Vania Bustamante, Cecilia McCallum
16 de maio de 2016
Feeding practices, healthcare and kinship during the first year of life
Alimentação, cuidado em saúde e parentesco durante o primeiro ano de vida
Vania BustamanteI; Cecilia McCallumII
IUniversidade Federal da Bahia, Instituto de Psicologia, Curso de Psicologia. Campus São Lazaro, R. Aristides Novis, 2, Estrada de São Lazaro, 40210-730, Salvador, BA, Brasil. Correspondência para/Correspondence to: V. BUSTAMANTE. E-mail: <vaniabus@yahoo.com>
IIUniversidade Federal da Bahia, Faculdade de Filosofia e Ciências Humanas, Programa de Pós-Graduação em Antropologia. Salvador, BA, Brasil
ABSTRACT
This paper reports a study of how babies are fed during their first year of life as practiced by families living in a low-income neighborhood of Salvador, Bahia, Brazil and served by the state's Family Health Program. Two families were followed up over a year using the Bick method for the observation of mother-infant relationships. The results showed that although the families appreciated the recommendations of health professionals regarding the need to practice exclusive breastfeeding until the child reached six months, in practice during their first few weeks of life the babies were started on complementary food in addition to breast milk. The mothers made decisions regarding feeding the babies taking into consideration the following: The opinions of a selection of relatives; food availability; ideas about what is suitable for the developing baby; and finally, their observations of the child's responses. The results show that food is part of the mutually imbricated processes of the social construction of the person and the constitution of kinship ties. The conclusion reflects on the implications of these findings for health practices.
Keywords: Healthcare; Kinship structure; Mother child relations; Nutrition.
RESUMO
Realizou-se um estudo sobre a alimentação durante o primeiro ano de vida em famílias que moram em um bairro de baixa renda em Salvador atendido pelo Programa de Saúde da Família. Participaram duas famílias que foram acompanhadas ao longo de um ano. Os dados foram coletados utilizando o método Bick de observação da relação mãe-bebê. A análise dos relatos das visitas teve como referência a técnica de análise de conteúdo. Os resultados evidenciam que, embora as famílias valorizem as prescrições de profissionais de saúde sobre a prática do aleitamento materno exclusivo até os seis meses, desde as primeiras semanas os bebês recebem alimentos em forma complementar ao leite materno. As decisões sobre a alimentação são tomadas pelas mães, considerando: opiniões de vários parentes, disponibilidade de alimentos, idéias sobre o que é adequado para o desenvolvimento do bebê, assim como a observação das respostas da criança. Mostra-se que a alimentação faz parte do processo de construção social da pessoa e dos laços de parentesco. Finalmente são tecidas reflexões sobre as implicações destes resultados para as práticas de saúde.
Palavras-chave: Cuidados da saúde; Laços de parentesco; Relação mãe-criança; Nutrição.
The present study discusses practices in low-income Brazil with respect to infant nutrition during the first year of life, focusing on three key aspects: The influence of the relationship between health service users and health professionals; family dynamics; and also the uniqueness of each baby.
The Brazilian Health Ministry sets out clear recommendations about infant feeding and the part to be played in this by health professionals (Brasil, 2005). These stipulate that the healthcare of pregnant women and babies is a priority when it comes to organizing primary care services, especially in the context of the Programa de Saúde da Família (PSF, Family Health Program). More specifically, breastfeeding encouragement is marked as a top priority for PSF care workers, who are given responsibility for stimulating the practice both of Exclusive Breastfeeding (EBF) until the child reaches six months and also of breastfeeding as a complementary nutritional activity thereafter, until it is two (Caldeira, Aguiar, Magalhães, & Fagundes, 2007).
The broad consensus about the benefits of breastfeeding is linked to numerous studies on the factors that favor or hinder the practice. By way of introduction to the discussion of findings about baby feeding practices in Brazil, the article begins with a brief exploration of the main issues tackled in this scientific literature on breastfeeding.
Caminha et al. (2010) point out that, despite wide recognition of the importance of breastfeeding and despite all the promotion, protection and support for the practice, there is still much ground to cover in order to achieve international goals and recommendations. Several studies identify the low prevalence of EBF in Brazil. In the data from study of a municipality fully covered by the PSF, Parada, Carvalhães, Winckler, Winckler, and Winckler (2005) note that for children under four years EBF stands at 25.4% while Predominant Maternal Breastfeeding (PMB) occurs at a rate of 44.4%. In another study, Carvalhães, Parada, and Costa (2007) show that 38.0% of the infants were exclusively breastfed and that the mothers justified the introduction of cow's milk (in the case of 33.4% of children surveyed) as related to the quantity and quality of breast milk and to the child's need. The use of pacifiers and breastfeeding difficulties were associated with an absence of EBF. Parada, Carvalhães, and Jamas (2007), in a study of complementary feeding practices in the first year of life, identified the consumption of inadequately prepared and unsuitable foods: Thus, ordinary family foods are given to children aged between six and eight months (48.8%); and soups are offered to children older than eight months (71.6%).
Various qualitative and quantitative studies in this literature seek to understand the factors that favor and obstruct EBF in the first six months. Several focus on the breastfeeding mother's perspective or on the way in which the presence of relatives - especially grandparents - interferes with EBF continuity (Fujimori, Nakamura, Gomes, Jesus, & Rezende, 2010; Marques et al., 2010). Other studies identify maternal characteristics that influence the duration of breastfeeding. The mother's inclusion in the labor market is an important factor, as is the woman's determination, especially when it comes to those who continue breastfeeding for more than six months (Polido, Mello, Parada, Carvalhães, & Tonete, 2011). In one study maternal pleasure was identified as the mother's most cited reason to continue breastfeeding (Carrascoza, Costa-Júnior, & Moraes, 2005). Another study highlights that for the mothers who participated, the breastfeeding experience was not child-focused (Carrascoza, Possobon, Costa-Júnior, & Moraes, 2011). Conversely, a study of nursing mothers in a healthcare facility found that 71% felt that they produced quality milk and that from their perspectives their child was satisfied after feeding (Monteiro, Gomes, Stefanello, & Nakano, 2011). Thus, in this case, the child's level of satisfaction was used to evaluate the milk. Rocha, Garbin, Garbin, and Moimaz (2010) studied the knowledge and perceptions of a group of women in relation to breastfeeding, concluding that knowledge about the properties of milk does not guarantee the success of the practice of breastfeeding.
Some studies explore possible differences between social groups. Fujimori et al. (2010) did not identify an association between duration of breastfeeding and the social groups studied. Conversely, Oliveira, Assis, Gomes, Prado, and Barreto (2005), in a study conducted in Salvador (BA), found that children from low-income families were 2.3 times more likely to be subject to precocious food consumption. In this study, early cessation of exclusive or predominant breastfeeding was associated with motherhood at an early age and with poor living conditions.
As far as health practices are concerned, several studies sought to evaluate healthcare during pregnancy and the post partum period with respect to breastfeeding. They relate care provided in areas such as access to consultations, quality of care, and the professional's level of knowledge of breastfeeding indicators. Thus, Pereira, Oliveira, Andrade, and Britto (2010) identified a positive association between EBF during the first six months and access to promotion, protection and support of breastfeeding in the primary care services. Frota, Mamede, Vieira, Albuquerque, and Martins (2009) aimed to identify cultural practices surrounding breastfeeding among families enrolled in a PSF clinic. They found that the mothers surveyed mentioned difficulties with breastfeeding, including biological, social and cultural problems, and also noted a lack of adequate support from the health service.
Other studies sought to understand the differences between mothers' and health professionals' views about breastfeeding. Marques et al. (2009) sought to identify the significance of breastfeeding for professionals who work in the PSF and to document convergent and divergent themes between their approaches to breastfeeding and those harbored by lactating mothers. Among the most relevant results were the following: Firstly, these health workers understood breastfeeding to be a woman's obligation and secondly, the study showed that there were clear shortcomings in the level of training in breastfeeding. This facilitates a continuing wide gap between what professionals know and the real demands of everyday healthcare practice.
This brief literature survey highlights an important lacuna in studies on infant feeding, namely, investigations concerning the way that babies are fed by people embedded in dynamic relational fields marked by ever-negotiated asymmetries of power. In the studies cited above the relational context of feeding is barely mentioned, despite its central importance for understanding the raison d'être of many of the practices that run counter to the World Health Organization recommendations, such as the precocious consumption of foodstuffs. A study of how babies are fed during day-to-day family life should help us understand the way in which feeding practices are constituted and transformed on a daily basis and thus enable us to pinpoint the factors that influence them most directly.
The present study shows that people take the advice of the health professionals' into consideration in their day-to-day practices, yet are also influenced by other factors. Specifically, the study highlights the key role played by the agency of the baby itself and draws special attention to the fact that feeding is an essential dimension in the daily constitution of kinship ties. Thus, it illuminates aspects of infant feeding that are poorly addressed in the specialized literature, particularly those that focus on breastfeeding and weaning.
This study takes it as given that nutrition is a central dimension of care for the social construction of the person and that social feeding practices are constructed jointly with the other exchanges that are constitutive of kinship. Accordingly, the present study is part of a broader theoretical enterprise that seeks to understand various dimensions of childcare within the framework of the conceptual discussion of care itself. For this, it is necessary to outline the approach to care developed in previous studies (Bustamante, 2009).
Care is conceived here as the construction of projects, a view that both aligns itself with Ayres (2004) approach and distances itself from it in some respects. While Ayres focuses on care within a restricted sphere of inter-subjectivity, the argument that follows explores how care is culturally and socially constructed within structured relations of power. The socio-historical aspects of care, highlighted by authors working from a feminist perspective, such as Scavone (2005), are central to the concept proposed here. Thus, the study argues that care can be thought of as the construction of the individual projects of the person that are expressed in daily practices, within a framework of power relations between agents who occupy different social positions.
Projects of the person are usually related to the multiple interests of caregivers who occupy different positions within a social field, an approach proposed by Bourdieu (1996). Following Rabelo's (1999) concept of project, this article argues that projects involve more than mental or discursive construction. Projects can be expressed through the body, without reference to a posited level of mental representations. Moreover, different projects may compete in the same situation. Leading on from Rabelo's contributions, then, and also from anthropological debates on the social construction of the person, it is a premise of this article that care, and with it the person, is constantly in the process of being constituted, and that this takes place in the form of projects which are not always spelled out discursively. Such a conceptualization of care requires a critique of the tendency to universalize the meaning of care and, at the same time, the proposal to extend this notion by showing that care is constructed every day, and is much more than a simple concern for the happiness or wellbeing of the person to whom the care is dispensed.
This interest in understanding how relational factors shape everyday feeding practices (Hernandez & Kohler, 2011) led to the present study's choice of a qualitative approach and, more specifically, to use of Bick method of observation of mother-infant relations. In the following, the methodological choices shaping the investigation are made explicit.
Methods
Participants
This research was developed in Prainha1, a neighborhood where the author conducted fieldwork between 2003 and 2006, developing several studies on different dimensions of childcare. This is a neighborhood located in theSuburbio Ferroviário region of Salvador (BA), which, like other low-income areas, suffers from inadequate services and poor urban infrastructure. It has some unpaved streets, a lack of both green spaces and recreational facilities, and many homes are permanently under construction. Reports of violent episodes, including domestic violence, fights between neighbors and police violence are frequent. The educational level of residents is low. However, there is a growing presence of state institutions - a Family Health Center, schools, daycare centers, a police station and also social programs.
This paper focuses on data concerning two families who allowed us to observe their babies throughout the first year of life. The main participants in the observation process are listed below in Table 1. The fictitious names used to designate them begin with the letter "I" in the case of Ivana and her relatives and "F" in the case of Fábio and his family members.
Instruments and Procedures
This study used the Bick method for observation of mother-infant relations. This is a device created by psychoanalyst Esther Bick and originally used for the training of psychotherapists. It involves conducting weekly visits (one hour long) during the babies' first year of life. The visits should take place on the same day and time, with the duration of one hour. The observer assumes a silent, attentive and respectful posture towards the baby and family. After the visit, the observer should produce a detailed report, related in weekly supervisory meetings (Oliveira-Menegotto, Menezes, Caron, & Lopes, 2006).
The observations were made between 2010 and 2011 by Adriana Correia and Marta Campos. Both were Psychology students and served as research assistants conducting home visits. Each family was visited by only one observer. As suggested by the Bick method, they wrote reports after each visit and held weekly meetings with the research head, who also acted as supervisor. The observation ceased when the infant reached one year of age.
Data analysis
To achieve the aims of the present study, analysts read the observation reports in order to identify passages that made reference to feeding. The information was organized by month, so it was possible to construct a sequential account of the feeding practices, from the early days of the baby's life up to its first birthday.
For the purposes of analysis the study used elements from different methodologies, as is clear from what follows. Based on content analysis, word repetition was identified, taking this as an indication that something may be significant. As in discourse analysis, attention was not only given to words but also to their relational contexts - and the power struggles in which the latter were constituted. Moreover, there are important points in common with the tenets of hermeneutic-dialectical analysis (Minayo, 2007). According to Minayo, this emphasizes the importance of historicity for understanding human interactions and recognizes the impossibility of truly impartial observation.
The results presented below are organized under three topics: 1) the babies and their families; 2) the first four months; and 3) feeding from the fifth month.
The research project that gave rise to this article was approved by the Research Ethics Committee of the Institute of Collective Health of the Universidade Federal da Bahia (nº 028-09).
Results
Babies Ivana and Fábio lived with their biological parents and maternal siblings. Their mothers, Isaura and Fatima, respectively, owned their own residences and, in both cases, their husbands moved in with them. However, each family had specific features and distinct dynamics. In the case of Isaura's family, the relatives were always present in the everyday life, while in Fatima's they were less so and there were often conflicts. As Sarti (2003) notes, the presence of relatives does not guarantee that kinship ties are constantly renewed or that there are exchanges that constitute sources of support.
Regarding the babies' parents, it was observed that Fábio's father, Fred was more present in day-to-day life than Isaac, Ivana's father. As discussed by Bustamante and Trad (2007) considering the relationship between paternal involvement in childcare and types of relationship with other relatives, this may have been associated with the greater involvement of maternal relatives in the care of the latter. One aspect common to the two families was the presence of conflicts linked to the interaction between the baby's father and maternal brothers. These uncles were very participative in caring for the babies.
There were economic differences between the families: Ivana's could rely on more stable sources of income than Fábio's. These differences may be associated with a greater supply of food in Ivana's case, while in Fábio's the quantity of food consumed daily was smaller and less varied for the whole family.
Both babies were well received in the family despite differences in the way in which the pregnancy came about. Ivana was the result of planned parenthood, however, Fábio was not.
The mothers received prenatal care in a Family Health Center in the neighborhood in which they resided. Isaura also had some check-ups in a suburban hospital (these being health services that promote exclusive breastfeeding during the first six months). This behavior is considered a good sign of maternal involvement, as well as caring for the baby (Bustamante & McCallum, 2010).
During the first year of life, the babies went from an almost exclusive relationship with their mothers (and the mother's breast) to a relationship with a network of relatives. Ivana and Fábio were breastfed by their mothers, who considered this fact important for their proper development. However, right from the start, there were questions about whether it would be appropriate to give them other foods. As shown below, this did not mean diminishing the importance of breastfeeding, but rather expressed the opinion that the baby needed these other foods as well. Mothers make decisions regarding the foods that are offered, influenced by suggestions from healthcare professionals, as well as the opinions of the grandparents and other relatives.
Both mothers considered giving herbal tea to their babies upon arrival home from the maternity hospital. When Fábio was 14 days old Fatima commented that she wanted to give him some fennel tea, but was not sure if she ought to, because though her sister had said yes, the doctor said no. At this point, Fred, the baby's father, stated that it was better to follow the doctor's recommendations. Fatima accepted her husband's opinion. In contrast, in the other family, Isaura, the mother, gave baby Ivana fennel tea as soon as she returned from the hospital, reasoning that she was suffering from bad digestion. According to Isaura, the tea made it possible for Ivana to sleep better. She said she knew that "doctors recommend not giving anything at this stage", however, she felt that it would do her child good. And what do you know, it worked!" (Ivana, 3 days old, Field notes).
Other foods were offered very early in the baby's life. Thus Fábio was started on cow's milk at one month and 12 days according to our field notes. However, the baby was not weaned as a result. For both families, the breast is a way to calm the baby, including making it sleep. Therefore, at times, other family members (father, aunt, grandmother, brothers), asked the mothers to "give the breast" and thus stop the child crying. On one hand, the mother has the power to calm the child with her breast. On the other hand, it is the baby who owns its mother's breast: "Want to eat? Grab the nipple, Fabinho! Looks like he wants the nipple" - Fred laughs, imagining the scene of his son looking for the breast (Fábio, a month old, Field notes). Relating to the breast as a possession of the baby is more marked in Fábio's family; thus it was noted that there were more comments encouraging the baby to suck his mother's breast in this family context, often as part of a conversation in which it was said that Fábio had many girlfriends, just like his father, and even that Adriana was his girlfriend.
Opinions differed on the inclusion of mingau de Farinha láctea (porridge: powdered milk enriched with corn flour and other ingredients) in baby Fábio's diet at four months. The recommendations of health professionals were at odds with those of his paternal grandmother:
Fatima said that on Saturday she was at her mother-in-law's house and that she gave porridge to Fábio. Fatima warned that the doctor had said not to, but her mother-in-law argued that she always did it with her own children and that they were all well, saying that: The doctor gives life and also death too. Fatima thinks Fábio liked it and noticed that her son put on some weight afterwards and that his feces were pasty and not as dry as they were before. Fatima decided to buy the ingredients that her mother-in-law used and to keep on feeding it to him, using the bottle that her mother-in-law borrowed from a neighbor to give this thickened milk to Fábio (3 months and 16 days, Field notes).
This description is convergent with the findings of other studies that note the importance of grandparents (mothers, mothers in law) on the length of EBF (Fujimori et al., 2010; Marques et al., 2010).
Mothers sometimes give advice to other mothers by citing the same health professionals whose counsel they ignore at other moments. One day Isaura criticized a neighbor who was already giving cow's milk to her baby. She referred to knowledge acquired in contact with health services to present herself as superior to her neighbor:
Isaura said to me then that the girl is already feeding artificial milk to the baby. I do not understand why. If she were thickening the milk, alright! But only milk? It is the same as breast milk. When the boy pees it all comes out. I've talked to her, but she thinks she is complementing his diet. At this stage, the baby really does suckle all the time. The pediatrician herself told me that if the baby is gaining weight, there is no need to give it anything more.
On the same day that Isaura made this comment, she reported that she had already introduced juice in Ivana's diet and that the baby imbibed everything. She also said that she was very keen to start giving fruits and vegetables to her (Ivana was 3 months and 10 days old at the time). Our researcher registered a report about the introduction of these foods during the visit when Ivana had reached four months and seven days: "So, I started to give her some vegetables. I gave her mashed potatoes and pumpkin. She liked it. Ate it all up. And I also gave her Danoninho" [a brand of strawberry yoghurt for children]. On the same day, Isaura reported that her daughter was capricious because sometimes she accepted foods and sometimes not. She also "knows what she likes" (the phrase used was something like "now she is into this"). This could be seen because she had preferences as to the way in which she was fed. She did not like baby bottles, accepted porridge and Danoninho by spoon only, but water and other liquids she preferred in a little glass. Thus, the baby's will plays a crucial part in introducing new foods. The baby shows its willingness not only to accept or reject the food offered, but also to demand a specific modality of presentation. This may be related to stimulating the autonomy of the baby, a practice that is made explicit in statements about the baby showing its own will, right from the time when it is in the womb (Bustamante, 2009).
This study's findings therefore contain some differences from those of other studies that suggest that the reasons for the continuation of breastfeeding or early weaning are related to the woman's pleasure (Carrascoza et al., 2005), maternal determination (Polido et al., 2011), the mother's return to the labor market, as well as due to a "lack of milk" or that the "milk dried up" (Rocha et al., 2010). Unlike these studies, in this study the justifications for feeding practices focused on offering foods considered best for the baby's health, which could respond to the child's preferences and also stimulate its autonomy. As shown below, another key reason was to stimulate the baby to participate actively as one more member of the family group.
When Ivana reached 4 months and 28 days, Isaura reported that during contacts with healthcare professionals she encountered a difference between their perspectives and made it clear that she chose not to openly contradict their recommendations:
The doctor even asked if I was giving her another kind of food. I told her I was not, that she just nursed. I... to be listening to her talk about how the baby is only to be breastfed until six months! I tried other things and she liked them. I gave her Danoninho, which she ate. If I had not given anything to her, I just wonder what she might have been like at six months... she would only want to breastfeed, not having known anything else. At least she is getting used to other kinds of food, you know? Pretty soon I'm going to buy milk for her to start feeding her with porridge. I'll start her on porridge.
Isaura showed that she knew the recommendations proffered by healthcare professionals and that, in her actual practice she sought to identify what the baby enjoyed. At the same time, Isaura was concerned about introducing her daughter to other foods before six months of age, at which time the baby needs to eat other things. This could be a way of gradually providing autonomy from dependency on breastfeeding.
Fatima and Isaura took initiatives on food that did not coincide with the recommendations of health professionals. At the same time, for them, continued contact with the services was important as a way of monitoring the healthy physical development. In this sense, Fatima referred to the "right weight" for Fábio, citing the nurse's evaluation and agreeing with it. Then she stated that the child was not accepting fruits and vegetables, but that she was following the nurse's recommendation and would persist until Fábio accepted and got used to this kind of food: "He eats everything that we eat: From the fifth month".
From the age of five months, Fábio and Ivana began to show more interest in objects and their interest in the breast diminished. Other objects could satisfy hunger and curiosity or be calming. Several people - father, grandparents, siblings, uncles, cousins, friends -, could have these objects. This is related to the consumption of other foods. Relatives give opinions about feeding babies, buy and offer food, help to prepare it and to spoon it into the babies mouths, and stimulate the baby to try out new foods. This process was more intense in Ivana's family.
At five months and eighteen days, on seeing her brother Igor eating a cookie, Ivana seemed to ask him for some to eat too. Their mother authorized this and he tried to give it to Ivana, but with no success. During the same visit, the research assistant drank some water, and the baby made the same movement as if to ask for some too. The mother said she is thirsty and brought her plastic glass. Ivana drank, but after a while moved in such a way as to allow the water to spill. Isaura says that when she does this it is because she no longer wants to drink - and explains that she often repeats this gesture.
At six months and twenty-six days Isaura told us that the baby already had five teeth and was eating everything that was offered to her, including bread and meat, and that she only refused porridge. Isaura reported that her daughter was still breastfeeding a lot and that now "she does not want to breastfeed lying down, she only wants to nurse sitting up".
Continued demand for the breast coexists with growing interest in other foods. Thus, in the same visit in which Ivana cried because she wanted to nurse (7 months and 7 days), our fieldworker reported that, one of her aunts dropped by and put a piece of chocolate into Ivana's hand, explaining to her how to eat it. Then she put it in her mouth. She smeared it over herself and Isaura commented that she thinks it is absurd that mothers should refrain from giving candy, lollipops and chocolates to their children just because they couldn't be bothered to clean up the mess children make as they attempt to eat.
At eight months and twenty-one days, while Ivana was sticky from a lollipop she was eating, Isaura answered a question about breastfeeding from the research assistant by saying, "does she want to stop?" in order to stress that she continued to breastfeed her daughter. She then added that the baby already ate everything that everyone else in the house ate:
She eats everything! Lollipops, popcorn, pepperoni, beef, chicken, beans! She eats everything we eat at home. Now, she does not stop to eat at lunch. She is eating little by little throughout the day. She will accept some spoonfuls at lunch, at dinner, at breakfast. And she will be breastfeeding too. See, she is able to go for more than three hours without breastfeeding. All she does is snack all day long.
In this excerpt we can identify the depiction of a gradual process through which Ivana acquired a status of similarity - that is, she became an active member of the family - through sharing the same food as that eaten by her relatives.
The introduction of various foods whilst continuing with breastfeeding is also a striking finding in the observations of Fabio and his family. For example, on the day he was 10 months and 15 days old, Fábio was fed with rice and mashed vegetables:
Fábio cried and then Fatima said that he was hungry. She picked up the plate of food - rice, mashed potatoes and pumpkin. Fábio grimaced when he ate. He only ate three spoonfuls and then wanted no more. Fatima said he was full, while she put him on her lap and gave him her breast. He sucked with ease. I do not understand. If he was full then why give him milk and let him breastfeed with such an appetite? With his mouth dirty with food and oil - the food was dripping with oil (Research assistant's field notes).
As is well known, each child goes through a unique process of development that would not be possible to describe here. With regard to our two subjects, it is worth noting that while Fábio was quick in his motor development - he walked at eight months -, Ivana developed more slowly. However, she had better communicative capacity than Fábio - perhaps through interacting on a daily basis with a greater number of relatives - and she developed verbal skills at a younger age than Fábio. During the first year of life he was always judged to have attained the "right weight", but Ivana had trouble gaining weight. This led to more frequent contact between Isaura's family and the health centre, who recommended Ivana to be breast fed in quieter places where she might not be distracted by so many people moving around. Given her persistent low weight, the health professional prescribed a medication, the use of which led to an increase in Ivana's weight.
Despite the differences between the two infants, in both cases continued interest in breastfeeding coexisted with the consumption of various foods. Thus, at 11 months of age, both babies were still breastfed various times a day: "Isaura says that the baby does not let her sleep at night because she wants to keep on suckling all the time". During a visit by the research assistant: Fábio approached Fatima and, without even looking at him, she gave him her breast. He nursed sitting on his mother's lap and never stopped, wriggling, threatening to slip down whilst holding the nipple in his mouth. While breastfeeding he squeezed the breast as if it were play dough.
Discussion
In these two cases we did not observe weaning, but rather a coexistence of breastfeeding with the early and increasing introduction of other foods. Our study partly conflicts with the findings of Sampaio et al., (2010) in their study of the psychodynamics involved in early and late weaning. In their research, early weaning seemed to be associated with a difficulty in bonding and the construction of motherhood. In the present study, the interruption of EBF was not an expression of difficulties in creating the mother-infant bond, but rather part of a process of building kinship ties.
Researchers have observed that from the beginning of a baby's life, adults make reference to the set of desires that are particular to an individual infant - as in the above-referred phrase "now she is into this"; in other words, they allude to the child's autonomous status as a separate, desiring and independently determined subject. For them, the child's own taste and desire is an important criterion in the choice of foods. Babies are treated as individuals from the start, and are stimulated both to be autonomous and also to act as active members of the family group. When encouraged to consume a variety of foods offered by relatives, babies are being disciplined and also kinship relationships are being created.
The families independently decided how to feed their babies while also seeking health services when necessary. In this, the present study leads us to a conclusion distinct from that of Boehs, Ribeiro, Grisotti, Saccol, and Rumor (2011) who find that when primary care is available to the population on a large scale, it tends to make mothers more dependent on the health services and to medicalize childcare to a greater extent. The present study identified a complex relationship with health professionals and their discourse. As seen in Bustamante and McCallum (2010), women and their families value the advice of health professionals and consider what they say when making decisions. However, decisions are also influenced by other relatives, especially grandparents and fathers, with the babies reactions also taken into account. Thus, rather than dependence, it is more appropriate to highlight the dialogue and the independence of health center users.
This article concerns a study of the everyday construction of the feeding practices during the first year of life. After discussing the main themes in the literature on breastfeeding, the approach taken here was put into the context of a set of studies on childcare and on the social construction of the person. Based on analysis of data from two case studies of babies and their families, it described distinct phases in feeding and sought to reflect on different factors influencing the practices involved.
This is the first study of its type and certainly does not offer results that can be generalized because it was based on the observation of only two babies and their day-to-day lives. Another limitation is that the observations were not carried out with a focus on feeding practices. Unlike other works, which focus on the mother's perspective through interviews, by using infant observation it was possible to detail how the practices unfold, even when people were not thinking about their actions. Thus, it became possible to pinpoint the importance of the baby's responses to the subject concerned in justifying certain feeding practices.
This study detected aspects of child feeding practices that can be investigated more deeply in future studies and also provides elements for contemplating health practices directed at infants and their families. By seeking to understand the different dimensions of feeding practices, it was possible to reflect on the development and health of babies and their families, in a sense that goes beyond the duration of EBF or the correct introduction of the sequence of foods.
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Article based on the post-doctoral project of V. BUSTAMANTE entitled "O cuidado de mulheres grávidas e bebês na relação entre profissionais do Programa de Saúde da Família e moradores de um bairro popular de Salvador:um estudo etnográfico". Universidade Federal da Bahia, 2011.
1 For ethical reasons all names used here are fictional.
Artigo original:
