PERCEPÇÕES VALORATIVAS DE PRÁTICAS EM BANCO DE LEITE HUMANO*

This study was aimed at identifying and analyzing the value perceptions of health professionals working at the Human Milk Bank about their practices. A descriptive and qualitative study was undertaken. The participants were 24 health professionals working at a Human Milk Bank in the state of Rio de Janeiro. The data were collected between July 2012 and February 2013 through semistructured interviews. In the thematic content analysis of the testimonies, three categories emerged: The practice of guiding breastfeeding; Human milk donation, pasteurization and distribution: nutritional care; and Affection in breastfeeding as a facilitator of the mother-child bond. The interviewed professionals demonstrate satisfaction with their work and with the engagement in all activities relevant to the Human Milk Bank. DESCRIPTORS: Breast feeding; Milk, human; Women’s health; Obstetrics. Autor Correspondente: Recebido: 05/10/2016 Diego Pereira Rodrigues Finalizado:03/02/2017 Universidade Federal Fluminense R. Desembargador Leopoldo Muylaert, 307 24350-450 Niterói, RJ, Brasil E-mail: diego.pereira.rodrigues@gmail.com http://dx.doi.org/10.5380/ce.v22i1.48679 Artigo original *Artigo extraído de dissertação intitulada: “A práxis dos profissionais de saúde na promoção, proteção e apoio ao aleitamento materno nos Bancos de Leite Humano do Estado do Rio de Janeiro”. Universidade Federal Fluminense, 2013. 1Enfermeira. Hospital Municipal Miguel Couto. Niterói, RJ, Brasil. 2Enfermeiro. Doutor em Enfermagem. Docente de Enfermagem da Universidade Federal Fluminense. Niterói, RJ, Brasil. 3Enfermeira. Mestre em Saúde Materno Infantil. Hospital Universitário Antônio Pedro da Universidade Federal Fluminense. Niterói, RJ, Brasil. 4Enfermeiro. Mestrando em Ciências do Cuidado da Saúde. Docente do Centro Universitário Anhanguera. Rio de Janeiro, RJ, Brasil. 5Enfermeira. Mestre em Saúde Materno Infantil. Docente da Faculdade Novo Milênio. Espírito Santo, ES, Brasil. Cogitare Enferm. 2017 Jan/mar; 22(1): 01-08 PERCEPCIONES VALORATIVAS DE PRÁCTICAS EN BANCO DE LECHE HUMANA RESUMEN: El objetivo del estudio fue identificar y analizar las percepciones valorativas de los profesionales de salud que actúan en el Banco de Leche Humano sobre sus prácticas. Se trata de estudio descriptivo del tipo cualitativo, cuyos participantes fueron 24 profesionales de salud que actúan en Banco de Leche Humana del estado de Rio de Janeiro. Los datos fueron recolectados entre julio del 2012 y febrero del 2013 mediante entrevista semiestructurada. En el análisis de contenido temático de los testimonios, emergieron tres categorías: La práctica de orientación de la lactancia materna; Donación, pasteurización y distribución de la leche humana: cuidado nutricional; y Afectividad en la lactancia materna como facilitador del vínculo madre-hijo. Los profesionales entrevistados demuestran satisfacción con el trabajo que efectúan y con el involucramiento en todas las actividades pertinentes al Banco de Leche Humana. DESCRIPTORES: Lactancia materna; Leche humana; Salud de la mujer; Obstetricia.


INTRODUCTION
Breastfeeding is an ancient practice that is cost-free and essential for humans, being not only determined by natural and biological aspects, but also constructed in the families' daily reality in their social and cultural spheres (1-2) .
Breastfeeding is giving milk; raising at the breast; nursing; feeding, nourishing. Nursing is a synonym of breastfeeding from the perspective of its definition, with the same functional connotation of giving milk or raising the child with the milk the woman produces. Therefore, the meaning of both words is not restricted to the strictly biological aspect of the action; on the opposite, it goes beyond by translating the emotions involving the woman's relationship with her child, the family and the surrounding world (2)(3) .
Breastfeeding is an ideal source of nutrition for the infant. It should be exclusive up to the age of six months and complementary up to the age of two years (4) . Breastfeeding promotion actions should take place since the start of prenatal care, as the postpartum women's lack of preparation to breastfeed often causes feelings of impotence that can lead to early weaning. The professionals working at the Human Milk Banks (HMB) offer support to the women and their relatives in order to facilitate the breastfeeding (5)(6) .
The first HMB was created in 1943 to collect human milk and redistribute it to premature and/or ill infants. Over decades of research and technological development, the HMB turns into a policy with established technical standards and an important partner in the Brazilian National Breastfeeding Policy (7) .
As from the 1980's, breastfeeding is intensified and gains value mainly as a resource to reduce child mortality rates. Then, the HMB expands its mission to attend to women and children's health through partnerships with public and private spheres, becoming responsible for breastfeeding promotion, protection and support actions; human milk collection, selection, classification and processing (7) .
In that context, the BLH should be part of the breastfeeding practice with the nursing mother, infant, family and community, promoting a care line for the mother-child binomial and contributing to the promotion, support and protection of breastfeeding (8) .
In the HMB actions, on the one hand, the Federal Health Department defends breastfeeding as excellent nourishment for small children, which is the main objective of the public policy. On the other hand, this practice involves characters (mother, infant and family) whose subjectivities need to be taken into account in their respective singularities, requiring professionals who are prepared for this purpose (9) .
The professional practices focused on breastfeeding aim to encourage exclusive breastfeeding up to the age of six months, and complementary breastfeeding up to two years or more, observing and correcting some common problems, such as wrong latching on, suction problems, maternal insecurity, as well as preventing nipple infections and mastitis which can interfere in the establishment of healthy breastfeeding and favor early weaning (4,10) .
From the perspective of the professionals working at the HMB in the state of Rio de Janeiro, breastfeeding practice permits identifying the extent to which they value their actions, as they act on a great demand using light technology and largely depend on their emotional resources to perform their actions satisfactorily. Hence, the objective in this study was to: identify and analyze the value perceptions of health professionals working at the HMB about their practices. The research scenarios were the five HMB cited above, and the information was collected between July 2012 and February 2013, using semistructured interviews based on a script with open and closed questions. The interviews were audio-recorded with the interviewees' consent.
The study participants were 24 randomly chosen health professionals from the HMB, in according with the following inclusion criteria: having delivered care at the HMB for at least six month; and being interested in participating in the research. The participants' professional categories totaled: ten Nursing Technicians, six Nutritionists, two Physicians, one Biologist, one Physiotherapist, one Laboratory Technician and one Nutrition Technician.
The search for new testimonies was interrupted when the saturation point of the collected information was reached by repetition. The participants were identified as Professionals and received a sequential alphanumerical code (P1, P2,...P24) to guarantee the secrecy and anonymity of the respective testimony.
Approval for the research was obtained from the Research Ethics Committee at Hospital Universitário Antônio Pedro, under protocol No. 191-2011, and the interviews were held after the signing of the Free and Informed Consent Form.
The transcription of the testimonies was submitted to the interviewees for validation before the content analysis, which includes the following phases: pre-analysis with floating reading of the collected material, constitution of the data corpus, in-depth reading and identification of context and registration units. After these phases, the material was explored and, finally, the results were treated (11) .

The practice of guiding breastfeeding
First, it can be affirmed that the health professionals value breastfeeding guidance. This value results from the knowledge gained and transmitted to the mothers, according to their testimonies: When we get here, give information, give advice, give counseling for breastfeeding, that it is the best for your child, that it stimulates a lot, we really encourage it. (P3) What is most important is to encourage the breastfeeding. We try to solve the mothers' doubts, I also like to go to the ward and latch on the infants, manage that.(P24) Furthermore, the importance of the guidance in prenatal care is highlighted with a view to successful breastfeeding: But one thing I try to find out from the women who come to us often is whether they got prenatal care here, if they received this guidance during prenatal care. We are even planning a project for some meetings, so that this woman receives the orientations at the right time.(P10) Some professionals' testimonies revealed guidance/information with a focus on practical problemsolving: So, I think, like: it is important to attend to the mother/woman, because our product is the milk, it's the breastfeeding, allow most women from the entire Metro II to breastfeed more calmly and be able to solve the situations. (P9) And who is able to come to us really wants to, which is to solve this problem.(P22) Human milk donation, pasteurization and distribution: nutritional care It is important to highlight that the health professionals directly related to the collection, processing and quality control of the human milk express the value of this practice, which is one of the forms of food safety: The importance of collecting this milk from the donors too, the processing of this milk and the quality control of this milk, for the premature infants from Neonatal care. Even when grouped in the same theme category, the professionals' testimonies mention the importance of affective value in practice, which strongly emerged in their relation with the mother; others value the mother's relation with her infant; and yet others value the work itself, as demonstrated in their discourse: What I find most important is to make the women feel safe in what they do, so they'll value all orientations from the people around them. I always tell them: breastfeeding is a process that happens between you and the baby. My function here is to promote the mother/infant integration, adjust the mother/infant relationship, you two will fit, you and your baby. I always value her. (P14)

What I find most important in my work? I think it's the way I sometimes treat the mothers. There's that kindness, you see? That is highly gratifying. It's priceless, it's really nice, it's really, really nice! I love it. (P15)
The following testimony expresses, beyond the value perception of the professional's affection as daily practice, an idea of breastfeeding as a condition of motherhood: I think it's the please of helping that life that has just been burn, to breastfeed, to be together with the mother, I find the smile of that mother when: You see, I managed! I am a real mother! And when I left the mother's house, she said: You gave me the best Mother's Day gift I could get, which was my son's breastfeeding. I left quickly because I was going to cry along the way. I really take great pleasure in watching that child breastfeed, that happy mother, I can't explain it, but it's something that comes from the heart really. I do something I like to do. (P7)

DISCUSSION
The health professionals at the HMB use guidance to promote breastfeeding, as recommended by the Federal Health Department. This has posed a challenge for all stakeholders in this guidance though, resulting in low exclusive and complementary breastfeeding rates, and therefore demanding political and institutional commitment to encourage this practice and favor the reduction in childhood mortality rates (12)(13) .
In Brazil, public breastfeeding policies have permitted the redesign of the health professionals' practice at the HMB, raising the nursing woman's awareness on the importance of breastfeeding through information and counseling, permitting an important change in the country's breastfeeding situation. Examples are the AmamentaBrasil Network; the Baby-Friendly Hospital Initiative; the Kangaroo Method; the Brazilian Network of HMB; legal protection through the Brazilian Standard for the Commercialization of Food for Nursing Infants and Young Children (NBCAL); social mobilization actions through campaigns and partnerships and monitoring by the Federal Health Department of breastfeeding actions and practices (1,5-6) .
The women's education and preparation for breastfeeding demonstrably contribute to successful breastfeeding. It is during prenatal care that the women should receive guidance on the benefits of breastfeeding, the disadvantages of using non-human milk, besides information on appropriate breastfeeding techniques, contributing to their management and confidence (2,(5)(6)10,14) .
In that sense, the health professional values the promotion and support for breastfeeding, offering the orientations needed for appropriate practice, inhibiting the risks of health problems for the women related to the positioning and latching on (14) . Nevertheless, the HMB professionals' acknowledgement of the importance of this guidance in prenatal care is highlighted.
Looking at the problem solving demonstrates the HMB professionals' engagement, which is extremely relevant, as two of the factors that contributed to the woman's distancing from breastfeeding in the 20th century were the health professionals' devaluation of this act and the lack of correct guidance and information on this aspect. These facts significantly affected the increased child mortality rates (1-2,15) .
The health professionals' practice at the HMB should be based on the reduction of breastfeedingrelated risks, such as: breast engorgement, mastitis, nipple pain, nipple abscess, among others. In addition, this professional serves as a facilitator of breastfeeding, making their knowledge on the aspects that hamper or facilitate the establishment and maintenance of breastfeeding (16)(17) . This finding was present in the interviewees' discourse in this research.
In that perspective, the public breastfeeding policies' recommendations affirm that, to act in HMB, the health professionals should be trained to perform the actions proposed, such as human milk collection, which depends on dissemination and awareness-raising campaigns of the nursing population to donate, which is a fundamental practice to respond to the demands of premature and/or ill infants. It should be reminded that human milk provides a unique combination of proteins, lipids, minerals, vitamins, enzymes and immunity protection cells, offering acknowledged and unquestionable nutritional and immunological benefits for the child's food safety (18)(19) .
In that sense, the health professionals from the HMB value thedonation process of the human milk, which they consider extremely important for child health, as well as the collection, processing and distribution of this milk, whose nutritional value they ratify in their practices. The valuation of the nutritional aspect of human milk also demonstrates the professionals' concern and care for the infants hospitalized at the Neonatal Intensive Care Units, in view of the importance of nursing them efficiently.
The health professionals working at the HMB should not be mere skilled technicians, but should also be capable of maintaining warm-hearted relationships with the mothers, so that their experience and daily practice contribute significantly to breastfeeding support, thus promoting the woman's emotional health (20) . In this research, the interviewees valued the relationship with the mothers.
When care at the HMB is humanized, permeated by actions to encourage breastfeeding, affection and the creation of bonds of trust in the communication process allow the health professionals to serve as multipliers in their social relationships, disseminating information and values that favor the engagement of new donors in the promotion and support of breastfeeding (18) .
The health professionals' practice shows that getting human milk donors is not detached from a perspective on care for mother and infant (18) . During the home visit mentioned in the testimony, they go beyond mere milk collectors when they provide breastfeeding support and contribute to increase its rates.
The teams working at these HMB are multidisciplinary; hence, they are fundamental for the complete functioning of these services because they benefit and quality the activities they develop in breastfeeding support. In that sense, the advice and opinions of close persons and health professionals are significant elements in the assessment of maternal and child health and wellbeing (20) .
In addition, the breastfeeding support should be encouraged, as this practice contributes to breastfeeding and inhibits early weaning. It is clear that these professionals' participation as agents in the clinical management process of breastfeeding is fundamental. They are responsible for observing and intervening as appropriate in the breastfeeding process involving the nursing women, infants and families, showing them the way towards successful breastfeeding.
Interaction is considered a framework for the appropriate development of interpersonal relationships. It is established in a dual and gradual manner, professional/woman; mother-infant; professional/practices. That constitutes a value for the breastfeeding practice. Hence, whenever possible, this affective bond should be stable and harmonic, with a view to preventing possible threats to the bond constructed among the stakeholders (20) .
The construction of bonding and its valuation contribute, as revealed in the testimonies, to the emergence of a feeling of gratification for well-developed daily work, related to affective issues that guarantee successful professional action, granting, besides happiness, not only professional but also personal satisfaction.
Attention is needed when the professional has exacerbated emotional reactions to breastfeeding issues and overvalues this process, because this professional starts to conceive motherhood based on the established breastfeeding practice, which shows to be a reductionist thought on what a "true mother" is (20) .
The extent of the emotional and affective issues' presence in the HMB professionals' practice is clear. They value not only health education, guidance, or the nutritional factor, but consider the bonding in the professional-user relationship more important, strengthened in the mother-infantfamily relationship.

REFERENCES FINAL CONSIDERATIONS
In this study, three categories were identified that synthesized the value perceptions of the health professionals working at the HMB in the state of Rio de Janeiro: guidance as breastfeeding practice; donation, pasteurization and distribution of human milk: nutritional care; affection in breastfeeding as a facilitator of the mother-child bond. In these categories, the professionals demonstrated their satisfaction in the work they perform, the engagement in all activities relevant to the HMB, even if each professional has his/her activity area and does not execute each activity individually.
One of the values these professionals express most about the practice refers to emotional aspects. The bonding, the relations of affection, the sensitivity, the pleasure in what they do, the possibility of contributing to the harmonization of the mother-infant-family triad and to the empowerment of the nursing mother are the most attractive facets for the professional working at the HMB.
Thus, they contribute to turn this Unit into more than a milk storage space or a breastfeeding school. These professionals' practice can be verified based on what they value, turning the HMB into a health promotion scenario for mothers, infants, families and communities and expressing the important role of the HMB in the complex and exciting breastfeeding movement.
Thus, it is evidenced that the practice goes beyond merely physiological nutrition processes of the infant or solutions like the clinical management of breastfeeding or the processing and quality control of human milk. The professionals perceive that their actions can determine better chances of quality of life for the many families that visit the HMB, presenting their uncertainties on the aspects of child feeding and relationship care.
As a study limitation, the impossibility to have contact with health professionals who were performing some procedures at the time of the data collection is appointed. This reduced the number of participants in a single scenario and impeded the generalization of the research findings.