Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil.

OBJECTIVE: To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality. DESIGN: Cost-effectiveness economic assessment from the health system perspective, preceded by a prospective cohort of mother-baby followed from birth to 6 months of life. The direct costs associated with two health outcomes were analysed: intermediate end point (BFFHL) and final end point (reduction in late neonatal mortality). SETTING: Study was carried out in six hospitals in the city of São Paulo (Brazil), three being Baby-Friendly Hospitals (BFH) and three non-BFH. PARTICIPANTS: Mothers with 24 h postpartum, over 18 years old, single fetus and breast-feeding at the time of the interview were included. Poisson regressions adjusted for maternal age and level of education were estimated to identify factors related to BFFHL and late neonatal mortality. Sensitivity analysis was performed to ensure robustness of the economic assessment. RESULTS: Cost-effectiveness analysis showed that BFHI was highly cost-effective in raising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from all causes and by 13·1 % of infant mortality rate from infections. CONCLUSIONS: The cost-effectiveness of the BFHI in promoting breast-feeding and reducing neonatal mortality rates justifies the investments required for its expansion within the Brazilian health system.

Interview Marina Rea: A Militant Doctor Active in the Endless Fight for Breastfeeding as a Human Right - A Luta Continua!

Marina Ferreira Rea is a Brazilian medical doctor. She has a masters and a doctorate degree in public health from the University of São Paulo (USP). She specialized in breastfeeding at Wellstart International, and completed post-doctoral research at Columbia University, New York, USA, focusing on working women and breastfeeding. She was a researcher at the Health Institute at Columbia University in New York, the Center for Population and Family Health, and at the postgraduate studies, Nutrition in Public Health, University of São Paulo, where she advised many students and published many articles and books (a few selected below). She was a Coordinator of International Breastfeeding Actions at the World Health Organization (Geneva), in the early 1990s, when actions like the Baby-Friendly Hospital Initiative, breastfeeding counseling, and other courses were started. During this same period, the World Alliance for Breastfeeding Action (WABA) and World Breastfeeding Week were initiated. In 1981 she participated in the launching of the International Code of Marketing of Breastmilk Substitutes. Marina Rea is a member of the International Baby Food Action Network and its Latin American policy committee, and is the founder of the International Baby Food Action Network (IBFAN) Brazil group. Since 2017, she has been a member of the IBFAN Global Council. She is now retired but continues to volunteer as an IBFAN member. She has two daughters and four grandchildren. A more detailed curriculum vitae in Portuguese can be found here: http://lattes.cnpq.br/8193850878281835 (MR = Marina Rea; MA = Maryse Arendt).

Methodology and indicators for NBCAL monitoring in stores and health services: a multicenter study (Multi-NBCAL). / Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL).

The Brazilian Code of Marketing of Infant and Toddlers Food, Nipples, Pacifiers and Baby Bottles (NBCAL), in force in Brazil since 1988, is still systematically violated, exposing mothers and family members to illegal marketing of products that compete with breastfeeding. This study aimed to describe a multicenter study methodology and propose standardized indicators for NBCAL monitoring. This is a Multicenter Study for NBCAL Compliance Assessment (Multi-NBCAL) conducted in seven Brazilian cities: Rio de Janeiro, São Paulo, Ouro Preto (Minas Gerais State), Florianópolis (Santa Catarina State), Brasília (Federal District), João Pessoa (Paraíba State), and Belém (Pará State). Assessment tools were adapted from NetCode/WHO and IBFAN Brazil (International Baby Food Action Network) to conduct two evaluations: (1) evaluation of NBCAL compliance in stores, and NBCAL knowledge and practices of store managers; (2) evaluation of the interaction between the baby food industry and health professionals and post-partum mothers in maternity hospitals. Five indicators were developed to assess NBCAL compliance in stores; seven indicators to assess the knowledge and practices of store managers; five indicators to assess the provision of incentives to maternity hospitals, health professionals, and mothers by sectors; and five indicators to assess NBCAL knowledge and practices of health professionals. The NBCAL assessment methodology with the proposal of standardized indicators allows comparability of studies about this theme. Using these indicators in periodic national or regional investigation can help monitor the level of NBCAL implementation in Brazil.

A Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância, Bicos, Chupetas e Mamadeiras (NBCAL), vigente no Brasil desde 1988, ainda é sistematicamente infringida, expondo mães e familiares ao marketing ilegal de produtos que competem com o aleitamento materno. O objetivo foi descrever metodologia de estudo multicêntrico e propor indicadores padronizados para monitoramento da NBCAL. Estudo Multicêntrico para Monitoramento da NBCAL (Multi-NBCAL) conduzido em sete cidades brasileiras: Rio de Janeiro; São Paulo; Ouro Preto (Minas Gerais); Florianópolis (Santa Catarina); Brasília (Distrito Federal); João Pessoa (Paraíba) e Belém (Pará). Instrumentos de avaliação foram adaptados do NetCode/WHO e da IBFAN Brasil (Rede Internacional em Defesa do Direito de Amamentar) para condução de dois inquéritos: (1) avaliação do cumprimento da NBCAL em estabelecimentos comerciais e das práticas e conhecimento dos seus gerentes sobre a NBCAL; (2) avaliação em maternidades da interação da indústria de alimentos infantis com profissionais de saúde e mães. Foram elaborados cinco indicadores para avaliação do cumprimento da NBCAL em estabelecimentos comerciais; sete indicadores para avaliar conhecimentos e práticas dos seus responsáveis; cinco indicadores para avaliar a oferta de incentivos a maternidades, profissionais de saúde e mães pelas indústrias e cinco indicadores para avaliar conhecimento e práticas de profissionais de saúde quanto à NBCAL. A metodologia de avaliação da NBCAL, com a proposta de indicadores padronizados, permite a comparabilidade de estudos sobre o tema. A utilização desses indicadores em inquéritos periódicos, nacionais ou regionais, pode contribuir para monitorar o grau de implementação da NBCAL no Brasil.

La Norma Brasileña de Comercialización de Alimentos para Lactantes y Niños en la Primera Infancia, Tetillas, Chupetes y Biberones (NBCAL), vigente en Brasil desde 1988, todavía es sistemáticamente infringida, exponiendo a madres y familiares al marketing ilegal de productos que compiten con la lactancia materna. El objetivo fue describir la metodología de estudio multicéntrico y proponer indicadores estandarizados para el monitoreo de la NBCAL. Estudio Multicéntrico para Monitoreo de la NBCAL (Multi-NBCAL) llevado a cabo en siete (7) ciudades brasileñas: Río de Janeiro; São Paulo; Ouro Preto (Minas Gerais); Florianópolis (Santa Catarina); Brasilia (Distrito Federal); João Pessoa (Paraíba) y Belém (Pará). Se adaptaron instrumentos de evaluación del NetCode/OMS y de la IBFAN Brasil (Red Internacional de Acción por la Alimentación Infantil)para la realización de dos encuestas: (1) evaluación del cumplimiento de la NBCAL en establecimientos comerciales y de las prácticas y conocimiento de sus gerentes sobre la NBCAL; (2) evaluación en maternidades de la interacción de la industria de alimentos infantiles con profesionales de salud y madres. Se elaboraron cinco indicadores para la evaluación del cumplimiento de la NBCAL en establecimientos comerciales; siete indicadores para evaluar conocimientos y prácticas de sus responsables; cinco indicadores para evaluar la oferta de incentivos a maternidades, profesionales de salud y madres por las industrias y cinco indicadores para evaluar el conocimiento y prácticas de profesionales de salud, respecto a la NBCAL. La metodología de evaluación de la NBCAL, con la propuesta de indicadores estandarizados, permite la comparabilidad de estudios sobre el tema. La utilización de estos indicadores en encuestas periódicas, nacionales o regionales, puede contribuir a monitorear el grado de implementación de la NBCAL en Brasil.

Infant and young child feeding counseling: an intervention study.

OBJECTIVE: To evaluate the effectiveness of an integrated infant and young child feeding counseling course for transforming the knowledge, attitudes and practices of pediatricians and nutritionists working for the municipal health system of São Paulo, Brazil. METHODS: A randomized intervention study enrolling 29 professionals in the intervention group and 27 in the control group. Interviewers were trained in advance to collect data on the professionals working at health centers, before and 2 months after the intervention. Three research instruments were used, the first was to assess the profile of each professional, the second assessed their knowledge and the third was a clinical observation protocol. Analysis was performed using the Kruskal-Wallis test for independent samples and the Tukey method. RESULTS: The results for the knowledge questionnaire showed improvements in the intervention group (p < 0.001) for the whole questionnaire and for questions on breastfeeding (p = 0.004); HIV and infant and young child feeding (p = 0.049); complementary feeding (p = 0.012); and counseling in infant and young child feeding (p = 0.004). In terms of performance, it was observed that the intervention group had significantly improved their dietary anamnesis after the intervention (p < 0.001). CONCLUSIONS: This course effectively promoted an increase in knowledge and improvements in dietary anamnesis performance, but the same was not true of counseling skills.

[Breastfeeding practices among paid working mothers in Paraíba State, Brazil: a cross-sectional study]. / A prática de amamentar entre mulheres que exercem trabalho remunerado na Paraíba, Brasil: um estudo transversal.

Paid work should not be an obstacle to women's breastfeeding. The World Health Organization (WHO) recommends exclusive breastfeeding for 6 months. In Brazil, women are legally entitled to 4 months of maternity leave, but in practice few women enjoy such benefits. How is it possible to practice exclusive breastfeeding for 6 months? We analyzed both the breastfeeding rates and whether paid jobs interfere with breastfeeding in Paraíba State, Northeast Brazil. We conducted a cross-sectional study in 70 of 223 municipalities (counties) during the annual immunization campaign in 2002. Among 11,076 infants (< 12 months of age), the exclusive breastfeeding rate at 0-4 months was 22.4% and was significantly higher among working women receiving maternity leave as compared to those who did not. The prevalence of total and predominant breastfeeding for 4 months was significantly lower among working women. In rural areas, having paid work was associated with a reduction in exclusive breastfeeding. The results show that breastfeeding practices in Paraíba fall far short of WHO recommendations, especially when mothers return to their paid jobs.

[Kangaroo Mother Care in public hospitals in the State of São Paulo, Brazil: an analysis of the implementation process]. / O Método Mãe Canguru em hospitais públicos do Estado de São Paulo, Brasil: uma análise do processo de implantação.

This study analyzed the implementation of the Kangaroo Mother method in 28 different São Paulo State public hospitals. Teaching hospitals, Baby-Friendly Hospitals, hospitals with human milk banks, and those with more than 12 trained health professionals showed higher implementation scores. Because of staff resistance to family participation in neonatal care, the Kangaroo Mother method is basically applied in-hospital. Changes in the initial training, including manager awareness-raising and proper financial resource allocation, are necessary for implementation, follow-up, assessment, and feedback.

[Advances in the Brazilian norm for commercialization of infant foods]. / Avanços na norma brasileira de comercialização de alimentos para idade infantil.

OBJECTIVE: To assess the advances in the Brazilian norm for commercialization of infant foods from 1988 to 2002, comparing the different texts with each other and with the International Code of Marketing of Breast-Milk Substitutes. METHODS: This was a descriptive study based on data collected from documents, reports, ordinances and resolutions from the Brazilian Ministry of Health. The versions utilized in the comparison were from 1992 and 2002. RESULTS: Comparative analysis made it possible to identify important advances in the legislation. In 1992, liquid and powdered milk were included in the scope, along with teats and dummies (pacifiers), and also warning phrases in advertising and on product labeling. In 2002, regulations for products were published by the National Agency for Sanitary Surveillance, thereby strengthening supervisory actions and including regulations for baby foods, nutrient formulae for high-risk newborns, and nipple protectors. The phrases used in commercial advertising and on product labeling, including dummies, teats and bottles, became Ministry of Health warnings. The labeling was defined according to product types, on the basis of more restrictive rules. CONCLUSIONS: Significant modifications in the control over the marketing of products aimed at mothers during the lactation period. However, there are still some legislative questions that would make it possible to improve the Brazilian norm, in order to protect breastfeeding. There is also a need for the government to implement systematic monitoring routines to supervise this legislation.

Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL) / Metodología e indicadores para el monitoreo de la NBCAL en establecimientos comerciales y servicios de salud: estudio multicéntrico (Multi-NBCAL) / Methodology and indicators for NBCAL monitoring in stores and health services: a multicenter study (Multi-NBCAL)

A Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância, Bicos, Chupetas e Mamadeiras (NBCAL), vigente no Brasil desde 1988, ainda é sistematicamente infringida, expondo mães e familiares ao marketing ilegal de produtos que competem com o aleitamento materno. O objetivo foi descrever metodologia de estudo multicêntrico e propor indicadores padronizados para monitoramento da NBCAL. Estudo Multicêntrico para Monitoramento da NBCAL (Multi-NBCAL) conduzido em sete cidades brasileiras: Rio de Janeiro; São Paulo; Ouro Preto (Minas Gerais); Florianópolis (Santa Catarina); Brasília (Distrito Federal); João Pessoa (Paraíba) e Belém (Pará). Instrumentos de avaliação foram adaptados do NetCode/WHO e da IBFAN Brasil (Rede Internacional em Defesa do Direito de Amamentar) para condução de dois inquéritos: (1) avaliação do cumprimento da NBCAL em estabelecimentos comerciais e das práticas e conhecimento dos seus gerentes sobre a NBCAL; (2) avaliação em maternidades da interação da indústria de alimentos infantis com profissionais de saúde e mães. Foram elaborados cinco indicadores para avaliação do cumprimento da NBCAL em estabelecimentos comerciais; sete indicadores para avaliar conhecimentos e práticas dos seus responsáveis; cinco indicadores para avaliar a oferta de incentivos a maternidades, profissionais de saúde e mães pelas indústrias e cinco indicadores para avaliar conhecimento e práticas de profissionais de saúde quanto à NBCAL. A metodologia de avaliação da NBCAL, com a proposta de indicadores padronizados, permite a comparabilidade de estudos sobre o tema. A utilização desses indicadores em inquéritos periódicos, nacionais ou regionais, pode contribuir para monitorar o grau de implementação da NBCAL no Brasil.

La Norma Brasileña de Comercialización de Alimentos para Lactantes y Niños en la Primera Infancia, Tetillas, Chupetes y Biberones (NBCAL), vigente en Brasil desde 1988, todavía es sistemáticamente infringida, exponiendo a madres y familiares al marketing ilegal de productos que compiten con la lactancia materna. El objetivo fue describir la metodología de estudio multicéntrico y proponer indicadores estandarizados para el monitoreo de la NBCAL. Estudio Multicéntrico para Monitoreo de la NBCAL (Multi-NBCAL) llevado a cabo en siete (7) ciudades brasileñas: Río de Janeiro; São Paulo; Ouro Preto (Minas Gerais); Florianópolis (Santa Catarina); Brasilia (Distrito Federal); João Pessoa (Paraíba) y Belém (Pará). Se adaptaron instrumentos de evaluación del NetCode/OMS y de la IBFAN Brasil (Red Internacional de Acción por la Alimentación Infantil)para la realización de dos encuestas: (1) evaluación del cumplimiento de la NBCAL en establecimientos comerciales y de las prácticas y conocimiento de sus gerentes sobre la NBCAL; (2) evaluación en maternidades de la interacción de la industria de alimentos infantiles con profesionales de salud y madres. Se elaboraron cinco indicadores para la evaluación del cumplimiento de la NBCAL en establecimientos comerciales; siete indicadores para evaluar conocimientos y prácticas de sus responsables; cinco indicadores para evaluar la oferta de incentivos a maternidades, profesionales de salud y madres por las industrias y cinco indicadores para evaluar el conocimiento y prácticas de profesionales de salud, respecto a la NBCAL. La metodología de evaluación de la NBCAL, con la propuesta de indicadores estandarizados, permite la comparabilidad de estudios sobre el tema. La utilización de estos indicadores en encuestas periódicas, nacionales o regionales, puede contribuir a monitorear el grado de implementación de la NBCAL en Brasil.

The Brazilian Code of Marketing of Infant and Toddlers Food, Nipples, Pacifiers and Baby Bottles (NBCAL), in force in Brazil since 1988, is still systematically violated, exposing mothers and family members to illegal marketing of products that compete with breastfeeding. This study aimed to describe a multicenter study methodology and propose standardized indicators for NBCAL monitoring. This is a Multicenter Study for NBCAL Compliance Assessment (Multi-NBCAL) conducted in seven Brazilian cities: Rio de Janeiro, São Paulo, Ouro Preto (Minas Gerais State), Florianópolis (Santa Catarina State), Brasília (Federal District), João Pessoa (Paraíba State), and Belém (Pará State). Assessment tools were adapted from NetCode/WHO and IBFAN Brazil (International Baby Food Action Network) to conduct two evaluations: (1) evaluation of NBCAL compliance in stores, and NBCAL knowledge and practices of store managers; (2) evaluation of the interaction between the baby food industry and health professionals and post-partum mothers in maternity hospitals. Five indicators were developed to assess NBCAL compliance in stores; seven indicators to assess the knowledge and practices of store managers; five indicators to assess the provision of incentives to maternity hospitals, health professionals, and mothers by sectors; and five indicators to assess NBCAL knowledge and practices of health professionals. The NBCAL assessment methodology with the proposal of standardized indicators allows comparability of studies about this theme. Using these indicators in periodic national or regional investigation can help monitor the level of NBCAL implementation in Brazil.

Protecting, promoting, and supporting breastfeeding among women in the labor force.

The need to protect, promote, and support breastfeeding among women in the labor force is an important global issue that requires greater attention. An increasing proportion of women of child-bearing age are employed outside the home. Women who resume full-time work outside the home when their infants are young tend to have shorter durations of breastfeeding and less exclusive breastfeeding. However, evidence indicates that appropriate breastfeeding policy and support programs can help sustain breastfeeding among employed women. Effective strategies include delayed return to work, working part-time, improved conditions at work for breastfeeding, breastfeeding breaks during work hours, milk expression and storage, and access to breastfeeding counseling. In this chapter, we consider the special needs of women working outside the home; provide a brief overview of the literature; and address international policy regarding the protection, promotion, and support of breastfeeding among women who work outside the home.

[A review of breastfeeding in Brazil and how the country has reached ten months' breastfeeding duration]. / Reflexões sobre a amamentação no Brasil: de como passamos a 10 meses de duração.

In 1975, one out of two Brazilian women only breastfed until the second or third month; in a survey from 1999, one out of two breastfed for 10 months. This increase over the course of 25 years can be viewed as a success, but it also shows that many activities could be better organized, coordinated, and corrected when errors occur. Various relevant decisions have been made by international health agencies during this period, in addition to studies on breastfeeding that have reoriented practice. We propose to review the history of the Brazilian national program to promote breastfeeding, focusing on an analysis of the influence of international policies and analyzing them in four periods: 1975-1981 (when little was done), 1981-1986 (media campaigns), 1986-1996 (breastfeeding-friendly policies), and 1996-2002 (planning and human resources training activities backed by policies to protect breastfeeding). The challenge for the future is to continue to promote exclusive breastfeeding until the sixth month, taking specific population groups into account.

[Breastfeeding patterns and energy adequacy]. / Padrões de aleitamento materno e adequação energética.

To analyze caloric adequacy in infant feeding six months of age or under, the volume of breast milk consumed was estimated through a regression equation as proposed by Drewett. Energy adequacy was estimated according to World Health Organization guidelines for developing countries and the recommended daily allowance of the Food and Nutrition Board. A cross-sectional analysis was conducted on data from a cohort of 118 infants in a neighborhood around a health center in Campinas, São Paulo, Brazil, with home interviews by trained students. Data were gathered on social and demographic characteristics, infant feeding patterns, duration of breastfeeding, frequency of feedings, and age when breast milk substitutes were introduced. On average, weaning began early, with a 2.7-month median duration of exclusive breastfeeding. Mean breast milk volume was estimated (from frequency of feeding) as 561.0 ml, 558.9 ml and 565.5 ml for children in exclusive, predominant, and supplemented breastfeeding, respectively. Mean energy consumption was adequate for all exclusively breastfed children regardless of age and above the recommended level for infants with supplemented breastfeeding and those already weaned.

[The Baby-Friendly Hospital Initiative and breastfeeding in a neonatal unit]. / Iniciativa Hospital Amigo da Criança e aleitamento materno em unidade de neonatologia.

OBJECTIVE: To evaluate the impact of the Baby-Friendly Hospital Initiative on breastfeeding practices among newborns admitted to a neonatal unit, during hospitalization and during the first six months of life. METHODS: The medical records of all newborns admitted to the neonatal unit of a teaching hospital in 1994 (N=285) and 1998 (N=368) were reviewed, and information on the infants' feeding practices during hospitalization and during the first six months of life was analyzed. The duration of breastfeeding and exclusive breastfeeding and the differences between the two years were assessed using the Kaplan-Meier technique and the Log-Rank test. Logistic regression and Cox analysis were performed for confounder control. RESULTS: There was an important increase in the percentage of infants given breast milk exclusively (1.9% in 1994 to 41.7% in 1998) during hospitalization, and feeding with formula alone, observed in 17.7% of infants in 1994, was no longer noted in 1998. With respect to breastfeeding practices during the first six months of life, the median duration of exclusive breastfeeding increased from 12 days in 1994 to 45 days in 1998. As to breastfeeding, which includes the ingestion of other types of food, no significant difference was observed. CONCLUSIONS: The implementation of the initiative in the studied hospital contributed towards an increase in the exclusive breastfeeding of newborn babies during neonatal unit admission and during the first six months of life.

[Frequency and determinants of breastfeeding in the State of São Paulo, Brazil]. / Freqüência e determinantes do aleitamento materno em municípios do Estado de São Paulo.

OBJECTIVE: To meet the information need of Brazilian municipalities concerning breastfeeding practices as part of health care planning, a study was carried out to describe breastfeeding and to identify weaning-related factors. METHODS: Of all municipalities in the State of São Paulo, Brazil, openly called to participate in the study, 84 joined in. Personnel underwent training to collect data during the national mass immunization day in 1998. A sample strategy, proportional to the infant population, was developed for each participant. Standardized questionnaires were applied to assess infant feeding practices in the previous 24 hours. Descriptive statistic analysis on breastfeeding prevalence and logistic regression analysis of risk factors for discontinuing exclusive breastfeeding of infants aged less than 4 months and weaning of infants aged less than a year were performed. RESULTS: Exclusive breastfeeding rates in the first four months of life were under 30%. The risk factors were: lower maternal education status; lack of access to the so-called "Baby Friendly Hospital Initiative"; primiparity; and early age pregnancy. Around 50% of children under a year old were breastfed. CONCLUSIONS: Lacks of access to the "Baby Friendly Hospital Initiative", primiparity, and mother's unemployment or engagement in an informal occupation activity were risk factors for weaning. Local breastfeeding rates are extremely variable in the State of São Paulo, reinforcing the importance of local, swift, and easily feasible health care actions.

The Baby-Friendly Hospital Initiative: increasing breastfeeding and decreasing infant mortality in Brazil / A Iniciativa Hospital Amigo da Criança: contribuição para o incremento da amamentação e a redução da mortalidade infantil no Brasil

Abstract Objectives: to estimate the population attributable fraction of preventable infant mortality rates due to changes in breastfeeding (BF) indicators attributable to the Baby Friendly Hospital Initiative (BFHI). Methods: an estimate on the impact of BFHI in reducing infant mortality with an inferential level of plausibility, using secondary data from the II Breastfeeding Prevalence Survey of 2008. Initially, the effect of BFHI on breastfeeding in the first hour of life, exclusive breastfeeding, and any breastfeeding based on the prevalence of the outcomes among infants born in BFHI or non-BFHI was calculated. Second, the population attributable fraction of nonbreastfeeding was estimated for late neonatal mortality, mortality by all causes and infant mortality by infections, for BFHI and non-BFHI, and the number of potentially avoidable deaths if all children were born in BFH. Results: reduction of 4.2% of late neonatal deaths due to the increase in BF prevalence in the first hour, as provided by BFHI. BFHI potentially contributed with 3.5% of all-cause deaths and 4.2% of deaths from infection by BF promotion in infants below 6 months. Conclusions: the reduction of mortality in children between 7 and 180 days in 2008 potentially attributable to BFHI through the promotion of BF indicators reinforces the importance of strengthening and expanding this initiative in Brazil to ultimately enhance child survival.

Resumo Objetivos: estimar a fração atribuível populacional da mortalidade infantil evitável mediante as mudanças em indicadores de amamentação no Brasil devido à Iniciativa Hospital Amigo da Criança (IHAC). Métodos: trata-se de uma estimativa do impacto da IHAC na redução da mortalidade infantil com nível de inferência de plausibilidade, utilizando-se dados secundários da II Pesquisa de Prevalência do Aleitamento Materno de 2008. Inicialmente calculou-se o efeito da IHAC em elevar as taxas da amamentação na primeira hora de vida, amamentação exclusiva e qualquer amamentação a partir das prevalências de amamentação entre os nascidos em hospitais amigos da criança (HAC) e os nascidos em não hospitais amigos da criança (NHAC). Posteriormente, foi estimada a fração atribuível da não amamentação para mortalidade neonatal tardia, mortalidade por todas as causas e mortalidade por infecções, para nascidos em HAC e NHAC e estimou-se o número de óbitos evitáveis caso todas as crianças nascessem em HAC. Resultados: a redução de 4,2% das mortes neonatais tardias foi atribuída ao aumento das prevalências de AMPHproporcionado pela IHAC. Mediante a promoção da amamentação em menores de 6 meses, a IHAC contribuiu potencialmente para reduzir 3,5% de mortes por todas as causas e 4,2% de mortes por infecção. Conclusões: a redução da mortalidade em crianças de 7 a 180 dias em 2008, potencialmente atribuível à IHAC através da promoção de indicadores de AM, reforça a importância de fortalecer e expandir essa iniciativa no Brasil para aumentar a sobrevivência infantil.

[Benefits of breastfeeding for maternal and child health: an essay on the scientific evidence]. / Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências.

This paper provides a literature review on breastfeeding, selecting studies that have helped explain its benefits for maternal and child health. A search for articles published since 2000 was conducted, including relevant studies for the advancement of knowledge in previous decades. An Internet search of the PubMed and SciELO databases was performed to select the studies. Besides the aspects on which there is widespread agreement, controversial results were also included, as well as intriguing ones from the field of neurobiology. Public policy recommendations have undergone substantial changes following those new discoveries. Some studies have also been conducted to search for the most cost-effective measures to promote breastfeeding practices. This paper highlights: current recommendations on child feeding; the importance of breastfeeding for early childhood; the implications of breastfeeding for health of both the infant and mother; and the effectiveness of key interventions to encourage breastfeeding.

Implantação da iniciativa hospital amigo da criança em umhospital universitário / Implantation of the baby friendly hospital initiative at universityhospital / Implantación de la iniciativa hospital amigo del niño en unhospital universitario

A Iniciativa Hospital Amigo da Criança é uma estratégia mundial patrocinada pela Organização Mundial daSaúde e pelo Fundo das Nações Unidas para a Infância com a finalidade de promover, proteger e apoiar oaleitamento materno mediante a prática pelos hospitais de ações pró-amamentação, conhecidas como “DezPassos para o incentivo do aleitamento materno”. O objetivo deste trabalho foi descrever o processo deimplantação dessa estratégia no Hospital Universitário Regional do Norte do Paraná, do município de Londrina. Ametodologia constou de entrevistas entre membros da equipe do Setor de Neonatologia e busca de dados emdocumentos referentes à implantação dos Dez Passos nesse hospital. A coleta de dados foi realizada noprimeiro semestre de 2001 e a análise foi comparativa entre o cumprimento dos Dez passos antes e após aimplantação dos mesmos. Os resultados mostraram que a estratégia implantada serviu para importantesmudanças na prática do aleitamento materno enquanto a mãe permanecia internada pelo nascimento do bebê.Conclui-se que a implantação dos Dez Passos contribuiu para o abandono das fórmulas lácteas que foramsubstituídas por leite materno.

The “Baby-Friendly Hospital Initiative” is a worldwide strategy endorsed by the World Health Organization and bythe United Nations Children’s Fund to promote, protect and support breastfeeding through hospital actions known as “10 Steps to successful breastfeeding”. The aim of this study was to describe the implantation process of thisstrategy at the Northern Paraná School Hospital, in Londrina. The methodology consisted of interviews withhealth workers of the Neonatology ward and search in documents referring to the “10 Steps to successfulbreastfeeding” implementation process in that institution. Data was collected in the first semester of 2001 anddata was analyzed comparing the fulfillment of the 10 steps before and after the strategy implementation. Resultsshow that the implemented strategy provided imported changes in breastfeeding during mothers’ hospitalizationdue to childbirth. We conclude that the implementation of the 10 steps contributed to the cessation of use of milkformulas which were replaced for human milk.

La iniciativa Hospital Amigo del Niño es una estrategia mundial patrocinada por la Organización Mundial de laSalud y por el Fondo de las Naciones Unidas para la Infancia, con el fin de promover, proteger y apoyar elamamantamiento materno mediante la práctica, por los hospitales, de acciones pro-amamantamiento conocidascomo los “Diez pasos para el incentivo al amamantamiento materno”. El objetivo de este trabajo fue describir elproceso de implantación de esta estrategia en el Hospital Universitario Regional del Norte de Paraná, delmunicipio de Londrina. La metodología constó de entrevistas entre miembros del equipo del sector deneonatología y de búsqueda de datos en documentos referentes a la implantación de los Diez pasos en estehospital. La recolección de datos fue realizada durante el primer semestre de 2001 y el análisis fue comparativoentre el cumplimiento de los Diez pasos, antes y después de su implantación. Los resultados mostraron que laestrategia implantada sirvió para importantes cambios en la práctica del amamantamiento materno mientras lamadre permanecía internada debido al nacimiento del bebé. Se concluyó que la implantación de los Diez pasoscontribuyó al abandono de las fórmulas lácteas, que fueron substituidas por la leche materna.

Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements.

AIM: This project aimed to assess the information and counselling on infant feeding in HIV+ mothers. METHODS: A cross-sectional study, based on 118 structured observations of mothers' visits to health professionals (5-8/professional)-in 15 purposively selected HIV/Aids healthcare units in Sao Paulo. RESULTS: The general quality of communication and counselling skills was good: for example, professionals responded to all mothers' questions (98%); kept eye-to-eye contact (82%); encouraged the mother to talk (77.1%). However, the information provided to mothers aimed to help their choices concerning infant feeding was of very poor quality. No mother, for example, was informed about alternatives to formula feeding and the danger of mixed feeding. None was offered the option of using banked breast milk. Only around 20% of mothers were informed about the safe preparation of formula feeding. When counselled by a nutritionist (compared with a paediatrician) more mothers were informed about the correct way to prepare bottle-feeds. No mention was made of cup feeding. CONCLUSION: Although health workers have good communication skills, the information provided to HIV+ mothers is insufficient. Recommending against breast-feeding and providing infant formula may not be enough to achieve safer infant-feeding practices.

Aconselhamento em alimentação infantil: um estudo de intervenção / Infant and young child feeding counseling: an intervention study

OBJETIVO: Avaliar a efetividade do Curso Integrado de Aconselhamento em Alimentação Infantil na transformação de conhecimentos, atitudes e práticas de pediatras e nutricionistas da rede municipal de saúde de São Paulo. MÉTODOS: Estudo de intervenção randomizado com 29 profissionais no grupo intervenção e 27 no grupo controle. Entrevistadores previamente capacitados coletaram dados dos profissionais nas unidades de saúde antes da intervenção e 2 meses após. Utilizaram-se três instrumentos para avaliar o perfil do profissional, seus conhecimentos e um roteiro de observação clínica. Para análise, utilizaram-se o teste de Kruskal-Wallis para amostras independentes e o método de Tukey. RESULTADOS: Quanto ao conhecimento, observou-se melhora no grupo intervenção (p < 0,001) para o conjunto das questões e para amamentação (p = 0,004); HIV e alimentação infantil (p = 0,049); alimentação complementar (p = 0,012); e aconselhamento em alimentação infantil (p = 0,004). Quanto ao desempenho, verificou-se que, após a intervenção, houve melhora significativa no grupo intervenção em anamnese alimentar (p < 0,001). CONCLUSÕES: Este curso foi efetivo em propiciar aumento de conhecimento e melhora de desempenho na anamnese alimentar, mas o mesmo não se obteve para habilidades de aconselhamento.

OBJECTIVE: To evaluate the effectiveness of an integrated infant and young child feeding counseling course for transforming the knowledge, attitudes and practices of pediatricians and nutritionists working for the municipal health system of São Paulo, Brazil. METHODS: A randomized intervention study enrolling 29 professionals in the intervention group and 27 in the control group. Interviewers were trained in advance to collect data on the professionals working at health centers, before and 2 months after the intervention. Three research instruments were used, the first was to assess the profile of each professional, the second assessed their knowledge and the third was a clinical observation protocol. Analysis was performed using the Kruskal-Wallis test for independent samples and the Tukey method. RESULTS: The results for the knowledge questionnaire showed improvements in the intervention group (p < 0.001) for the whole questionnaire and for questions on breastfeeding (p = 0.004); HIV and infant and young child feeding (p = 0.049); complementary feeding (p = 0.012); and counseling in infant and young child feeding (p = 0.004). In terms of performance, it was observed that the intervention group had significantly improved their dietary anamnesis after the intervention (p < 0.001). CONCLUSIONS: This course effectively promoted an increase in knowledge and improvements in dietary anamnesis performance, but the same was not true of counseling skills.

Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências / Benefits of breastfeeding for maternal and child health: an essay on the scientific evidence

Este ensaio reúne uma seleção de estudos, particularmente revisões sistemáticas que têm contribuído para aumentar a compreensão sobre os benefícios do aleitamento materno para a criança e para a mulher e sua implementação. Realizou-se uma busca de artigos publicados a partir do ano 2000, sem, no entanto, deixar de lado estudos relevantes para o avanço do conhecimento publicados décadas atrás. Para a seleção dos estudos efetuou-se uma busca na Internet com base nas ferramentas disponíveis no PubMed e SciELO. Além dos aspectos para os quais há consenso, procurou-se incluir estudos sobre resultados controversos e outros que são instigantes, como os provenientes da neurobiologia. Verificam-se mudanças substanciais nas recomendações para políticas públicas em decorrência desses novos conhecimentos. Algumas investigações também têm sido realizadas com o objetivo de avaliar quais intervenções seriam mais efetivas para um aumento das práticas de amamentação. Procurou-se neste artigo dar destaque a: recomendações atuais sobre alimentação da criança pequena; importância da amamentação no início da vida; implicações do aleitamento materno para a saúde da criança; implicações do aleitamento materno para a saúde da mulher; e efetividade de algumas ações pró-amamentação.

This paper provides a literature review on breastfeeding, selecting studies that have helped explain its benefits for maternal and child health. A search for articles published since 2000 was conducted, including relevant studies for the advancement of knowledge in previous decades. An Internet search of the PubMed and SciELO databases was performed to select the studies. Besides the aspects on which there is widespread agreement, controversial results were also included, as well as intriguing ones from the field of neurobiology. Public policy recommendations have undergone substantial changes following those new discoveries. Some studies have also been conducted to search for the most cost-effective measures to promote breastfeeding practices. This paper highlights: current recommendations on child feeding; the importance of breastfeeding for early childhood; the implications of breastfeeding for health of both the infant and mother; and the effectiveness of key interventions to encourage breastfeeding.