enfermagem de amamentação no binômio mãe-filho em Unidade Básica de Saúde Prevalence of nursing diagnoses of breastfeeding in the mother-infant dyad in basic health unit

Estudo transversal, realizado com 28 binômios mãe-filho, usuários de um Centro de Saúde da Família de Fortaleza-CE, Brasil, com o objetivo de identificar os diagnósticos de enfermagem de amamentação, sua frequência de ocorrência, suas características definidoras e o valor da confiança materna com base na escala de autoeficácia em amamentação. Realizou-se a coleta de dados em setembro/outubro de 2010, incluindo entrevista, anamnese e exame físico do binômio. O diagnóstico mais prevalente foi Amamentação eficaz (50%). A escala de autoeficácia em amamentação revelou significância com a presença do diagnóstico Amamentação eficaz e com a ausência de Amamentação interrompida. Embora o diagnóstico Amamentação eficaz tenha uma ocorrência expressiva, evidenciou-se a necessidade de ações efetivas do enfermeiro nesse processo de amamentação. Descritores: Aleitamento Materno; Autoeficácia; Diagnóstico de Enfermagem.


Introduction
Breastfeeding offers significant benefits as it strengthens the affective relationship between mother and child, promotes the baby development by providing the necessary nutrients in the first months of life, and protects against infectious and chronic diseases.For nursing mothers, this brings numerous advantages such as reducing the incidence of breast and ovarian cancer, protecting against osteoporosis, supporting uterine involution, reducing the likelihood of hemorrhage, protecting against anemia, and helping women to regain the weight they had before pregnancy (1)(2) .
Early cessation of breastfeeding can trigger serious consequences, causing damage to both mother and baby, namely: malnutrition, low organic strength, and irreversible infectious cases, thus significantly increasing the infant mortality rate (3) .
The results of a meta-analysis study conducted under the auspices of the World Health Organization (WHO), based on data from three continents, demonstrated that the risk of death from infectious disease in infants weaned in the first two months of life increases by 5.8 times when compared to those breastfed (4) .
Maternal confidence and their ability to breastfeed influence early weaning.Research indicates that low levels of confidence in breastfeeding during the prenatal period lead about 27% of women to stop breastfeeding in the first postpartum week (5) .The risk of breastfeeding cessation is 3.1 times higher in women with low confidence levels than in those who have full confidence (6) .The woman's perspective and belief that she is able to satisfactorily breastfeed her baby describes her confidence in breastfeeding (7) .
Through the breastfeeding self-efficacy scale, the professional can measure the maternal confidence, since by facing their perspectives and skills in breastfeeding, they can plan a better and more individualized assistance seeking to prevent breastfeeding cessation and ending (8) .
The promotion of breastfeeding represents one of the main functions performed by primary care professionals, from the prenatal to the postpartum period.The nurse is extremely important in stimulating and maintaining breastfeeding by encouraging the achievement of guidelines and supports for pregnant and lactating women.However, these professionals need training in order to promote an appropriate practice (9) .
In order for the nurses to commit and assume this role, they need to possess an instrument to standardize and provide quality and individuality to this care.Thus, the use of nursing diagnoses on breastfeeding based on prior knowledge of parenting skills and perspectives provided through the breastfeeding self-efficacy scale is an important tool that will guide them to a better reflection, decision, and action in the care for the mother-infant dyad.a break in the continuity of the breastfeeding process as a result of inability or inadvisability to put the baby to the breast for feeding (10) .
Given the above, this study aimed to identify the nursing diagnoses on breastfeeding, determining their frequency of occurrence as well as their defining characteristics and maternal confidence value based on the breastfeeding self-efficacy scale.

Method
This is a cross-sectional study with quantitative approach, carried out in a basic health unit of 101  and the fifth with the breastfeeding self-efficacy scale.
To assess the agreement between the diagnostic inferences of experts, we applied the Kappa coefficient.
For agreement, we considered the significance level of 5% and the value of the test.

Since the nursing diagnosis Interrupted
Breastfeeding did not achieve a significant p-value for the test, we analyzed each case to determine whether the diagnosis was present or not.We used measures

Results
Of the 28 children assessed, the majority (57.1%) were male.The mean age was 3

Discussion
As presented, this research showed that the nursing diagnosis Effective Breastfeeding was the most prevalent in the 28 dyads analyzed, with 50% occurrence.
A similar survey conducted with puerperas revealed that the Effective Breastfeeding diagnosis was found in 87.5% of the sample, despite 75% presenting the nursing diagnosis Risk for ineffective breastfeeding (12) .Likewise, another study that evaluated the nursing diagnoses in rooming unit identified an occurrence of 88.5% for the Effective Breastfeeding diagnosis (13) .Thus, the results of the abovementioned studies show high prevalence of this nursing diagnosis.
Despite recognizing the increasing trend of breastfeeding in the country, through the efforts of many national and international institutions, data of the II Survey of the Prevalence of Breastfeeding in the Brazilian capital cities and the Federal District, conducted in 2008, revealed that only 9.3% of children breastfed exclusively at the age of 180 days (14) .Among the various causes identified as responsible for this phenomenon, we highlight the lack of professional guidance to current and future mothers on appropriate practices for breastfeeding (15) .
The United Nations Children's Fund (UNICEF) and the WHO launched the Baby-Friendly Hospital Initiative (BFHI), in 1990, aiming to encourage health professionals and institutions to change their routines and behaviors in relation to exclusive breastfeeding, seeking to decrease the rate of early weaning.
In a study conducted in a Baby-Friendly Hospital in the city of Quixadá-CE, Brazil, with 181 mothers, there was a 55.3% prevalence of exclusive breastfeeding at 4 months, and 46.2% at 6 months.
Despite the support to breastfeeding in its various stages in this health institution, the prevalence rates are considered low (16) .
Nevertheless, we recognize that breastfeeding promotion should have a more effective support, being part of routine care.Thus, the nurse professional is responsible for the care to these mothers at all times and after discharge, seeking to guide, show the advantages of exclusive breastfeeding and disadvantages of introductions from other foods in children's diets, warn of the difficulties that may arise, and teach strategies to overcome them.
The data analyzed in this study showed that the Ineffective Breastfeeding diagnosis presented as the most expressive defining characteristic the "Unsatisfactory breastfeeding process", with an incidence of 42.9%, and for Interrupted Breastfeeding: "Insufficient nourishment by the infant at the breast for some or all feedings" with 50%, and "Lack of knowledge regarding expression of breast milk" with 46.5%.
Two studies corroborate the results of this research, identifying that the most frequent defining occurrence.In the present study, this characteristic presented 42.9% frequency, being the most prevalent (17)(18) .
Many factors contribute for mothers to stop exclusively breastfeeding their children, being the most common, reported by them, the perceived inadequate milk supply, the actual inadequate milk supply, or the child that does not want to breastfeed.
This reality reveals the maternal insecurity and the conflicts in this new phase of life (16) .Thus, the nurse professional can minimize the conflicts between scientific and popular knowledge through a careful and comprehensive look to evaluate, guide, and support maternal feelings regarding beliefs, fears, and insecurities.
It is worth mentioning that the identification of risk factors for not breastfeeding or early weaning should be quick, so we can direct the care for the puerperal woman and the child, in order that the diagnostic risks do not become real diagnoses.
The results of this study show that the percentage of mothers who had prenatal care was relatively high, indicating its importance in the breastfeeding process, as it represents a unique moment for health professionals to guide, teach, answer questions, and encourage exclusive breastfeeding.There is evidence that education in prenatal care regarding breastfeeding may have significant effects on its indicators (19) .
The self-efficacy theory defines this term as the belief in one's ability to successfully perform certain tasks or present certain behaviors to produce a desirable outcome (20) .In this perspective, this study showed the importance of the self-efficacy scale, because it was intrinsically associated with nursing diagnoses related to effective breastfeeding in the mother-infant dyad.The results of the study showed that mothers with nursing diagnosis Effective Breastfeeding had higher scores on the scale.
The struggle to reverse the low rates of breastfeeding duration is part of the routine of researchers and professionals involved in maternal and child health.It is necessary to identify women at high risk of early weaning and seek strategies to promote breastfeeding based on maternal confidence in breastfeeding and its elements subject to change, creating the clinical and educational interventions for the necessary changes (11) . The

Conclusion
The study identified that the nursing diagnosis Effective Breastfeeding was the most prevalent (50%) in the mother-infant dyad in a Basic Health Unit of the State of Ceará, followed by the diagnoses Interrupted Breastfeeding (28.6%) and Ineffective Breastfeeding (25%).
The survey also showed that the defining characteristics more prevalent for the Effective Breastfeeding diagnosis were "Infant content after The NANDA International taxonomy (NANDA-I) has three diagnoses on the breastfeeding process: Effective Breastfeeding; Ineffective Breastfeeding; and Interrupted Breastfeeding.These nursing diagnoses are part of Domain 7: Role Relationships and Class 3: Role Performance.The Effective Breastfeeding diagnosis is the state in which a mother-infant dyad-family exhibits proficiency and satisfaction with the breastfeeding process.Ineffective Breastfeeding is the dissatisfaction or difficulty a mother, infant or child experiences with the breastfeeding process.Interrupted Breastfeeding is have a performance review of the nursing role, playing an important role in the acquisition and change of behavior.The filling of both instruments happened through interview, based on information provided by the mother and by physical examination of the dyad, performed in the unit.We collected the anthropometric data of the participating children from records in the child's medical card verified by the health service staff at the time of reception.We invited the mothers to participate and informed them about the objectives of the research; all of them signed the Free and Informed Consent Form.We presented the data to two specialist nurses for the diagnostic inference.For selection of specialist nurses, we conducted a survey on the Lattes Platform, searching for professionals living in the city of Fortaleza and participants of research groups focusing on elements of nursing practice.We informed the experts about the purpose of research, the methods adopted, and availability required for study participation.Upon acceptance, we sent the Free and Informed Consent Form, as well as the reports from the evaluations to determine the nursing diagnoses.We compared the result of the diagnostic inferences made to the result of the breastfeeding self-efficacy scale.We organized the survey data related to each of the reviews in Excel spreadsheets and subsequently processed them in the IBM SPSS version 19.0.We systematized the data compiled in Excel into five spreadsheets: the first identifying the dyad; the second with the nursing diagnosis Effective Breastfeeding; the third with the Ineffective Breastfeeding diagnosis; the fourth with the Interrupted Breastfeeding diagnosis; of central trend and dispersion (mean, median, mode, minimum, maximum, percentiles, and standard deviation) and applied the Mann-Whitney test, Fisher's test, and chi-square test according to the characteristics of each variable and purposes of each test.We respected the ethical aspects regarding research involving human subjects, according to resolution 196/96.The Research Ethics Committee of the Universidade Federal do Ceará approved the research under protocol No. 178/10.
characteristics belonged to the Effective Breastfeeding diagnosis, making this the most prevalent type of diagnosis.The most common defining characteristic in nursing diagnosis Ineffective Breastfeeding was the unsatisfactory breastfeeding process with 100% use of the self-efficacy scale allows the professional to know the area in which women have less confidence, thus enabling a better intervention before she decides for non-breastfeeding or early weaning.During the data collection, the researchers did not find any difficulty.The mothers were quite available and cooperative during the physical examination and completion of the questionnaire and the breastfeeding self-efficacy scale.As a limitation of the study, we highlight the collection of research subjects, since we selected only mothers who sought the health unit spontaneously, without performing active search for the missing ones or looking for all the puerperas of the region covered by the unit.This may somehow have contributed for selecting more proactive mothers in their health care.Despite the results of this study have shown a higher prevalence of the nursing diagnosis Effective Breastfeeding, the rates of exclusive breastfeeding for the six months of a child's life are still considered low, indicating the need for increased knowledge and attention to cultural beliefs and values of mothers when encouraging exclusive breastfeeding.In this context, the nurse assumes a very important role, especially in the quest to reduce rates of early weaning, adopting positive impact interventions, with guidance based on knowledge of the physiology of breastfeeding, home visits, and knowledge of the social environment.
feeding", "Adequate infant elimination patterns for age", and "Effective mother-children communication patterns".For the Ineffective Breastfeeding diagnosis, the most common characteristics was "Unsatisfactory breastfeeding process".For the Interrupted Breastfeeding diagnosis: "Insufficient nourishment by the infant at the breast for some or all feedings" and "Lack of knowledge regarding expression of breast milk".The breastfeeding self-efficacy scale revealed significance with the presence of the Effective Breastfeeding diagnosis and the absence of Interrupted Breastfeeding.We highlight that the nurse must be prepared to provide a more effective assistance, which may be achieved through inference of accurate nursing diagnoses, given that the use of NANDA-I taxonomy favors a more complete view of the mothers in the context of their community.It enables organizing, planning, and directing assistance during the postpartum period.The evaluation of the nursing diagnoses on breastfeeding contributes to the individualization and humanization of care, because it focus on the real needs of puerperas as regards to breastfeeding, also facilitating communication among the professionals responsible for this care.We also highlight the importance of developing new studies, especially in relation to maternal confidence in their breastfeeding, because this knowledge allows the professional to develop actions and more targeted strategies in advance, which may lead, in the medium and long term, to reducing the high rates of early weaning, thus improving the quality of life of the mother-infant dyad.CollaborationsCarvalho OMC and Andrade LZC contributed to drafting the article and final approval of the version to be published.Silva KR contributed to designing the study, data collection, and drafting the article.Silva VM contributed to designing of the study, data interpretation, and drafting the article.Lopes MVO contributed to the analysis and interpretation of data.

diagnoses Nursing diagnosis n Mean age of children p* Mean age of mothers p* %
the tallest being 1.70 m.Most mothers did not plan the pregnancy (57%), but all had prenatal care.Table 1 presents the frequency of occurrence of nursing diagnoses Effective Breastfeeding, Ineffective Breastfeeding, and Interrupted Breastfeeding, as well as the ages of the children and mothers with and without the breastfeeding nursing diagnoses.Table 1 -Distribution of the breastfeeding nursing diagnoses, difference in median age of children and difference in median age of mothers with and without the breastfeeding nursing

Table 2 -
Defining characteristics of the nursing diagnosis Effective Breastfeeding in the mother-infant

Table 3 -
Defining characteristics of the nursing diagnosis Ineffective Breastfeeding in the mother- characteristic was "Insufficient nourishment by the infant at the breast for some or all feedings", present in 14 of the dyads analyzed (50%).

Table 5 -
Difference in mean scores of the Breastfeeding Self-Efficacy Scale among dyads with and without the breastfeeding nursing diagnoses