In this study, we found a high prevalence of complement offer, which corroborates the findings of studies conducted in other countries and in Brazilian cities [2, 14, 15, 19]. Although the WHO recommends skin-to-skin contact at birth, breastfeeding in the first hour of life and “Do not give the newborn baby any food or drink other than breast milk, unless such procedure has a medical indication”, most NB received the complement in the first hours and days after birth. We even found that this offer happened without any justifiable indication on the part of BFHI and often without a medical prescription.
The actions instituted by the United Nations Children’s Fund and the WHO, through BFHI, have contributed to the success of breastfeeding and to the reduction of the offer of complementary food [4, 20], which differs from the results introduced in this research. Among the participating institutions, only one did not have the degree named “Baby-Friendly Hospital Initiative”. Nevertheless, holding this degree did not favor the achievement of differentiated outcomes. The administrative nature, the level of complexity and the ratio of the number of professionals per bed did not influence the offer of the complement. These findings differ from those obtained by studies in the United Kingdom, whose lack of personnel, perception of the importance of support and professional education were associated with the offer of the complement with infant formulas [12]. However, sociocultural and biological maternal factors were protective (age) and predictors (parity and type of delivery) for such an outcome.
The maternal age under 29 years behaved as a protective factor, opposing the Australian study developed by Bentley and collaborators [17]. This study had the participation of mothers whose intention was to exclusively breastfeed. However, NB whose mothers were less than 25 years old had 20% more indication of maternal milk complement than those with higher ages. The protective effect identified in this study may be due to the priority care recommended by the WHO for this most vulnerable group.
Conversely, the prevalence of this offer increased by 1.37 times for NB of primiparous mothers, being consistent with the pertinent literature. This vulnerability can be justified by the absence of previous breastfeeding [16, 21], inadequate milk perception, pain, breast milk problems [22] and cesarean section. The latter was associated to a 20% increase in the complement prevalence, corroborating the findings in the pertinent literature [17]. When knowing that 46% of the children in this study were born from cesarean section – being even higher than the recommended by the WHO (10%) to reduce maternal and neonatal mortality – such association is worrying. Brazil has implemented public policies that, in addition to contributing to the reduction of unnecessary interventions to the mother-child binomial, also aim at improving breastfeeding indicators from their promotion. Among them, we can highlight the Stork Network, the Apice-On qualification and the BFHI [1, 23].
Nonetheless, the main reason for indicating the complement was the absence of colostrum; however, this does not fit as an acceptable medical reason. Conversely, only 42.3% showed clinical conditions justifiable through BFHI (deficiency of latch and suction, large NB for gestational age, among other reasons related to the clinical conditions of NB and mothers) [4].
Besides these, the absence of records about the reasons in the medical records and the absence of explanation about the offer of the complement to the mother encompassed 24% of the sample. Such findings are in agreement with the study by Newhook et al. [10]; and in disagreement with those of Pinheiro et al. (2016) [6], also conducted in Rio Grande do Norte – the same state where the present study happened – as well as in the study by Biggs et al. [12] in the United Kingdom.
No matter how strictly the indication criteria are defined, in order to maintain NB in EB, the occurrence of hypoglycemia is a constant concern of the health care team. The maternal desire in offering the complement has been another reason that has led the health team to adopt such behavior [24]. In order for the mother to be able to go through this process without the newborn needing the use of a complement, we should underline the essentiality of the support of the multiprofessional team – who must be engaged and follow the guidelines of the “Ten Steps to Successful Breastfeeding” – in the delivery room and in the rooming-in setting. Breastfeeding in the first hour of life, as well as guidance on breastfeeding techniques and the characteristics and benefits of breastfeeding, allow maternal empowerment and are fundamental to reassure the mother. Accordingly, emotional balance is achieved, lactogenesis is favored, baby sucking is successful and breastfeeding becomes mutually beneficial: for the child and his/her nursing mother, thus strengthening the mother-child bond.
The absence of colostrum or hypogalactia – reported in the pertinent literature as the main reason for early weaning – consists in the reduction of milk secretion. It is caused by hormonal changes in oxytocin and prolactin levels, a condition often associated with biological, psychosocial and behavioral factors. Among them, we can mention the first delivery, the surgical procedure, the pain, the discomfort, the anxiety, the stress and the prematurity. Such situations can delay the hormonal release and the first support (which usually happens within 72 hours after delivery) and, consequently, favor the maternal desire for the complement [6, 25, 26]. Late lactogenesis may also be due to inadequate latch, lack of suction and formula offer in the first hours of life [27, 28]. Nevertheless, it is necessary to hold a careful assessment in such a way as to consider the type of delivery and parity, since, in a study performed by Isik and collaborators [29], there was no statistically significant correlation regarding the production of prolactin and these factors. Moreover, we should underline that, although the absence of colostrum is not justifiable, if such condition is prolonged, the risk of hypoglycemia is eminent, especially in premature NB and gestational age [14, 17]. Glycemia was one of the studied variables, but a limitation of its use was to have been collected in only 3 maternity wards. For this reason, we chose not to include it in the final model. However, it is important to point out that only one third of NB that received the complement had glycemic records.
When considering that hypoglycemia is a concern of the health team and is among the conditions where the complement is prescribed, this study found that such offer happened without this assessment in most cases. Then, we observed a significant association of indication when the glycemia was between 40–50 mg/dL – although there was also a high quantitative of NB that received complement when the glycemia was higher. There is still no consensus in the pertinent literature about the offer of formulas to reduce cases of hypoglycemia in NB, nor the definition of glycemic values that characterizes it and, therefore, supports the indication of complements. The dialogue with the team revealed interprofessional and institutional differences in the standardization of these values. Accordingly, such definition is still at the discretion of clinical assessment, according to the individuality of each child [30].
In healthy conditions, parturient women have biological conditions that are sufficiently favorable for breast milk production in the first hours after birth. However, mother’s and health team’s perception of “insufficient milk” is still frequent. This leads to the lack of adequate waiting and/or stimulation for colostrum dripping – including the absence of skin-to-skin contact and breastfeeding in the first hour of life of NB. In this study, the complement was offered, on average, 5.6 hours after birth, being this time lower than the reported in the pertinent literature (8.7 hours). Nevertheless, this may be a harmful factor to EB after discharge [19.21]. The time of the offer is highlighted in the pertinent literature and justified by the longer period of professional activity and maternal tiredness for the day shift, which may undermine exclusive breastfeeding after discharge [6, 21].
Another much discussed point is the type of complement offered. Despite the unanimity in offering BM, the maternity wards that have a milk bank – two of the institutions participating in this study – do not have sufficient stock for the full-term NB, thus prioritizing, for them, the offer of starting infant formulas. The pertinent literature warns that artificial formulas are associated to the risk of allergies and changes of the intestinal microbiota. A control case study reported a 16 times higher probability in the development of allergy to cow’s milk protein when NB received a complement to the maternal milk with artificial milk formula in the first 24 hours of life [14]. Other studies identified dysbiosis, with lower quantities of Bifidobacteria and higher quantities of Enterobacteria, being this a condition that was also associated to NB born from cesarean section [18, 31].
The quantity of the complement offered may also interfere with breastfeeding. In this study, more than 80% of NB received it in quantity less than or equal to 10 mL, which corresponds to the approximate volume of colostrum produced in each feeding in the first week of life. The pertinent literature points out complement volumes higher than those of the present research, initially varying from 30 to 57 mL, progressing to about 100 mL on the fourth day and reducing to, on average, 26 mL in the period of discharge [6, 19].
Policies to combat advertising and discounts of infant formulas from the pharmaceutical industry to hospitals may be viable alternatives to decrease the offer of complements in these environments. As an example, there is a hospital in Hong Kong, where the offer of formula complements was reduced by 57%, the EB rate was increased by 23.6% during hospitalization and the breastfeeding time was increased from 8 to 12 weeks [32]. In Brazil, this practice was instituted by the Brazilian Standard for Commercialization of Food for Infants, Young Children, Nipples, Pacifiers and Bottles (NBCAL – Law 11.265/2006) [9], but the effect on the use of formulas to replace breast milk in hospitals is still unknown. Strategies such as the milk donation campaign are fundamental to increase stocks in HMB and, therefore, promote breastfeeding.
Among the limitations of this study, we should mention the non-totality of the sample of some of the explanatory variables for the complement offer – such as the time of its offer and the capillary glycemia. Although it has been held in only one city, the results of this research are consistent with the pertinent literature. At the same time, such findings are strengthened by the previous accomplishment of a pilot study for better applicability of the research instrument and by the collection of information having been performed when NB were exposed to the use of the complement. Accordingly, memory biases were minimized and the confirmation and validation of the information entered in the medical records was allowed.