saidtheyteachthebenefitsofbreastfeeding.

SCOPUS 107teachers(48nursesand59primaryandsecondaryeducationteachers).

Virginia,U.S.

GalvãoDMPG,SilvaIA(21)Toknowhowbreastfeedingisapproachedtothechildrenofthe1stCycle,andwhat

theylearninschoolonthistopic.

Descriptive,qualitative.Contentaboutthepromotionofbreastfeedingidentifiedinonlytwoguidelinesofthe3rdyear;presenceoftextsandimagesthatalludetothecultureofartificialfeeding(pacifier,

feedingbottle,childdrinkingmilkwithfeedingbottleinthefamily).

19schoolguidelinesfrom1stto4thyearofprimaryeducation.

CINAHL Coimbra,Portugal.

GalvãoDMPG,SilvaIA(22)

PUBMED

ToanalyzethecurricularprogramsdefinedforthefirstyearsintheSciencessubjectofPrimaryEducationandthecontentsofthe

textbooksadoptedinthissubjectinBrazilianpubliceducationestablishmentsregardingthepresenceornotoftermsrelatedtothebreastfeedingpractice.

Descriptive,qualitative.Curricularprogramsandtextbooksofsubjects

from2ndto5thgrades.SãoPaulo,Brazil.

Unidentifiedcontentsinschooltextbooksandguidelines:physiologyoflactation,useofpacifierandfeedingbottleasaninappropriatepractice;identifiedimages:pacifierand

feedingbottle;contentsforbreastfeeding:mammalbreastfeeding,beginnerofbreastfeedingrightafterbirth,periodforbreastfeeding,theimportanceofthefather,familysupport,advantagesofbreastfeedingformother,infant,familyandsociety,and

contraindicationstotheuseofwaterandartificialfeeding.



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DISCUSSION

The studies showeddifferent approaches about promotion of breastfeeding in primary education,

ranging from interviews(16-17,20)with children, teachers and nurses, educational interventions directed at

students(17-18),andconsultationincurriculumprogramsandguidelines(21-22).

Interviews with the children revealed inadequate knowledge about breastfeeding since they

frequently refer to the use of infant feedingwith feeding bottle andhavenot favorable beliefs towards

breastfeeding.Londonschoolchildrenbetweentheagesof13and15alsodemonstratedsimilarknowledge

instatingthatthefeedingbottlebringshealthbenefitsfortheinfantdespitehavingpreviouslyagreedonthe

advantagesofbreastmilk.Thisconfusingviewmayarisefromadvertisingcampaignsontheuseofmilk-fed

bottleordairyformulamanufacturersthatadvocateindustrializedmilkforinfantgrowthanddevelopment(5).

Earlyintroductionofindustrializedmilkand/orotherfoodsbeforethesixmonthsoflifeisacommon

practice amongmothers because they believe their milk is weak and does not provide for their child's

nutritionalneeds.Mothersjustifygivingwatertoinfantsbecausethebreastmilk isunabletoquenchthe

child'sthirst(23).Women'sunfamiliaritymaybeinfluencingchildren'slearningastheyrepeatthebeliefsand

mythsaboutbreastfeedingtheyobserveintheirsociallives.Insufficientknowledgeandbeliefsarefactors

thatcanleadtoearlyweaning.

Clarificationonmythsandbeliefssuchasweakmilkandlowmilkarefundamentaltomakewomen

moreconfidentaboutbreastfeeding(24).Thissafetyattitudemayreflectonthebreastfeedingprocessand

consequentlyontheteachingandlearningofchildrenabouttheactofbreastfeeding.

Students who receive informal education about breastfeeding or have contact with this practice

throughsocialortelevisionviewinghavemorepositiveattitudesinrelationtobreastfeeding,especiallygirls,

when compared to boys. Therefore, gender differences should be considered in planning educational

activitiesincludingboyssothattheyknowhowtheycansupportwomeninthebreastfeedingprocess.The

boymaybeinthefuturefatherandhaveasignificantroleinchoosingthetypeofinfantfeeding(4).

Regardingtheboys,theresultsrevealedcontradictoryperceptions,fromthepretensionofsupporting

thewomaninthedecisiontobreastfeeduntilembarrassmentwithpublicbreastfeeding.Schoolchildrenaged

13 to15yearsofboth sexesofprimaryeducation in Londonwerealso resistant tobreastfeeding in the

presenceofotherpersons,characterizingthissituationasunacceptableorembarrassinganduncomfortable

for themother(5). In this context, we believe that the practice of breastfeeding, while physiological and

undeniablybeneficialtowomen,children,societyandtheenvironment,seemstobedistancingitselffrom

beinganaturalacttobeperceivedasembarrassing.

Theboys'perceptionaboutbreastfeedingdeservestobehighlighted,sincetheymaybeinvolvedwith

thispracticeasfathersorasmeninsociety.Evidenceindicatesthatthepartner'ssupporttothewomancan

exertsignificantinfluenceforthebeginningofthebreastfeedingprocess(25),beingarelevantfactorforthe

woman's confidence in the decision and the continuity of breastfeeding.When the partners realize the

importanceofthispractice,theystimulatethewomanthroughwordsofencouragement,assistanceinthe



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careofthebabyandevenwithhelptobetterpositionitduringbreastfeeding(26).

Strategiestopromotebreastfeedingwiththeparentsinthepregnancy-puerperalcyclehaveapositive

effectontheincreaseinbreastfeedingratesand,therefore,agreaterinvolvementofthepartnerinhealth

educationactionssinceprenatalcarehasbeenencouraged(27).Thepartners’participationtowardsthecare

along with the woman, mainly during breastfeeding, can begin to be worked from childhood. Playful

momentscanbeanopportunitytodiscusshowinfantsshouldbefedduringchildhoodplays.Perhapsthese

smallattitudesmighthelpchildrenbecomeadultsmoreawareof their role in supportingwomenduring

breastfeedingandperceivethisactmorenaturally.

Forthatmatter,theapproachtobreastfeedingcanbebeneficialwhenstartedearlyon,forbothsexes,

both inthefamilyand intheschoolbecausethesearetheprivilegedspacesforthe infant's learningand

development.Andalthoughthechildrenreceiveinformationaboutbreastfeeding(18),theschoolenvironment

contributesverylittle.Thismaydemonstratetheneedforteachertrainingtodealwiththisissueorevento

bringthenurseclosertohealtheducationatschool.

Educational interventions,whilehavingapositiveeffectonchildren's learning,werecarriedout in

differentways.Whileoneusedthelecture(17)fromthetraditionalmethodologyperspective,anothertooka

moreparticipatoryapproach,usingvideoanddramatization(18).Thetechniqueofstorytellingdrawings(19)as

amethodofdatacollectionalsoencouragedchildren'sparticipation,althoughitwasnotintendedtobean

educationalactivity.

Encouraging the students' participation in health education activities involves the identification of

attractiveapproachesaccordingtothelocalcontext.Theselectionofmethodologiesshouldbeginwiththe

contactbetweenthehealthteamandthepedagogicalteamtodefinethemostappropriatestrategiestothe

targetaudience.Thereareavarietyofmethodsthatcanbedevelopedforhealthcontents,suchaslectures,

workshops,theater,dance,musicandgames(28).

Teachersaretheprivilegedagentsintheeducationalprocess,because,theoretically,theyhavethe

necessary instrumentation so that learninghappens inameaningfulway for thechild.Andalthough the

schoolhaslittleparticipationinthepromotionofbreastfeeding,studentsexpressedawillingnesstolearn

more about the subject(17), which can be seen as positive and reinforces the need for greater school

participationinthisprocess.

A study(10) conductedwithadolescentsbetween12and13 yearsof age in Irelandhas shown that

educationalinterventionshaveapositiveeffectonmoralattitudes,subjectivenorms,andgirls'intentionto

breastfeed.However,thepositiveeffectsfortheboyswereonlyinrelationtotheconstructionofknowledge

aboutbreastfeeding.

Theauthors(10)describeplausibleexplanations for thisoutcomeregardingthe interventionandthe

imageofbreastfeedingasanexclusivelyfemaleact.Inthecaseofboys,theinterventionmaynothavemet

their learning needs about breastfeeding. In addition, the idea of the man supporting a partner on

breastfeedingmayseemaverydistantrealityformalechildren.



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Thefactthatboysarelessreceptivetothebreastfeedingteachingmaybeduetoaculturethatdoes

notvaluemen'sparticipationinthispractice.However,positivepartnersupportisasignificantpredictorof

women'sself-efficacyinbreastfeeding(26).Thus,extendingthebreastfeedingteachingbeyonditsbenefits,

andincludeothersocialnetworkmembers,especially,thepartner,iskeytopromotingbreastfeeding.

Thegenderissueisalsomanifestedinthedifferencesofopinionofthechildrenregardingtheinclusion

ofbreastfeeding inprimaryeducation,perceived in ambivalentways. Somegirls stated that the content

shouldbetaughtasthereisinterestinknowingmoreaboutit.Othersbelievedthatschoolisnotaplaceto

address breastfeeding since pregnancy at this age should not happen. For the boys, some considered

breastfeedingteachingtobemorerelevanttogirls,whileothersfeltthatitwasuptotheschooltodecide

whattoteach(5).

Infact,theschoolasaneducationalinstitutionhasthepowertodecideonthecontentstobeincluded

in theprogramand the resultsof thestudiesof this reviewhaveevidencednumerousaspects regarding

breastfeedingthatneedtobeclarifiedtothechildren.

Intheanalyzedarticles,thebreastfeedingcontentwassuperficiallyapproachedintheguidelinesof

the1sttothe4thyearofthepubliceducationofCoimbra,inPortugal(21).Inthetextbooksfromthe2ndtothe

4thyearofstudentsfromSãoPaulo(22),althoughtherewerebreastfeedingcontents,therewerealsopacifier

and feedingbottles images. These illustrationsmay reinforce a practice commonly seenby children and

consequentlyreproducedinchildhoodplays.Thisresultisworryingbecausetheuseofpacifierisariskfactor

tostopexclusivebreastfeeding(29)andtheuseofartificialnipples(pacifiersandfeedingbottles)isassociated

withtheabsenceofbreastfeedinginthesecondhalfofthechild'slife(30).

Thereducedthematicapproachtohealthwasalsofoundinsciencetextbooksforstudentsfrom2ndto

5thgradesofprimaryeducationinUruguaiana,RioGrandedoSul.Thefocusondiseasediscussionprevails,

distancingitselffromtheideaof"health"asacross-sectionalthemeproposedbytheNationalCurriculum

Parameters(31).

In the didactic material intended for primary education students in São Paulo, health promotion

aspects related to food and nutrition content were identified, especially in the subjects of History,

Geography,SciencesandPortuguese.However, somecontentswere inconsistentdue to thepresenceof

"learningsituations",whichindicatethemesandsuggestionsofteachingactivities.Thecontentselectionis

theresponsibilityoftheteacherandthestudent,whichmakesitimpossibletoevaluatethequalityofthe

concepts.Inaddition,itmayhampertheteacher'staskasthisactivitysometimesrequiresknowledgeaway

fromtheirtrainingarea(32).

Regardingbreastfeeding,thelittleorinadequatereferencetothethemeintextbookscanreinforce

thedifficultyandinsecurityoftheteacherinaddressingthecontentintheschoolprogram,eventhoughthey

recognizetherelevanceofteachingitinbasiceducation(20).

The actions of health promotion in schools are, in most cases, individual initiatives, isolated,

disconnectedfromtheschoolcurriculumanddisarticulatedfromtheinstitution'spedagogicalproject.The



11

lackofteachers'intentionalityineducationalhealthactivitieslosesopportunitiesthatcouldberichinthe

constructionofstudents'knowledge(8).

Teachershighlight severalhealthpromotionneeds that canbeworkedonwith the supportof the

family'shealthteamthroughvariousactionssuchaslectures,workshops,dynamics,healthfairsanddebates.

However,thesuccessofschoolhealtheducationdepends,amongotherfactors,ontheintegrationofthe

health teamwith educationprofessionals andon the intersectoriality effectiveness(28). Thepromotionof

breastfeedinginschoolneedstobeseenasacommongoalofhealthandeducationtoadvancetheteaching-

learningprocessofchildrenandtocontributetothetrainingofmoreawareadultsaboutbreastfeedingasa

naturalandmoreadequateinfantfeedingpractice.

FINALREMARKS

Themethodologicalapproachtobreastfeedinginprimaryeducationinthisreviewwaspredominantly

descriptive,directedmainlytochildrenbutwithasmallnumberofeducationalinterventions.Thearticles

indicated little use of active methodologies and inadequate knowledge of the students on the subject.

Insertingbreastfeedingintheeducationalactivitiesplanningisnotfrequent,inaddition,textbookshavelittle

referencetothiscontentandsometimesbringincorrectinformation.

The studies indicated that gaps have to be filled in the promotion of breastfeeding in primary

education,sincethepreparationofeducatorstoteachthissubject,adequacyofeducationaltoolsindicated

byofficialeducationalbodiesandgreaterarticulationbetweenhealthprofessionalsandbasiceducation.

The effectiveness of educational interventions in promoting breastfeeding demonstrates the

importanceofplanningactionsforstudentsatschool,asthisshouldbeaprivilegedenvironmentforlearning

ahealthierlife,startingwiththewaychildrenshouldbefedfromthebirth.Inthisteaching-learningprocess,

itisessentialtouseactiveandplayfulmethodologiesthatmotivateandarousechildren'sinterest.

Therefore,thecontributionsofthisreviewrefertothenurse'sroleinbroadeningthedebateofthis

content in the school environment considering its technical-scientific domain of the subject. Primary

educationisaphaseinwhichchildrenaresensitivetotheacquisitionofnewlearningandbecauseofthe

transformativeeducationpotentialtheycanbecomeagentsofchangeintheircommunityandthen,perhaps

impactonthefutureofthenextbreastfeedinggeneration.

Finally, it should be noted that the small number of publications suggests greater investments in

research in this area, especially in intervention studies, and reinforces the inclusionof the theme in the

programmaticcontentofprimaryeducationtobuildaculturefavorabletobreastfeeding.

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