RESEARCH ARTICLES
Perceptions of nurses: the use of the glass by the mothers in feeding the newborn in the neonatal unit
Sandra Teixeira de Araújo PachecoI; Raissa Rodrigues OrganistaII; Benedita Maria Rêgo Deusdará RodriguesIII; Mirian Carla Rosse DionisioIV; Michele de Oliveira Guimarães CarvalhoV; Simone Muniz de SouzaVI
IPhD in Nursing. Adjunct Professor of the Maternal-child Nursing Department of the Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: stapacheco@yahoo.com.br
IINurse by the State University of Rio de Janeiro. Resident in Collective Health by the Fluminense Federal University. Rio de Janeiro, Brazil. E-mail: raissa05091991@yahoo.com.br
IIIPhD in Nursing. Professor of the Maternal-child Nursing Department of the Nurisng School of the State University of Rio de Janeiro. Brazil. E-mail: benedeusdara@gmail.com
VMaster degree in Nursing. Nurse of the Neonatal and Pediatric Unit of the University Hospital Gafreé and Guinle. Nurse of the Pathology Nursery of the Municipal Hospital São Francisco Xavier. Rio de Janeiro, Brazil. E-mail: mirianrosse@yahoo.com.br
VMaster degree student of the Post-graduate Program of the Nursing School of the State University of Rio de Janeiro. Nurse of the Municipal Hospital Jesus and of the State Health Secretary of Rio de Janeiro in the technic area of actions against violence. Rio de Janeiro, Brazil. E-mail: michelle.g@oi.com.br.
VIMaster degree in student of the Post-graduate Program of the Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: simonsms@ig.com.br.
ABSTRACT: the objective was to describe the perception of nurses regarding the use of glass by the mothers in neonatal unit. This is a qualitative study, carried out in a neonatal unit of a university hospital in the municipality of Rio de Janeiro, through semi-structured interviews with 11 nurses. it occurred in the months of January and February 2013. The data were subjected to content analysis on thematic mode, resulting in two categories: mothers´ difficulties facing the use of glass, in the view of nurses; mother's fears in the accomplishment of the technique of glass. It is concluded to be essential that nurses offer appropriate spaces for mothers to express their difficulties, uncertainties and limitations, which can be reflected in a nursing care more cozy with these women and consequently better adherence to this practice feed.
Keywords: Nursing; mothers; perception; feeding.
INTRODUCTION
The glass is an alternative way to feed the newborn (NB), recommended by the United Nations Children's Fund (UNICEF). This method is used in the NBs who have initial difficulties in breastfeeding (difficulties on the handle and positioning), when they are not being breastfed exclusively on breast or when the mother is absent or is unable to breastfeed her child, because of medical reasons1.2.
The Ministry of Health (MH) suggests the use of glass to stimulate the continuity and success of breastfeeding, in addition to reduce of weaning causes related to the use of bottle-feeding2.3.
To receive food through the glass, the newborn must be in alert state of consciousness, preferably wrapped in a diaper and sitting on the lap of the mother or of the health professional in order to let him organized in bent and vertical posture to provide a better performance of his oral functions. By offering the glass to the newborn, the health professional must position him in such a way that the rim of the glass rests under his lower lip, stimulating him to put the tongue into the glass to be able to sip the milk4.
The glass must be tilted so that the baby's lips touch the milk without being dumped inside his mouth. During the offering of the glass, the newborn usually lick the milk or can take in small sips1,5-8.
Currently, the work related to the use of glass in the feeding of newborns are scarce in scientific literature.
Understanding that the : mothers´ difficulties facing the use of glass, in the view of nurses; mother's fears in the accomplishment of the technique of feeding by a glass requires skill and practice not only by the health professionals, but also by the mothers who at times also feed their children by this tool in the neonatal unit, the study aimed to describe the perception of the nurse about the use of the glass by the mothers in neonatal intensive care unit.
LITERATURE REVIEW
The use of glass in the neonatal unit has been an alternative technique of feeding over a few years in developing countries. It is intended with this technique, to provide an artificial mode of feeding low birth weight and pre-term babies, until they have developed the skills to feed exclusively by breast9.
Several advantages of using the glass have been described, such as: the baby sets the amount of milk that will be ingested and the time that will be used, it has a lower energy expenditure; there is development and coordination of sucking and swallowing reflexes; besides benefiting the secretion of saliva and enzymes of the tongue, making easier the process of digestion of the milk. The development of orofacial structures, determined by the movements of tongue and mandible performed during the use of the glass are similar to movements determinants for breastfeeding, and there is still the promotion of relationship between the child and the caregiver6.
The disadvantages, on the other hand, consist of: the baby drool; may be because of being easy, he replaces the natural breastfeeding; there may be formation of bubbles in the milk; and the person who applies the technique can dump the milk entirely in the child's mouth, being susceptible to gagging and aspirations6.10.
Although the technique cause amazement to all those who are not familiar with it, it is found in the routine of the hospital the possibility of NB doing it, not being common gagging or aspiration of milk for babies that do not have swallowing difficulties11.
Thus, it is understandable that the nurse has a crucial role in attention to the NB and his family in feeding practice through a glass. He is the professional which is in greater touch with both and holds the responsibility for the theoretical-practical clarification of technique to the responsible caregiver, on guidance on the alternative technique, as well as supporting the family in the use of this appliance in feeding the son, so that it can ensure the success of this practice feed alternative with the newborn and her family.
METHODOLOGY
This is a qualitative study, descriptive type, in a neonatal unit of a university hospital, located in the municipality of Rio de Janeiro. The subjects were 11 nurses. As inclusion criteria, there were: male nurse on duty and/or nursing resident who at some point in their professional practice, be fed babies through the technique of glass and supervised mothers in this feeding practice. Nurses day laborerr, as their care is eventually direct to the newborn in the neonatal unit and nurses who were on maternity leave, sick leave and other types of dismissal during the period of data collection were excluded.
The data were collected through semi-structured interview with the following guiding question: How do you perceive the use of the glass by the mothers in neonatal unit?
To not miss any speeches, the interviews were recorded with a MP3. All nurses have authorized the recording and their identity has been preserved by replacing their names for flours names.
The data were generated in the months of January and February 2013. The project was approved by the Ethic Committee in Research (COEP) of the institution where the research was developed. (CEP/HUPE-214,846), respecting the resolution 466/2012 of the National Health Council, which regulates the guidelines and standards for research involving human subjects. Subjects that have agreed to participate as volunteers in this study have signed an informed consent.
The evidence obtained in the interviews were submitted to content analysis12 which allowed the coding, deployment, grouping and summary of the statements, resulting in two categories: analytical difficulties of mothers in the accomplishment of the technique of glass, in the view of nurses; and the different mothers fears in the realization of the technique of glass.
RESULTS AND DISCUSSION
Through the nurses´ speeches, it was possible to highlight the difficulties perceived about the use of the glass by the mothers in neonatal unit. These were mainly related to the provision of milk to the newborn and baby positioning and the glass during the performance of the technique.
Difficulties of mothers in the accomplishment of the technique of glass, in the view of nurses
As regards the difficulties related to maternal milk supply to the NB through the glass, one of the perceptions of nurses was related to the waste of milk through this tool.
[...] They [mothers] are worried if they're wasting milk [...] if suddenly there's milk coming out so the child is losing, milk dripping down the gauze [...] they think too much about it, and end up not wanting to feed their son by the glass. (Daisy)
[...] or you can waste a lot [...] dropping the milk [...]. (Carnation)
[...]When they [mothers] give milk, they think that the milk is coming out the mouth and falling in the gauze. (Lotus)
The perception of these nurses was similar to the findings of a study that sought to understand the significance of the low birth weight baby's mother in feed their son by the glass. According to the authors, mothers feeding their children by a glass, realized that it was a waste of milk that was offered to her baby3.
The waste of milk is a problematic point when the newborn baby is fedding by a glass. For mothers being satisfied that their child will receive the total volume of milk required, it is necessary that the glass is filled in 3/4 of its capacity and placed it along the lips of their son. The glass should rest lightly on the lower lip and the edges touching the outside of the upper lip; pour the milk in his mouth, just bring the cup of his lip and let the baby take for himself; when it has received enough, he will close his mouth and will not take any more9.
In this sense, it is of the utmost importance that the nurses realize these difficulties by the mothers, helping them and clarify about the correct way to administer the milk by the glass, so that they feel able to use this feature in the feeding of their children.
The interviews also refer to nurses´ perception about the misunderstanding of mothers about the milk being sipped by the baby, in the use of this technique, as it can be seen in the testimonials:
They can't understand the issue, that the child has to sip the milk. (Chrysanthemum)
[...] the NB has to sip and don't turn the glass into the mouth of the newborn. (Liz)
The hardest thing is they understand that the baby has to sip the milk and pour the milk into his mouth. (Carnation)
When the food is held by the glass, the baby using first the licking motion to reach the milk and it can be observed the protrusion of the tongue, being such a move essential for removal of the mamillary ducts milk, when in the process of breastfeeding in maternal bosom. Then, this movement is being replaced by th sip. This technique allows the babies to control the movements of sipping, coordinating breath and preparing to be able to perform the function of swallow6.
However, only from 30 weeks of gestational age the baby may be able to use this alternative method of feeding, coordinating movements of tongue, swallow and breathe without difficulty13.
So it is understandable that mothers can at first, not understand this mechanism. Thus, it is necessary that the nurse face to this perception, guiding the mothers about the ability to lick and suck the milk for the newborn.
In addition, discursive fragments found in the interviews have mentioned difficulties related to the coordination of the speed of the glass:
The coordination of mother in offering the glass, if you're going too fast, if you're giving very slow [...]. (Daisy)
[...] and also at the time the child is swallowing, if he is accepting the diet, they [mothers] have to take a break, to give a little time for him [the baby]; give time to eliminate the gauze, so they [mothers] do not understand and wish to continue giving milk, that's what I see difficulty. (Poppy)
When the child receives food liquids through the glass, the amount deposited in the oral cavity can also be abundant, especially at early ages, in which the ability to swallow properly through glasses or cups is not normal yet14.
However, when the technique of the glass is employed correctly, the baby determines his own consumption, referring to the time and quantity; he has lower energy expenditure; there is encouragement of the development and coordination of sucking and swallowing reflexes; there is increased secretion of saliva and lingual lipase, making digestion more efficient with the breast milk and it is an easy method of diet15.
Pauses during the offering of milk must be offered to the newborn rest and for the eructation. However, it is not recommended a the feeding period more than 30 minutes to avoid fatigue, as well as not to use the technique in a baby that is very sleepy4.
Another difficulty perceived by the nurse was related to the positioning of the baby to receive the milk by the glass, reporting:
[...] I think they [mothers] are afraid to hold it too [the baby], sometimes the baby is very fussy and we already know how to hold straight, wrap the baby, to contain better, I think mothers are afraid of the baby shaking [...]. (Carnation)
[...] I think difficulty in the correct position to hold the baby, because you have to hold the baby with one hand and give the glass with the other, and it is difficult holding the baby, when the baby is bigger it is more difficult, because they have no way [mothers] still, primarily first-time mothers [...] (Chrysanthemum)
[...] the position, how to get the child to the correct position of the head, to hold him. (Daisy)
Several studies showed how it should be positioned the baby at the time of food through the glass. They confirm that the child should be in a state of wakefulness; and he should be wrapped and contained, preventing the movements of the upper limbs interfering negatively in the completion of the technique. Then, he must be willing sitting or semi-seated in the lap of his mother or caregiver, positioned vertically (90°) and kept bent in order to allow swallowing properly. In addition to sitting, the baby must be wrapped in a diaper to maintain his upper limbs contained preventing dropping the glass. All these precautions make the application of the technique faster, safer, and efficient1,4,6.
With regard to difficulties in positioning of the glass by the mothers, nurses pointed out:
Difficulty where to put the glass, how to hold the glass, it leans too much, if it drop it a lot [...]. (Pink)
At first they (the mothers) have great difficulty in putting the glass, they pour the glass in his mouth [...] we have to explain that she can't, she have to put it [the glass] on the tip of the mouth [...]. (Chrysanthemum).
[...] and not giving milk, turning the glass in the baby's mouth [...]. (Liz)
It is essential a the proper position of the NB and the glass, performed by the mothers for the successful administration of the diet on the glass, since inadequate position can promote change of sipping milk speed, long pauses and premature leak of the milk6.
In this sense, while feeding the baby by the glass, mothers should be guided that the rim of the glass should touch the outside of the upper lip, resting the glass on the lower lip; the tongue must be positioned in such a way that it can touch the milk. The correct implementation of the technique also aims to contribute to the premature and oral motor development for the relationship mother and baby4.
Therefore, the difficulties of mothers perceived by nurses, concerning the use of the technique of the glass, reiterate the importance of educational activities to practice safe care of this alternative form of feeding supply.
The fear of mothers before the accomplishment of the technique of glass
This category shows the perception of the nurse about the fears of the mothers against feeding by the glass. More often mentioned mothers´ fears by the nurses were the baby regurgitate, choking when receiving the milk that way and, consequently, aspiration occurred.
I think they are afraid of the baby choking, to do any harm to the baby, of aspirating the milk [...]. (Lotus).
They [mothers] see so, they feel very frightened of child regurgitating. (Daisy)
They think the baby is going to throw up. (Sunflower)
Thus, from this findings we can see that the guidance, support and supervision of the team in the
feeding technic by a glass, are essential to understand how it works, reducing fears with a negative
impact for the mothers to perform this feeding technic.
Findings similar to the perception of these nurses were found in another study, which also pointed out the fear of drowning or choking her own son, during feeding, as reasons alleged by the mothers in not wanting to feed their children through the use of a glass16.
In this respect, the use of glass provides complications such as pulmonary aspiration and apnea, being unusual gagging or aspiration of milk for babies that do not have swallowing difficulties17, 18.
It is worth mentioning that the risks of baby choke with the bottle are larger than using the glass.
Therefore, from these findings, one can infer that the guidance, support and supervision of staff in relation to feeding technique for glass are essential to understanding its operation and reducing the fears that affect negatively mothers to perform this technique of food.
CONCLUSION
With the feed technique through the use of the glass by the mothers, nurses pointed to several perceptions, among which, the difficulties in offering the glass to her son, depends on the positioning of the baby and the glass.
The nurses also perceive different mothers´ fears by offering milk by the glass to her son, among them, there were: fear of the baby choking, aspiration or regurgitate.
Therefore, these perceptions reiterate the need of educational activities with their mothers to help prevent them from using it safely outside this way alternative food. However, the proposition of these educational practices need to be rooted in the dialogic model of health education, whose essence is in sharing knowledge, feelings and actions.
In this sense, it is essential that nurses give appropriate spaces for mothers to express their difficulties, doubts, uncertainties and limitations, which can be reflected in a nursing care more welcoming of these women. It is important to promote more guidance to mothers, through individual or group dynamics, and supervision of nurses in order to investigate the factors that interfere with the adhesion of this practice feed.
It is worth noting that one of the limitations of the study was to deal with the complexity of the phenomenon of perception. Another refers to the fact of the study have been developed in only one scenario that prevent the generalization of the findings.
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