Abstract

This review evaluated the knowledge of health professionals (HP) about breastfeeding and factors that leading the weaning. A search was performed in four electronics databases and the grey literature. The search strategy included Mesh terms and synonyms. No language or date restrictions were adopted. Studies that evaluated the knowledge of HP about breastfeeding and weaning were considered eligible. The studies retrieved by the searches were evaluated by two independently examiners. From 1,417 studies retrieved, 35 were included. Many countries and professionals from different health areas were analyzed. No studies evaluated the dentists’ knowledge. Although the included HP know the benefits of breastfeeding for health, the length of breastfeeding recommended by the World Health Organization, exclusive or not, was not aligned with all professionals’ endorsement. Information about weaning is scarce; however, HP are mindful of the main potential causes of early weaning. The knowledge of HP is conflicting about breastfeeding and unusual about weaning. Furthermore, no studies were found that presented data on the knowledge of dentists on the subject. Thus, assessments of dentists’ knowledge and education measures for HP are necessary since they are frequently questioned about these issues.

Key words:
Breast feeding; Weaning; Health personnel; Health knowledge; Attitudes

Resumo

Esta revisão avaliou o conhecimento dos profissionais de saúde (PS) sobre amamentação e fatores que levam ao desmame. Realizou-se buscas em quatro bancos de dados eletrônicos e literatura cinzenta. A estratégia de busca incluiu termos Mesh e sinônimos. Não se adotou restrição de idioma ou data. Estudos avaliando o conhecimento dos PS sobre amamentação e desmame foram elegíveis. Estudos recuperados pelas buscas foram avaliados por dois examinadores independentes. Dos 1.417 estudos recuperados, 35 foram incluídos. Muitos países e PS de diferentes áreas foram analisados. Nenhum estudo avaliou o conhecimento dos dentistas. Embora os PS conheçam os benefícios da amamentação, a duração recomendada pela Organização Mundial da Saúde, exclusiva ou não, não está alinhada com o endosso de todos os PS. Considerando o desmame, a informação é escassa. No entanto, os PS estão atentos às principais causas potenciais do desmame precoce. O conhecimento dos PS é conflitante sobre amamentação e incomum sobre o desmame. Não foram encontrados estudos que apresentassem dados sobre o conhecimento de dentistas sobre a temática. Investigações quanto ao conhecimento dos mesmos e medidas de educação para todos os PS são necessárias, considerando que são frequentemente questionados sobre o tema.

Palavras-chave:
Aleitamento materno; Desmame; Pessoal de saúde; Conhecimentos; Atitudes

Introduction

The American Academy of Pediatrics and the World Health Organization (WHO) recommend that infants receive human milk exclusively for the first six months of life and that breastfeeding continue beyond the first or second year of life as long as a family deems appropriate¹1 Cunniff A, Spatz D. Mothers' Weaning Practices When Infants Breastfeed for More Than One Year. MCN Am J Matern Child Nurs 2017; 42(2):88-94.. Breastfeeding offers numerous health benefits for both the baby and the mother in the short and long term. Exclusive breastfeeding reduces the risk of infant mortality by protecting the baby from infectious and chronic diseases, as well as promoting his sensory and cognitive development²2 Gertosio C, Meazza C, Pagani S, Bozzola M. Breastfeeding and its gamut of benefits. Minerva Pediatr 2016; 68(3):201-212..

The term weaning refers to the long transition process in which the child changes from the total dependence on breast milk to the complete interruption of feeding with milk³3 Greiner T. The Concept of Weaning: Definitions and Their Implications. J Hum Lact 1996; 12(2):123-128.^,44 Sellen DW, Smay DB. Relationship between subsistence and age at weaning in "preindustrial" societies. Hum Nat 2001; 12(1):47-87.. Therefore, weaning begins with the introduction of any food other than breast milk and ends when the baby is fed with milk for the last time. Complementary feeding is the period between these two milestones, that is, the association of other foods together with milk⁵5 World Health Organization (WHO). Complementary feeding: report of the global consultation, and summary of guiding principles for complementary feeding of the breastfed child. WHO; 2002. [cited 2020 Jun 4]. Available from: https://apps.who.int/iris/handle/10665/42739
https://apps.who.int/iris/handle/10665/4... .

Therefore, WHO and United Nations International Children’s Emergency Fund (UNICEF) have suggested implementing a program called Ten Steps to Successful Breastfeeding in all institutions providing maternity and newborn services worldwide. The program seeks to support breastfeeding in ten steps, such as ensuring that the professionals involved have sufficient knowledge, competence and skills to support this practice, as well as counseling mothers on the use and risks of feeding using bottles with teats and sucking on pacifiers⁶6 World Health Organization (WHO). Ten steps to successful breastfeeding. [cited 2020 Jun 02]. Available at: http://www.who.int/nutrition/bfhi/ten-steps/en/
http://www.who.int/nutrition/bfhi/ten-st... .

In this context, a multiprofessional team is the ideal, where the dentist, as a health professional, should be included being able to guide the woman on the importance of breastfeeding since there is a strong relationship between natural breastfeeding and the development of the stomatognathic system⁷7 Antunes LS, Antunes LAA, Corvino MPF, Maia LC. Breast-feeding as a source of prevention in healthcare. Cien Saude Colet 2008; 13(1):103-109..

Therefore, knowing the importance of breastfeeding for general health of the baby, this scoping review aimed to evaluate in the available literature the knowledge of health professionals about breastfeeding and weaning, mainly related to exclusive breastfeeding time, weaning age and factors that may be related to early weaning. Thus, this review sought to answer the following question: “What does the literature report about the knowledge of health professionals on breastfeeding and weaning and what are the work areas of these professionals?”

Materials and methods

This scoping review was developed and conducted following the recommendations of Arksey and O’Malley’s⁸8 Askey H, O'Malley L. Scoping Studies: Towards a Methodological Framework. Int J Soc Res Methodol 2005; 8(1):19-32. and Levac, Colquhoun and O’Brien⁹9 Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci 2010; 5:69..

Information sources and search strategy

The search was performed in four electronic databases (PubMed, Lilacs/BBO SciELO and Web of Science) and the grey literature (Open Grey and Trip Database) up to April 2020. The search strategy included the health terminology identified at the Medical Subject Headings (Mesh terms) and synonyms related to the review objective and adapted for each database. There was no language or date limitation. The terms used to construct the strategies were “weaning”, “breastfeeding”, “health education”, “health knowledge, attitudes, practice”, “health education”, “health knowledge, attitudes, practice”, “health personnel” and “allied health personnel”. An expert librarian (DMTPF) guided all process of definition of the included terms in the applied search strategy, as well as the search in each database. The combinations of the terms used in each database are described in Chart 1.

Eligibility criteria and selection of studies

Based on the PCC framework¹⁰10 Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169(7):467-473., the inclusion criteria were cross-sectional study, qualitative study, and self-report survey design with humans (P), found by online search strategy (C) to assess the knowledge of health professionals about breastfeeding and weaning as primary or secondary outcomes (C). Two reviewers (MLD and KRD) analyzed independently the titles and abstracts of the articles retrieved from searches to identify those potentially eligible for this study. The exclusion criteria were animal and clinical trials studies, literature or systematic reviews, guidelines, editorials, letters to the editor, studies with health students and/or professionals from areas different of health, studies about mother’s knowledge, studies that assessed knowledge after an intervention and studies that did not cover the topic relevant to the review objective. If some abstract did not provide enough information for a definite decision, full articles were evaluated. Uncertainties about inclusion were discussed with a third reviewer (AFG), who had read the respective titles and abstracts. Studies available in more than one database were considered only once. Finally, a hand search was performed in the reference list of the included studies. When the full texts were not available, the authors were contacted by e-mail and the research gate website (eight articles were requested by this means). The EndNote website was used for literature management.

Data extraction

Data extracted of the included studies were: characterization of the study (authors, year of publication and country), study design (cross-sectional, qualitative study and self-report survey design), sample (professional category and number of participants), methodology used (questionnaires or others) and main results (exclusive or not exclusive breastfeeding, exclusive and combined breastfeeding time and factors that lead to weaning and others results). When these data were not available in the full texts, the authors were contacted by e-mail and the research gate website. The data collected were analyzed descriptively.

Results

Study selection

Figure 1 presents the flow diagram with the search process. A total of 1,417 studies were identified and 1,362 records remained after the removal of duplicates using the reference manager website. Posteriorly, another 1,310 studies were removed after their titles and abstracts have been evaluated because they did not meet the inclusion criteria. Fifty-two full texts were read and 17 were excluded due to not fulfilling the inclusion criteria. The reasons for the exclusions are described in Figure 1. Ultimately, 35 studies were included in this scoping review.

Study characteristics

Chart 2 shows the characteristics of the 35 included studies in this scoping review. The articles were published between 1984 to 2019. Twelve studies were carried out in the United States of America (USA), four in Brazil, two in Australia, two in Turkey, two in Pakistan and two in Puerto Rico. The other countries that carried out a study were China, Sweden, Chile, Norway, Egypt, France, Lithuania, Iraq, Nigeria, England and India. The articles were written in four languages, English, Portuguese, Spanish, French and Chinese.

Twenty-six cross-sectional studies, five qualitative studies, two descriptive studies, one self-report design and one exploratory study were selected. Questionnaires were used by 27 studies as a method of assessing knowledge, the number of questions ranged from 10 to 139. The other forms of evaluation were interviews and focus groups, chosen by six and two studies, respectively.

A total of 43,579 health professionals were investigated. Of these, 4542 were nurses, 1763 were doctors, 893 midwives, 177 nutritionists, 119 nursing technicians, 99 paramedics, 65 health educators, 29 pharmacists, 23 community health agents, 12 medical office assistants and 1 dental assistant. In four studies, the professional category was not described and one study did not differ the number of nurses from the number of midwives, totaling 35,809 professionals. No studies that evaluate dentists’ knowledge were found.

When the knowledge about breastfeeding was investigated in general - such as the benefits, the difference between the formula used, importance of colostrum - four studies reported a high knowledge level related to breastfeeding¹¹11 Hellings P1, Howe C. Breastfeeding knowledge and practice of pediatric nurse practitioners. J Pediatr Health Care 2004; 18(1):8-14

12 Sallam SA, Babrs GM, Sadek RR, Mostafa AM. Knowledge, Attitude, and Practices Regarding Early Start of Breastfeeding Among Pregnant, Lactating Women and Healthcare Workers in El-Minia University Hospital. Breastfeed Med 2013; 8(3):312-316.

13 Alakaam A, Lemacks J, Yadrick K, Connell C, Choi HW, Newman RG. Maternity Nurses' Knowledge and Practice of Breastfeeding in Mississippi. MCN Am J Matern Child Nurs 2018; 43(4):225-230.^-1414 Xian S, Yue Z, Weiwei F, Lixia C, Xi J, Huishan W, Meijing A, Yanping X. [Research on Knowledge Status and Relevant Factors of Breastfeeding Among Medical Staff in China Based on Network Platform]. [article in Chinese]. Zhonghua Yu Fang Yi Xue Za Zhi 2019; 53(11):1170-1173.. Other studies reported regular knowledge level¹⁵15 Al-Nassaj HH, Al-Ward NJA, Al-Awqati NA. Knowledge, Attitudes and Sources of Information on Breast Feeding Among Medical Professionals in Baghdad. East Mediterr Health J 2004; 10(6):871-878.

16 Spear HJ. Nurses' attitudes, knowledge, and beliefs related to the promotion of breastfeeding among women who bear children during adolescence. J Pediatr Nurs 2004; 19(3):176-183.^-1717 Szucs KA, Miracle DJ, Rosenman MB. Breastfeeding Knowledge, Attitudes, and Practices Among Providers in a Medical Home. Breastfeed Med 2009; 4(1):31-42. or good knowledge level¹⁸18 Marambio LM, Benadof D, Huerta CT. Breastfeeding Knowledge of Health Professionals Working in Municipal Healthcare Centers in Maipu, Chile. Medwave 2017; 17(3):e6891. for most of the investigated sample. With regard to the benefits of breastfeeding, the professionals cited: best source of nutrition for babies¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101.

20 Burglehaus MJ, Smith LA, Sheps SB, Green LW. Physicians and breastfeeding: beliefs, knowledge, self-efficacy and counselling practices. Can J Public Health 1997; 88(6):383-387.

21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24.^-2222 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854., protection against infections in babies¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101.^,2323 Register N1, Eren M, Lowdermilk D, Hammond R, Tully MR. Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J Hum Lact 2000; 16(3):210-215.

24 Hellings P, Howe C. Breastfeeding knowledge and practice of pediatric nurse practitioners. J Pediatr Health Care 2004; 18(1):8-14.

25 Marques ES, Cotta RMM, Franceschini SCC, Botelho MIV, Araújo RMA, Junqueira TS. Práticas e percepções do aleitamento materno: consensos e disssensos no cotidiano de cuidado numa Unidade de Saúde da Família. Rev Saude Colet 2009; 19(2):439-455.^-2626 Hanif R, Khalil E, Sheikh A, Harji A, Haris S, Rasheed MW, Ahmed S, Abdul Aziz K, Shaheen E, Younus A, Mansoor M, Hameed F, Touseef M, Yaseen T. Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals. J Pak Med Assoc 2010; 60(10):881-886., increased immune function²³23 Register N1, Eren M, Lowdermilk D, Hammond R, Tully MR. Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J Hum Lact 2000; 16(3):210-215.

24 Hellings P, Howe C. Breastfeeding knowledge and practice of pediatric nurse practitioners. J Pediatr Health Care 2004; 18(1):8-14.^-2525 Marques ES, Cotta RMM, Franceschini SCC, Botelho MIV, Araújo RMA, Junqueira TS. Práticas e percepções do aleitamento materno: consensos e disssensos no cotidiano de cuidado numa Unidade de Saúde da Família. Rev Saude Colet 2009; 19(2):439-455., prevention of maternal diseases - such as breast cancer²⁷27 Artantas AB, Tetis BK, Kilic M, Eray IK, Cetin N, Güney S, Akdogan D, Domad U, Ustu Y, Ugurlu M. [Knowledge Level, Attitude and Own Experience of Health Professionals About Breastfeeding and Breast Milk in a City of Turkey: Cross-sectional Study]. [article in English, Spanish]. Arch Argent Pediatr 2016; 114(6):514-520.^,2828 Dias RB, Boery RN, Vilela AB. [Knowledge of nurses and incentive strategies for family participation in breastfeeding]. [article in Portuguese]. Cien Saude Colet 2016; 21(8):2527-36., increased emotional bond between mother and child²⁸28 Dias RB, Boery RN, Vilela AB. [Knowledge of nurses and incentive strategies for family participation in breastfeeding]. [article in Portuguese]. Cien Saude Colet 2016; 21(8):2527-36., be convenient²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854. and that it is a cheap food¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101.^,2222 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^,2828 Dias RB, Boery RN, Vilela AB. [Knowledge of nurses and incentive strategies for family participation in breastfeeding]. [article in Portuguese]. Cien Saude Colet 2016; 21(8):2527-36..

The duration of exclusive breastfeeding was investigated by eleven studies. A high level of recommendation was reported by two authors, reaching more than 90% of participants who recommended exclusive breastfeeding until to six months²⁷27 Artantas AB, Tetis BK, Kilic M, Eray IK, Cetin N, Güney S, Akdogan D, Domad U, Ustu Y, Ugurlu M. [Knowledge Level, Attitude and Own Experience of Health Professionals About Breastfeeding and Breast Milk in a City of Turkey: Cross-sectional Study]. [article in English, Spanish]. Arch Argent Pediatr 2016; 114(6):514-520.^,2929 Silvestre PK, Carvalhaes MA, Venâncio SI, Tonete VL, Parada CM. Breastfeeding knowledge and practice of health professionals in public health care services. Rev Lat Am Enfermagem 2009; 17(6):953-960.. Regular level of recommendation was found in four studies, where the recommendation up to six months ranged from 49% to 61% among professionals³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70.

31 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247.

32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^-3333 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483.. In five studies, a low knowledge level about the time of exclusive breastfeeding was observed²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^,2626 Hanif R, Khalil E, Sheikh A, Harji A, Haris S, Rasheed MW, Ahmed S, Abdul Aziz K, Shaheen E, Younus A, Mansoor M, Hameed F, Touseef M, Yaseen T. Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals. J Pak Med Assoc 2010; 60(10):881-886.^,3434 Hull VJ, Thapa S, Wiknjosastro G. Breast-feeding and health professionals: a study in hospitals in Indonesia. Soc Sci Med 1989; 28(4):355-364.

35 Okolo SN, Ogbonna C. Knowledge, Attitude and Practice of Health Workers in Keffi Local Government Hospitals Regarding Baby-Friendly Hospital Initiative (BFHI) Practices. Eur J Clin Nutr 2002; 56(5):438-441.^-3636 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129. where the percentage reached up to 61% of error in the recommendation³⁶36 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129..

Eight studies assessed knowledge about the duration of breastfeeding. Of these, three reported a high knowledge level of the sample with a recommendation level for breastfeeding continuation up to 24 months by 70%²⁶26 Hanif R, Khalil E, Sheikh A, Harji A, Haris S, Rasheed MW, Ahmed S, Abdul Aziz K, Shaheen E, Younus A, Mansoor M, Hameed F, Touseef M, Yaseen T. Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals. J Pak Med Assoc 2010; 60(10):881-886., 83.1%²⁹29 Silvestre PK, Carvalhaes MA, Venâncio SI, Tonete VL, Parada CM. Breastfeeding knowledge and practice of health professionals in public health care services. Rev Lat Am Enfermagem 2009; 17(6):953-960. and 84.8%²⁷27 Artantas AB, Tetis BK, Kilic M, Eray IK, Cetin N, Güney S, Akdogan D, Domad U, Ustu Y, Ugurlu M. [Knowledge Level, Attitude and Own Experience of Health Professionals About Breastfeeding and Breast Milk in a City of Turkey: Cross-sectional Study]. [article in English, Spanish]. Arch Argent Pediatr 2016; 114(6):514-520. of the professionals, respectively. The other four studies reported a low knowledge level about breastfeeding time²¹21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24.^,2222 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^,3131 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247.^,3636 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129.^,3737 Barnett E, Sienkiewicz M, Roholt S. Beliefs About Breastfeeding: A Statewide Survey of Health Professionals. Birth 1995; 22(1):15-20., where 66% of the sample did not recommend that it would be performed until 12 months³⁶36 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129. and almost half of another sample (45%) did not agree or were not sure about that time²¹21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24..

The reasons cited by the professionals to stop breastfeeding or does not recommend its performance were related to mothers, such as: breast abscess¹³13 Alakaam A, Lemacks J, Yadrick K, Connell C, Choi HW, Newman RG. Maternity Nurses' Knowledge and Practice of Breastfeeding in Mississippi. MCN Am J Matern Child Nurs 2018; 43(4):225-230.^,3838 Popkin BM, Yamamoto ME, Griffin CC. Traditional and Modern Health Professionals and Breast-feeding in the Philippines. J Pedriatr Gastroenterol Nutr 1984; 3(5):765-776.^,3939 Pereda LM, Torres RRD, Pérez JA, Rodríguez AMP. [Gynecologists-obstetricians and Pediatricians: Knowledge and Experience Concerning Breast Feeding] [Article in Spanish]. P R Health Sci J 1999; 18(3):251-256., mastitis¹³13 Alakaam A, Lemacks J, Yadrick K, Connell C, Choi HW, Newman RG. Maternity Nurses' Knowledge and Practice of Breastfeeding in Mississippi. MCN Am J Matern Child Nurs 2018; 43(4):225-230.^,3232 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3939 Pereda LM, Torres RRD, Pérez JA, Rodríguez AMP. [Gynecologists-obstetricians and Pediatricians: Knowledge and Experience Concerning Breast Feeding] [Article in Spanish]. P R Health Sci J 1999; 18(3):251-256.^,4040 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., HIV infection³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3333 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483.^,3636 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129., active tuberculosis³³33 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483.^,3838 Popkin BM, Yamamoto ME, Griffin CC. Traditional and Modern Health Professionals and Breast-feeding in the Philippines. J Pedriatr Gastroenterol Nutr 1984; 3(5):765-776., cracked nipples³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,4141 Rasheed S, Siddiqui I, Baig LA. Decline in Breast Feeding, Who Is to Be Blamed?!! A Study of Knowledge, Attitude and Practice of Breast Feeding Amongst Nurses. J Pak Med Assoc 2000; 50(1):8-11., hepatitis B³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3333 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483., hepatitis C³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3333 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483., working mothers³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70.^,3737 Barnett E, Sienkiewicz M, Roholt S. Beliefs About Breastfeeding: A Statewide Survey of Health Professionals. Birth 1995; 22(1):15-20.^,4040 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., student mothers⁴⁰40 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., teenage mothers¹⁶16 Spear HJ. Nurses' attitudes, knowledge, and beliefs related to the promotion of breastfeeding among women who bear children during adolescence. J Pediatr Nurs 2004; 19(3):176-183.^,4040 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., mental retardation⁴⁰40 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., maternal fatigue²¹21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24., use of illicit drugs³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5. and lack of breast milk³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70.. The reasons related to babies were: baby’s diarrhea¹³13 Alakaam A, Lemacks J, Yadrick K, Connell C, Choi HW, Newman RG. Maternity Nurses' Knowledge and Practice of Breastfeeding in Mississippi. MCN Am J Matern Child Nurs 2018; 43(4):225-230.^,3838 Popkin BM, Yamamoto ME, Griffin CC. Traditional and Modern Health Professionals and Breast-feeding in the Philippines. J Pedriatr Gastroenterol Nutr 1984; 3(5):765-776.^,3939 Pereda LM, Torres RRD, Pérez JA, Rodríguez AMP. [Gynecologists-obstetricians and Pediatricians: Knowledge and Experience Concerning Breast Feeding] [Article in Spanish]. P R Health Sci J 1999; 18(3):251-256.^,4141 Rasheed S, Siddiqui I, Baig LA. Decline in Breast Feeding, Who Is to Be Blamed?!! A Study of Knowledge, Attitude and Practice of Breast Feeding Amongst Nurses. J Pak Med Assoc 2000; 50(1):8-11., child’s galactosemia³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3333 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483., child’s jaundice³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5., engorgement⁴⁰40 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., biting while breastfeeding²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854., dehydration up to three days after delivery⁴²42 Fonseca-Machado Mde O, Haas VJ, Monteiro JC, Gomes-Sponholz F. Continuing education in nursing as a factor associated with knowledge on breastfeeding. Invest Educ Enferm 2014; 32(1):139-147., baby seems to be hungry⁴²42 Fonseca-Machado Mde O, Haas VJ, Monteiro JC, Gomes-Sponholz F. Continuing education in nursing as a factor associated with knowledge on breastfeeding. Invest Educ Enferm 2014; 32(1):139-147., insufficient weight gain for babies³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70. and premature babies or low birth weight³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70..

In two studies⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223.^,4444 Sims AM, Long SA, Tender JAF, Young MA. Surveying the Knowledge, Attitudes, and Practices of District of Columbia ACOG Members Related to Breastfeeding. Breastfeed Med 2015; 10(1):63-68. the professionals pointed out causes that can influence early weaning, such as: maternal mental health conditions, breast surgeries, prescribed medications, social situations, socioeconomic conditions, return to work⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223., families that were not well informed, families that prefer a formula, a nurse’s recommendation, a nursing team that did not encourage breastfeeding, a neonatologist’s recommendation, doctors that do not encourage breastfeeding and inadequate lactation consultation⁴⁴44 Sims AM, Long SA, Tender JAF, Young MA. Surveying the Knowledge, Attitudes, and Practices of District of Columbia ACOG Members Related to Breastfeeding. Breastfeed Med 2015; 10(1):63-68..

The barriers highlighted by health professionals to promote breastfeeding were: lack of knowledge and psychological support to mothers⁴⁵45 Patton CB, Beaman M, Csar N, Lewinski. Nurses' Attitudes and Behaviors that Promote Breastfeeding. J Hum Lact 1996; 12(2):111-115., lack of professional time³³33 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483.^,4545 Patton CB, Beaman M, Csar N, Lewinski. Nurses' Attitudes and Behaviors that Promote Breastfeeding. J Hum Lact 1996; 12(2):111-115., need for training, being comfortable to guide mothers only when they asked, and they do not believe that they can influence the mother³³33 Schaffar A, Huyghe A-S, Bomy H, Duriez P, Ego A, Pierrat V. [Breastfeeding: Opinion and Knowledge of Pharmacists. A Study in a Semi-Urban Territory] [Article in French]. Arch Pediatr 2012; 19(5):476-483..

Discussion

Breastfeeding is a natural process of mammals that has health and psychological benefits for both mother and baby²2 Gertosio C, Meazza C, Pagani S, Bozzola M. Breastfeeding and its gamut of benefits. Minerva Pediatr 2016; 68(3):201-212.. As evidenced by our results, most professionals are familiar with these benefits¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101.^,2121 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24.

22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^-2323 Register N1, Eren M, Lowdermilk D, Hammond R, Tully MR. Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J Hum Lact 2000; 16(3):210-215.^,2727 Artantas AB, Tetis BK, Kilic M, Eray IK, Cetin N, Güney S, Akdogan D, Domad U, Ustu Y, Ugurlu M. [Knowledge Level, Attitude and Own Experience of Health Professionals About Breastfeeding and Breast Milk in a City of Turkey: Cross-sectional Study]. [article in English, Spanish]. Arch Argent Pediatr 2016; 114(6):514-520.^,2828 Dias RB, Boery RN, Vilela AB. [Knowledge of nurses and incentive strategies for family participation in breastfeeding]. [article in Portuguese]. Cien Saude Colet 2016; 21(8):2527-36.^,3232 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.. However, according to the World Health Organization (WHO), almost two out of three babies are not exclusively breastfed until the age of six months, a fact that has not improved in decades⁴⁶46 World Health Organization (WHO). Health topics: Breastfeeding. [cited 2020 Jun 02]. Available at: https://www.who.int/health-topics/breastfeeding#tab=tab_1
https://www.who.int/health-topics/breast... .

The economic benefit of breastfeeding was highlighted among the health professionals who participated in the reviewed studies¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101.^,2222 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^,2828 Dias RB, Boery RN, Vilela AB. [Knowledge of nurses and incentive strategies for family participation in breastfeeding]. [article in Portuguese]. Cien Saude Colet 2016; 21(8):2527-36., being considered the cheapest way to feed a baby. Despite this benefit, Melin, Björklund and Zwedberg⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223. reported that doctors believed that one of the factors related to the mothers’ decision not to breastfeed or stop after a few months would be the socioeconomic condition, since low-income countries have lower rates of breastfeeding. This behavior contradicts the findings of a major literature reviewed that states that, with a few exceptions, the duration of breastfeeding in high-income countries is shorter compared to low-income countries⁴⁷47 Victora CG, Bahl R, Barros RJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC. Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect. Lancet 2016; 387(10017):475-490..

In our results, many professionals agree that they play an important role in the approach of breastfeeding⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223.^,4444 Sims AM, Long SA, Tender JAF, Young MA. Surveying the Knowledge, Attitudes, and Practices of District of Columbia ACOG Members Related to Breastfeeding. Breastfeed Med 2015; 10(1):63-68. and that they act directly in this process helping with breastfeeding techniques, advice on infant feeding methods¹⁹19 Lazzaro E, Anderson J, Auld G. Medical professionals' attitudes toward breastfeeding. J Hum Lact 1995; 11(2):97-101., prenatal counseling and lactation problems¹³13 Alakaam A, Lemacks J, Yadrick K, Connell C, Choi HW, Newman RG. Maternity Nurses' Knowledge and Practice of Breastfeeding in Mississippi. MCN Am J Matern Child Nurs 2018; 43(4):225-230.. However, professionals report that they receive guidelines about the benefits of breastfeeding during their courses, but practical training on breastfeeding techniques is insufficient³²32 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.. Melin, Björklund and Zwedberg⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223. highlight that courses are concerned with the type of baby’s nutrition and not with the practical of breastfeeding itself. Thus, health professionals reported having acquired their knowledge about the practical of breastfeeding with professionals different from their own area⁴⁵45 Patton CB, Beaman M, Csar N, Lewinski. Nurses' Attitudes and Behaviors that Promote Breastfeeding. J Hum Lact 1996; 12(2):111-115., or through their own experience as mothers or still through the observation of mothers in the community that they live or work²⁵25 Marques ES, Cotta RMM, Franceschini SCC, Botelho MIV, Araújo RMA, Junqueira TS. Práticas e percepções do aleitamento materno: consensos e disssensos no cotidiano de cuidado numa Unidade de Saúde da Família. Rev Saude Colet 2009; 19(2):439-455., and also through lectures¹⁵15 Al-Nassaj HH, Al-Ward NJA, Al-Awqati NA. Knowledge, Attitudes and Sources of Information on Breast Feeding Among Medical Professionals in Baghdad. East Mediterr Health J 2004; 10(6):871-878..

It is important to report that attitudes and practices about breastfeeding and weaning were not actually evaluated in the present study, as there were no studies that assessed such outcomes, which could be a limitation. This was the reason why the keywords “attitudes” and “practice” appears in the search strategy, but nothing is presented about this issue.

Two studies show that the level of professional qualification influences the knowledge about breastfeeding of health professionals, where professionals with higher educational background had a higher rate of knowledge than those with less education¹⁴14 Xian S, Yue Z, Weiwei F, Lixia C, Xi J, Huishan W, Meijing A, Yanping X. [Research on Knowledge Status and Relevant Factors of Breastfeeding Among Medical Staff in China Based on Network Platform]. [article in Chinese]. Zhonghua Yu Fang Yi Xue Za Zhi 2019; 53(11):1170-1173.^,4141 Rasheed S, Siddiqui I, Baig LA. Decline in Breast Feeding, Who Is to Be Blamed?!! A Study of Knowledge, Attitude and Practice of Breast Feeding Amongst Nurses. J Pak Med Assoc 2000; 50(1):8-11.. In our work, studies with graduated and non-graduated professionals were included. Thus, we do not believe that this factor has negatively influenced our results, as some professionals included in the samples of the selected studies did not graduate from universities, but receive specific training for breastfeeding and breast milk²³23 Register N1, Eren M, Lowdermilk D, Hammond R, Tully MR. Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J Hum Lact 2000; 16(3):210-215.^,2727 Artantas AB, Tetis BK, Kilic M, Eray IK, Cetin N, Güney S, Akdogan D, Domad U, Ustu Y, Ugurlu M. [Knowledge Level, Attitude and Own Experience of Health Professionals About Breastfeeding and Breast Milk in a City of Turkey: Cross-sectional Study]. [article in English, Spanish]. Arch Argent Pediatr 2016; 114(6):514-520.. However, most of the studies included in our review have a sample of graduated professionals.

Another factor that influenced the level of knowledge of professionals was personal experience. However, this personal experience should be interpreted with caution, as demonstrated by Szucs et al.¹⁷17 Szucs KA, Miracle DJ, Rosenman MB. Breastfeeding Knowledge, Attitudes, and Practices Among Providers in a Medical Home. Breastfeed Med 2009; 4(1):31-42., who affirmed that personal experience of health professionals referring to breastfeeding may be related to recommendations contrary to the evidence-based recommendations. In addition, Xian et al.¹⁴14 Xian S, Yue Z, Weiwei F, Lixia C, Xi J, Huishan W, Meijing A, Yanping X. [Research on Knowledge Status and Relevant Factors of Breastfeeding Among Medical Staff in China Based on Network Platform]. [article in Chinese]. Zhonghua Yu Fang Yi Xue Za Zhi 2019; 53(11):1170-1173., highlighted that health professionals who were parents of children up to two years old had more knowledge about breastfeeding than professionals who did not have children. Also, Svendby et al.³⁶36 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129. reported that female professionals had more knowledge than male professionals.

When comparing the knowledge of different professionals, one study related that the knowledge of doctors was lower than those of nutritionists, midwives and nurses¹⁸18 Marambio LM, Benadof D, Huerta CT. Breastfeeding Knowledge of Health Professionals Working in Municipal Healthcare Centers in Maipu, Chile. Medwave 2017; 17(3):e6891.. However, in another evaluation⁴⁰40 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804., they did not show scores that were statistically different from those of nutritionists or nurses. Although they reported being able to manage medical problems such as mastitis, doctors reported delegating the responsibility of providing practical breastfeeding support to lactation consultants²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854. and midwives⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223.. Therefore, there is a need to improve multiprofessional work and communication between the groups involved with breastfeeding, highlighting that they should receive mutual learning⁴³43 Melin A, Björklund P, Zwedberg S. Pediatricians' Experiences of Working with Breastfeeding: An Interview Study. Sex Reprod Healthc 2018; 16:218-223..

Considering the breastfeeding time, the WHO recommends exclusive breastfeeding for the first six months of life, followed by breastfeeding associated with adequate complementary food for up to two years or more⁴⁸48 World Health Organization (WHO). Global strategy for infant and young child feeding. Fifty-Fourth World Health Assembly. Geneva: WHO; 2003. [cited 2020 Jun 4]. Available at: http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.pdf.. It is known that exclusive breastfeeding is the best source of protection and nutrition for the baby up to the sixth month of life, with no other type of food or liquid necessary⁴⁹49 Lima APC, Nascimento DS, Martins MMF. The practice of breastfeeding and the factors that take to early weaning: an integrating review. J Health Biol Sci 2018; 6(2):189-196.. However, our results show that knowledge about exclusive breastfeeding for up to six months is not satisfactory²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854.^,2626 Hanif R, Khalil E, Sheikh A, Harji A, Haris S, Rasheed MW, Ahmed S, Abdul Aziz K, Shaheen E, Younus A, Mansoor M, Hameed F, Touseef M, Yaseen T. Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals. J Pak Med Assoc 2010; 60(10):881-886.^,3131 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247.^,3434 Hull VJ, Thapa S, Wiknjosastro G. Breast-feeding and health professionals: a study in hospitals in Indonesia. Soc Sci Med 1989; 28(4):355-364.

35 Okolo SN, Ogbonna C. Knowledge, Attitude and Practice of Health Workers in Keffi Local Government Hospitals Regarding Baby-Friendly Hospital Initiative (BFHI) Practices. Eur J Clin Nutr 2002; 56(5):438-441.^-3636 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129.. It has been shown that doctors and nurses recommended that mothers give liquids and solid foods to babies under six months of age³¹31 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247..

Even though the WHO recommendation is not current⁴⁸48 World Health Organization (WHO). Global strategy for infant and young child feeding. Fifty-Fourth World Health Assembly. Geneva: WHO; 2003. [cited 2020 Jun 4]. Available at: http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.pdf., our results demonstrate that there is a lack of knowledge among professionals regarding the duration of breastfeeding. Levinienė et al.³¹31 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247. reported that the most of general practitioners and nurses did not know that breastfeeding with complementary foods should be continued until two years of age or older. In addition, more recent studies have cited that general practitioners have demonstrated negative opinions about breastfeeding up to twenty-four months²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854. and almost half have recommended that children be breastfed up to twelve months³⁶36 Svendby HR, Løland BF, Omtvedt M, Holmsen ST, Lagerløv P. Norwegian General Practitioners' Knowledge and Beliefs About Breastfeeding, and Their Self-Rated Ability as Breastfeeding Counsellor. Scand J Prim Health Care 2016; 34(2):122-129.. It is worth mentioning that one of the studies²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854. was carried out in Australia where the national health and medical research council recognizes the continuation of breastfeeding for at least twelve months, which can cause confusion regarding the professionals’ guidelines and is not according to the guidelines established by the WHO.

A review of the previous literature evaluating studies with nursing mothers highlighted the factors that make breastfeeding difficult and cause early weaning, which could be: the perception of weak or insufficient milk, use of a pacifier, return to work or school, nipple fissure and pain, lack of encouragement from health professionals for exclusive breastfeeding, precarious knowledge of mothers about the importance of breastfeeding, low level of education of the mother and increasing the child’s age⁴⁹49 Lima APC, Nascimento DS, Martins MMF. The practice of breastfeeding and the factors that take to early weaning: an integrating review. J Health Biol Sci 2018; 6(2):189-196.. In our results, we observed that many professionals reported at least one of these situations as a factor for not indicating or not encouraging breastfeeding³⁰30 Karaçam Z, Kitis Y. What Do Midwives and Nurses in Turkey Know About Nutrition in the First Six Months of Life. Midwifery 2005; 21(1):61-70.^,3232 Leavitt G, Martínez S, Ortiz N, García L. Knowledge About Breastfeeding Among a Group of Primary Care Physicians and Residents in Puerto Rico. J Community Health 2009; 34(1):1-5.^,3737 Barnett E, Sienkiewicz M, Roholt S. Beliefs About Breastfeeding: A Statewide Survey of Health Professionals. Birth 1995; 22(1):15-20.^,4040 Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Knowledge and Attitudes Toward Breast-Feeding: Differences Among Dietitians, Nurses, and Physicians Working with WIC Clients. J Am Diet Assoc 1993; 93(7):801-804.^,4141 Rasheed S, Siddiqui I, Baig LA. Decline in Breast Feeding, Who Is to Be Blamed?!! A Study of Knowledge, Attitude and Practice of Breast Feeding Amongst Nurses. J Pak Med Assoc 2000; 50(1):8-11.. However, these studies were carried out more than ten years ago and what makes us believe that a change in the knowledge regarding factors such as weak milk, nipple fissure and returning to work or school is happening. Despite this, the lack of maternal knowledge and the lack of encouragement from health professionals reported by mothers demonstrates their direct influence on the success of breastfeeding, as observed by Sims et al.⁴⁴44 Sims AM, Long SA, Tender JAF, Young MA. Surveying the Knowledge, Attitudes, and Practices of District of Columbia ACOG Members Related to Breastfeeding. Breastfeed Med 2015; 10(1):63-68..

Our results demonstrated a conflict of knowledge related to weaning and beginning of deciduous dentition. McLaughlin et al.²¹21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24. and Pereda et al.³⁹39 Pereda LM, Torres RRD, Pérez JA, Rodríguez AMP. [Gynecologists-obstetricians and Pediatricians: Knowledge and Experience Concerning Breast Feeding] [Article in Spanish]. P R Health Sci J 1999; 18(3):251-256. reported that doctors and nurses do not recommend weaning when the rash starts. However, Holtzman and Usherwood²²22 Holtzman O, Usherwood T. Australian general practitioners' knowledge, attitudes and practices towards breastfeeding. PLoS One 2018; 13(2):e0191854. reported that a doctor stated he recommends that mothers wean if the baby bites while breastfeeding. The American Academy of Pediatric Dentistry (AAPD) recommends that children should be taken to the pediatric dentist at no later than your child’s first birthday or when the time of the eruption of the first tooth⁵⁰50 American Academy of Pediatric Dentistry (AAPD). A National Children's Dental Health Month Letter from AAPD President Dr. Donly. [cited 2020 Jun 02]. Available at: https://www.aapd.org/about/about-aapd/news-room/latest-news/a-national-childrens-dental-health-month-letter-from-aapd-president-dr.-donly/
https://www.aapd.org/about/about-aapd/ne... . This is an opportune time for the dentist to provide guidance on the benefits of breastfeeding, the correct weaning protocol and appropriate oral hygiene guidelines. It is known that oral health is an integral part of the general health and that child’s general health care cannot be achieved if oral care is not included⁵¹51 American Academy of Pediatric Dentistry (AAPD). Policy on Oral Health Care Programs for Infants, Children, and Adolescents. The Reference Manual of Pediatric Dentistry. Pediatr Dent 2019-2020; p. 32-33.. Despite that, none of the selected studies evaluated the knowledge of dentists about breastfeeding and weaning. That is, after the systematic search in each electronic base, none of the studies included dentists as part of the sample. Thus, it represents a warning sign for dentists, which suggests that they are not considered by many to be professionals who work directly with such themes in their clinical practices.

An important habit reported in our results and the dentist’s technical competence is the use of pacifiers. The use of pacifiers can cause a decrease in the frequency of feedings, reduced stimulation, and withdrawal of breast milk, which leads to less milk production, and consequently to weaning⁵²52 Sertório SCM, Silva IA. As faces simbólicas e utilitária da chupeta na visão de mães. Rev Saúde Pública 2005; 39(2):156-162.. In addition, non-nutritive sucking habits, such as the use of pacifiers, can negatively affect the orofacial system. Scientific evidence has shown an association between the use of pacifiers and the presence of anterior open bite and posterior cross bite. So-called orthodontic pacifiers reduce the prevalence of open bite when compared to non-orthodontic pacifiers; however, it is not possible to state that orthodontic pacifiers show a positive effect on crossbite⁵³53 Schmid KM, Kugler R, Nalabothu P, Bosch C, Verna C. The Effect of Pacifier Sucking on Orofacial Structures: A Systematic Literature Review. Prog Orthod 2018; 19(1):8.. In our results, opinions about the use of pacifiers were contradictory, Levinienė et al.³¹31 Leviniene G, Petrauskiene A, Tamuleviciene E, Kudzyte J, Labanauskas L. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina (Kaunas) 2009; 45(3):238-247., Silvestre et al.²⁹29 Silvestre PK, Carvalhaes MA, Venâncio SI, Tonete VL, Parada CM. Breastfeeding knowledge and practice of health professionals in public health care services. Rev Lat Am Enfermagem 2009; 17(6):953-960. and Fonseca-Machado et al.⁴²42 Fonseca-Machado Mde O, Haas VJ, Monteiro JC, Gomes-Sponholz F. Continuing education in nursing as a factor associated with knowledge on breastfeeding. Invest Educ Enferm 2014; 32(1):139-147. agree that pacifiers should not be recommended as it can negatively affect breastfeeding. However, more than a half of the nurses assessed by McLaughlim et al.²¹21 McLaughlin M, Fraser J, Young J, Keogh S. Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant. Breastfeed Rev 2011; 19(3):13-24. did not know that pacifiers can cause confusion in babies who are starting the breastfeeding. In addition, Szucs, Miracle and Rosenman¹⁷17 Szucs KA, Miracle DJ, Rosenman MB. Breastfeeding Knowledge, Attitudes, and Practices Among Providers in a Medical Home. Breastfeed Med 2009; 4(1):31-42. reported that some professionals advise the early use of pacifiers. These counterpoints once again demonstrate the importance of including all health professionals, involving dentists, in child health promotion programs and research on breastfeeding and weaning.

As previously highlighted, breastfeeding plays an important role in child health. In this sense, it has an extremely importance for the development of a normal dental occlusion. Studies have shown a lower proportion of malocclusion in primary dentition in children breastfed up to 12 months⁵⁴54 Corrêa-Faria P, de Abreu MHNG, Jordão LMR, Freire MCM, Costa LR. Association of Breastfeeding and Malocclusion in 5-year-old Children: Multilevel Approach. Int J Paediatr Dent 2018; 28(6):602-607. or more⁵⁵55 Peres KG, Chaffee BW, Feldens CA, Flores-Mir C, Moynihan P, Rugg-Gunn A. Breastfeeding and Oral Health: Evidence and Methodological Challenges. J Dent Res 2018; 97(3):251-258., regardless the sociodemographic factors. Another advantage of natural breastfeeding clarified in the recent years is that breast milk alone does not cause a decrease in the biofilm pH, suggesting that breastfeeding alone may not contribute to early childhood caries⁵⁶56 Neves PAM, Ribeiro CCC, Tenuta LMA, Leitão TJ, Monteiro-Neto V, Nunes AMM, Cury JA. Breastfeeding, Dental Biofilm Acidogenicity, and Early Childhood Caries. Caries Res 2016; 50:319-324.. In addition, a systematic review suggests that children breastfed exclusively for up to 12 months compared to those breastfed for less time were protected from tooth decay⁵⁷57 Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau ZXM, Dai X, Allen KJ, Lodge CJ. Breastfeeding and the Risk of Dental Caries: A Systematic Review and Meta-Analysis. Acta Paediatr 2015; 104(467):62-84.. Thus, we emphasize the importance of pediatric dentistry in the care of newborns, so that risk assessments of early childhood caries should be carried out, as well as the diagnosis and early intervention of malocclusions.

Health education can be considered a process that induces behavioral change related to health, not only individual, but also collective⁵⁸58 Miranda J, Lemos M, Torres M, Sovieiro V, Cruz R. Promoção de saúde bucal em odontologia: uma questão de conhecimento e motivação. Rev do CROMG 2000; 6(3):154-157.. Given the importance of the dentist highlighted here earlier, the rapprochement between pregnant women/infants and a multiprofessional health team including dentists appears to be a fundamental challenge for the beginning of a promising oral health promotion cycle for women and babies. It is essential to rethink the formation of an interprofessional prenatal work team⁵⁹59 Finkler M, Oleiniski DMB, Ramos FRS. Pregnancy and Oral Health: a Social Representation Study. Texto Contexto Enferm 2004; 13(3):360-368.. In this context, the dentist may be part of this team, being responsible for the development of oral health education actions, where women can become aware of their important role in the acquisition of positive oral health habits and their maintenance, acting as an information multiplying agent⁶⁰60 Reis DM, Pitta DR, Ferreira HMB, de Jesus MCP, de Moraes MEL, Soares MG. Health education as a strategy for the promotion of oral health in the pregnancy period. Cien Saude Colet 2010; 15(1):269-276.. In addition, dentists in a pre-natal team would welcome and support breastfeeding, highlighting its importance for the development of the stomatognathic system⁷7 Antunes LS, Antunes LAA, Corvino MPF, Maia LC. Breast-feeding as a source of prevention in healthcare. Cien Saude Colet 2008; 13(1):103-109..

The need and lack of specific training on breastfeeding were reported by the authors²³23 Register N1, Eren M, Lowdermilk D, Hammond R, Tully MR. Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J Hum Lact 2000; 16(3):210-215.^,2525 Marques ES, Cotta RMM, Franceschini SCC, Botelho MIV, Araújo RMA, Junqueira TS. Práticas e percepções do aleitamento materno: consensos e disssensos no cotidiano de cuidado numa Unidade de Saúde da Família. Rev Saude Colet 2009; 19(2):439-455. and observed in our study. We believe that this factor may have influenced the low level of knowledge of professionals, especially regarding the time and management of practical problems that may occur during the breastfeeding period. Thus, the importance of implementing breastfeeding promotion programs during the training of health professionals and effective policies to promote child health is highlighted. In addition, we emphasize the inclusion of the dentist in this context as a fundamental part of promoting the child’s comprehensive health.

Conclusion

This scope review shows that health professionals with different formations are aware of the benefits of breastfeeding for the mother and the baby. However, these issues have conflicting knowledge about the exclusive breastfeeding time and the duration of breastfeeding. Moreover, despite the knowledge of the main reasons that may lead to early weaning, many professionals are trapped in barriers to promote breastfeeding.

Acknowledgments

We are grateful to the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for granting the doctoral scholarships to the first and second authors respectively.

References

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