Sonia Cristina Masson SertórioI; Isilia Aparecida SilvaII
ICurso de Graduação em Enfermagem. Universidade Paulista. São Paulo, SP, Brasil
IIDepartamento de Enfermagem Materno-infantil e Psiquiátrica. Escola de Enfermagem. Universidade de São Paulo. São Paulo, SP, Brasil
OBJECTIVE: Despite governmental initiatives that control, discourage and even prohibit the divulgation of the usage of dummies and pacifiers in maternity wards, the frequency of pacifier use by Brazilian children is still high. In light of this phenomenon, the aim of the present study was to investigate the social representations of the pacifier constructed by mothers whose children used pacifiers.
METHODS: The present study is based on the conceptual framework of social representations, proposed by Moscovici. We studied women who gave birth at a teaching hospital in the city of Sao Paulo that prohibits the use of pacifiers during hospital admission. We conducted non-structured individual interviews that were transcribed in full and organized for analysis according to the collective subject discourse method.
RESULTS: Our results indicate maternal representations that the pacifier "symbolizes the child," that is "is a tranquilizer for the child and an aid for the mother," and that "its use is inherited from generation to generation."
CONCLUSIONS: Pacifiers are an alternative for the mother for comforting and hushing her child in moments of agitation or for when the mother is not able to tend to the child in a direct and continuous manner.
Keywords: Pacifiers, utilization. Mother-child relations. Breast feeding. Perception. Health knowledge, attitudes, practice.
Tomita et al17 define the pacifier as a low-cost consumption good, widely accessible to the population. Its use is encouraged by parents since very early in the baby's life. These authors also point out that the terms 'pacifier' and 'comforter' indicate that pacifiers are meant to be used for pacifying, or comforting the restless child. However, it is difficult to find records of the origin and spreading of this habit in our society.
The frequency of pacifier use among Brazilian children is quite high. Data from 1993 show that 50% of women form Pelotas, southern Brazil, owned pacifiers already before delivery. Moreover, seven out of ten children already used pacifiers in the first week of life.18
A study carried out in 1997 in Juiz de Fora, southeastern Brazil, with 100 children two to seven years old, found 79% reported pacifier use.5
Some studies show a significant association between pacifier use and decreased duration of breastfeeding.5,13,18 However, the studies found in the current literature were not developed specifically to address this association. It is thus difficult to define the causal relationship between pacifier use and its interference on breastfeeding, or to determine breastfeeding characteristics or variables that may influence the mother's decision whether or not to offer a pacifier to the child.
Notwithstanding, even in the absence of controlled studies that effectively demonstrate the negative interference of pacifiers over breastfeeding, pacifier use has been combated based also on the other hazards it poses to the child's health, which include dental5,9,13,17 and speech problems.2,6
To this end, a number of healthcare institutions have taken measures aimed to systematically discourage pacifier use, preventing their supply to newborns inside the hospital environment.
This strategy is based on the policy of incentive to breastfeeding that directs the Baby-Friendly Hospital Initiative (BFHI)7 and adopts the principles of the "Ten Steps to Successful Breastfeeding", the ninth of which forbids the use of pacifiers by children seen at institutions that follow this program.
These measures seem to ensure only that pacifiers are not adopted while the child is in the hospital, since a study carried out by Paz et al11 (2002), aimed at evaluating the practice of breastfeeding and factors associated to the termination of breastfeeding, showed that 88.2% of children born in a public hospital in the city of Sao Paulo used pacifiers in their first year of life. The institution where these children were delivered, although not a BFHI member, employs the same principles, not offering pacifiers to the newborns and preventing mothers from doing so while mother and child are in the hospital.
The expressive number of children that use pacifies, despite the contrary recommendations made to their mothers by hospital services, encouraged us to undertake the present survey.
Breastfeeding is a practice which involves several dimensions of the woman's life, and may be considered as a hybrid of nature and culture.1 One may therefore speculate that the institutional regulations that attempt to discourage the use of pacifiers based on a professional and scientific rhetoric are not achieving their goals due to the conceptions ingrained in the community. Thus mothers ignore such prohibitions and maintain their reasons for using pacifiers.
The theoretical assumptions adopted are based on the 'social representation' concept, developed in the late 1950's by social psychologist Serge Moscovici. This is a set of concepts, statements, and explanations that constitute the common sense theory, revolutionary in that it values popular knowledge.10
The elaboration of social representations is based on information that circulate among society, often due to the process of social interaction, and which guide the actions of its members.16 Thus, the reality experienced is also represented, and it is through this reality that the social actors move, build their lives, and explain reality in terms of their accumulated knowledge. For Moscovici,9 the beliefs and intentions of social subjects may be used as causal explanations for behavior and actions. Behavior and actions are necessarily connected to representational beliefs, but their consequences are not.
In light of these questions, we sought, in the assumptions of social representations, a theoretical and methodological framework capable of directing the present study, in an attempt to understand and describe the elements that partake in the mother's decision to offer a pacifier to the child.
Based on the database of a study carried out by Paz et al11 (2002), evaluating the use of pacifiers and its relationship to breastfeeding in a population of approximately 800 children, we identified mothers that offered pacifiers to their children (88.2%). We contacted some of these mothers in order to request their participation in the present study.
The number of participants was determined by the saturation of the data, which depended on achieving an understanding of the phenomenon being studied, regardless of the number of women interviewed. Data saturation occurs when the information under scrutiny become repetitive, i.e., new ideas or concepts cease to appear.11
We thus obtained the participation of seven women (two with only one child, three with two children, and two with three children). Inclusion in the study depended solely on their having offered a pacifier to the child.
Non-structured interviews were conducted with the selected women, and were recorded and transcribed in full. The driving question was: "What led you to offer a pacifier to your child?"
Following transcription, interviews were analyzed using the Collective Subject Discourse (CSD) approach,4 which attempts to revive the discourse as a sign of the social representation of phenomena. "Four methodological figures are employed: anchorage: the assumptions, theories, concepts, or hypotheses present in the subject's discourse; central idea: statements that convey the essential content of the discourse; key expressions: transcripts of parts of the discourse that allow for a recovery of the essence of the content of the discourse; and elaboration of the CSD: the selection of the main anchorages, central ideas, and key expressions present in each of the individual discourses and in all discourses together, which culminates with a speech-like reconstitution of the social representation."
The present study was approved by the Research Ethics Committee of the Escola de Enfermagem da Universidade de São Paulo. All participants read and signed a term of free and informed consent, in accordance with statute 196/96 of the Brazilian National Health Committee.8
RESULTS AND DISCUSSION
Central idea 1: The pacifier symbolizes the child
CSD: "I bought a lot of pacifiers when I was pregnant, I bought them so I'd have them, it was part of the baby's layette. They've all had them, because one day you'll need them. Actually everyone buys a lot of pacifiers when the baby is born. And, in my opinion, when a baby doesn't have a pacifier, something's missing, I think it's cute, I've even got a collection of pacifiers, each outfit he'd wear I'd give him a different pacifier, because I thought it was cute, it matched, it was like an accessory..."
We see in the subjects' discourse that a symbolic relationship has been established between the pacifier and the image of the newborn baby. Thus, pacifiers are an item in the baby's layette, along with the clothing and hygiene items traditionally provided to babies.
According to Modesto & Camargo,8 pacifiers are a regular item in the baby's layette. The authors also report that different brands, shapes, colors, and designs have become an irresistible consumption attraction for mothers.
The inclusion of this artifact in the baby's belongings and its acquisition prior to delivery denote two dimensions of common sense that drive maternal choices and actions when preparing for the baby's arrival. The first one concerns the practical and utilitarian aspect of the pacifier, since the mother anticipates the possibility of the baby needing it. Therefore, possessing a pacifier is of particular importance to the mother, since she feels the need to be prepared for such an occurrence.
On the other hand, the discourse also points towards a symbolic representational dimension, which rises the pacifier to the status of a complement to the child's image. Here utility is mingled with a purely ornamental function, given that the image of the child is completed by the use of a pacifier.
According to Moscovici9 "the structure of each representation is an unfolding of two facets as indissociable as the recto and verso of a sheet of paper: the figurative and the symbolic facets."
We may thus consider as the figurative facet of this representation the manner in which the pacifier is perceived by the mother, its connotation of utility. The symbolic facet, on the other hand, leads us to identify the significance given to this artifact: that of an accessory capable of representing the newborn and of complementing the image of the baby.
Central idea 2: The pacifier calms the child and helps the mother
CSD: "The pacifier is a comforter that helps the child. It's a tranquilizer. Children that don't use pacifiers are really agitated, you try to cheer them up, but there's no way. With the pacifier the child calms down. It's good for when the child cries, for when the child is nervous, irritated. Sometimes we get scared, then we give the baby a pacifier and he stops crying, calms down, and sleeps a little, especially when he's had milk, but not enough to go to sleep. The pacifier replaces the breast. Children on breast milk have no hours, they want milk all the time, and sometimes the mother gets tired and offers a pacifier so the child will think he's on the breast. It's a trick, a gimmick, for at that time, that moment, when you can't stop to breastfeed. The pacifier is a type of aid, it's not medicine, but it helps. While the child's quiet you can get a lot of stuff done. So you can avoid trouble."
We see here that the maternal representation of the pacifier is that of a tranquilizer, able to hush and comfort the child.
According to Lopes,6 the pacifier is considered by the mother as a 'divine remedy,' capable of quieting the child.
It is based on this representation that mothers offer the pacifier to their children, in an attempt to provide them with some satisfaction. According to the mothers, with the pacifier the child becomes calmer, cries less, and sleeps more easily. There is, therefore, an overt satisfaction that reinforces the common-sense notion that the pacifier acts as a consolation and a tranquilizer to the newborn child.
In childcare, mothers' actions reflect their expectations regarding an idealized behavior of children.14 When the pacifier is considered as an element capable of quieting the child, it is offered as an attempt to mold the child's behavior, or at least to approximate it to the expected ideal, considering the common-sense notion that children that use pacifiers are calmer.
Silva14 reports that, from the moment the child is born, the mother goes through a learning process of getting to know the child and to understand its language. She acts and reacts in her interaction with the newborn and thus begins to attribute meanings to the child's crying and other manifestations, according to the interpretations she gives to these behaviors.
According to Lebovici,3 crying is a form of communication for the newborn, and is not easily interpreted by the mother, causing anxiety and irritability in adults when not promptly resolved. Thus crying favors maternal insecurity, generating doubts as to her ability to care for the child.
In the present study, we see that mothers interpret persistent crying associated to agitation and alterations in the sleep patterns idealized for the baby as a sign of hunger or dissatisfaction, even if is no more than a need for suction, and not necessarily of complementation of the amount of milk obtained during breastfeeding.
In this light, the child's manifestations are perceived as a further need, which is suction. Thus, due to the impossibility of directly satisfying the child by sustaining breastfeeding for longer periods, pacifiers are considered as replacement, or complement, for maternal care in satisfying the child's suction needs.
For Silva,14 interpreting crying as hunger is also related to the mothers expectation that the child must sleep, or remain awake but calm and quiet, after breastfeeding.
However, in the present study, we see that the mother too can qualify breastfeeding as insufficient in terms of satisfying the baby's suction needs. In this case, the mother seeks alternatives to ensure the baby's satisfaction, and attempts to 'complement' breastfeeding, or the need for suction, with the pacifier, when the child has effectively saciated its hunger.
Pacifiers are also used as a strategy for 'organizing' the breastfeeding schedule to conform to the mother's expectations and availability.
Our results show that, if the baby is being breastfed too frequently i.e., more frequently than the mother's expectations assume thus becoming vexing to the mother, the latter will seek alternatives other than constant breastfeeding in order to keep the child calm.
According to Nakano,10 the experience of breastfeeding includes a conflict between expectation and reality that often frustrates the woman and her romantic view of breastfeeding, thus inducing anxiety and a feeling of needing to overcome problems and obstacles in order to sustain breastfeeding.
In light of the above, we see that the need for being always available to the child generates in the mother a feeling of limitation, especially when breastfeeding is requested at intervals considered 'short' by the mother. Hence, the restriction of the mother's activities, which, before the child's birth, were carried out freely, generates the need for support in caring for the child.
In this sense, the mother sees the pacifier as a source of help. She will thus have more time available for other activities while the child is satisfied with the pacifier.
According to Silva,14 women believe it to be more difficult to care for a newborn than for a preschooler, due to the amount of care required by the former. The baby requires substantial care time, which reinforces the mother's feelings of responsibility, toil, and concern.
From this perspective, especially for multiparae, pacifiers are seen as a form of maternal aid, or support, as a means for 'cheating' the child. Mothers with a single child are dedicated to that child only. From the second child onwards, however, maternal care must be shared between siblings. Thus, by offering a pacifier, the mother is able to comfort the younger child and, at the same time, to care for the other children and attend to her own personal or domestic tasks.
Therefore, we see that, even when facing a current positive experience with respect to breastfeeding, the mother will attempt to offer a pacifier to the child, thus reinforcing its representation as a player in childcare, based on the perception that caring for children who use pacifiers is less toilsome a task.
There is thus a relationship of complicity between mother and pacifier in the quest for hushing the child in moments of restlessness, comforting and tranquilizing the child, helping the mother, and providing security in caring for the child.
Central idea 3: Pacifier use is inherited from generation to generation
CSD: "I did everything they told me to They'd tell me: 'when you have a baby, as soon as it's born, give it a pacifier; pacifiers are good, they'll calm down the baby.' I had that in my head, and I ended up buying a lot of them. So I thought: 'I'm going to make him take it soon, from the very beginning.' My mother and grandmother say that babies that use pacifiers are calmer. People say that babies that don't use them cry too much. Everyone says pacifiers are a good thing. My small cousins used them, my brother uses one still, my sister stopped when she was 12, so I wanted to buy one too. This goes back many generations "
According to Moscovici,9 common sense is defined as the knowledge produced spontaneously by the members of a group, founded on tradition and consensus. In other words, it is knowledge constituted based on our own experiences and on models of thought received and transmitted by social communication.
Therefore, elements drawn from her interaction with the newborn, relatives, and community and from her daily activities lead the mother to structure her attitudes towards breastfeeding and general care for her child. One of these is to offer a pacifier to the baby.
The mother's daily contact with very close persons that use pacifiers in childcare, and that prescribe them based on its presumed ability to hush the newborn, helps reinforce the mother's representation of the pacifier as beneficial to her child.
From the discourse reconstructed based on the mothers' interviews, we have an idea of how much the social context influences the construction of the representation these women have of the pacifier, and the strength this structure exerts upon their conduct regarding the use of pacifiers in childcare.
According to Silva,15 crying is among the child's manifestations most afflicting to mothers in general. Crying can be stressful to both mother and family, especially when it is resistant to attempts to feed or comfort the child.
In these situations, mothers either resort to their own acquired knowledge or allow themselves to be influenced by close persons that provide 'solutions' to the problem. In general, it is these circumstances that favor the use of a bottle, in cases when the baby's manifestation is interpreted as hunger, or of a pacifier, when the cause of the child's restlessness is unknown and hunger is excluded.
In the discourse presented above, we notice the mother's anticipated concern with the baby's crying, along with desire that theirs be a quiet child.
In this context, we can perceive the process of learning the role of mother, which includes developing strategies for caring for the child. Such learning, according to the data presented above, is based on 'watching, listening, and living' with a social group, in which pacifiers may be seen in different models, shapes, and colors, but which consolidates the symbolic and utilitarian representations that span generations.
Thus, by incorporating common-sense knowledge, the mother considers the use of pacifiers as something natural and rational in her future childcare projects.
The results of the present investigation suggest the existence of a social representation of pacifiers that may be used as a causal explanation for mothers' behavior and practice when offering these artifacts to the child. Behavior and practice are logically and necessarily connected to representational beliefs, but their consequences are not.
It is thus possible to understand the symbolic relationship established between the pacifier and the image of the newborn baby, and the anticipation of providing comfort to the child and tranquility to the mother.
Although the present study does not focus on the process of breastfeeding, it is impossible to isolate the use of pacifiers from its context, which seems to occur primarily in connection with the daily practice of breastfeeding or its interruption.
For this reason, it is important to value the knowledge of maternal attitudes towards the breastfeeding experience, since it seems that it is in this context that pacifier use is inserted.
Dependent on factors such as the consolability of the newborn baby, and the mother's ability to hush her child is an extremely significant experience for the mother, and is seen as an element that can qualify her performance as a mother.
In light of the results of the present study, it is necessary to review the content and the approaches currently used by healthcare professionals for discouraging the use or pacifiers, since the arguments used to this end do not seem to target the essence of the maternal motivation behind the act of offering a pacifier to the child.
Our results call for further investigation into this subject, aimed at effectively understanding the effects of pacifiers on child health and behavior.
On the other hand, these results also indicate a need for developing an assistance model able to contemplate and address the mother's need for feeling secure when caring for her child, so that she may find in the healthcare system all the support that she needs.
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Sonia Cristina Masson Sertório
Av. Itaboraí, 424 Apto 81 Bosque da Saúde
04135-000 São Paulo, SP, Brasil
Received on 22/9/2003. Reviewed on 4/6/2004. Approved on 23/9/2004.
Based on the Master's dissertation presented at the Escola de Enfermagem da Universidade de São Paulo in 2002.