Dojenje skozi zgodovino v Sloveniji Historical overview of breastfeeding in Slovenia Avtor / Author Dušanka Mičetic Turk1, Eva Turk1, Maja Šikic Pogačar1 Ustanova / hs^te 1Univerza v Mariboru, Medicinska fakulteta, Maribor, Slovenija 1University of Maribor, Faculty of Medicine, Maribor, Slovenia Ključne besede: dojenje, zgodovinski pregled, Slovenija Key words: breastfeeding, historical overview, Slovenia Članek prispel / Received 7. 11. 2017 Članek sprejet / Accepted 15. 11. 2017 Naslov za dopisovanje / Correspondence Prof. dr. Dušanka Mičetic Turk, dr. med. Univerza v Mariboru, Medicinska fakulteta, Taborska ul. 8, 2000 Maribor Telefon +386 22345827 E-pošta: dusanka.turk 13@gmail.com Izvleček Dojenje je optimalna prehrana, ki omogoča zdravo rast in razvoj dojenčkov. Obstajajo številni kazalniki, ki govorijo o pozitivnem vplivu dojenja na zdravje otrok, kot tudi pozneje v življenju. Čeprav je dojenje zelo priporočljivo s strani Evropskega Združenja za pediatrično gastroen-terologijo, hepatologijo in prehrano (ESPGHAN), Ameriške Akademije za pediatrijo (AAP), Svetovne Zdravstvene Organizacije (SZO), Sklada Združenih narodov za otroke (UNICEF) in številnih drugih, ni vedno izvedljivo, primerno ali ustrezno (npr. pri nekaterih presnovnih motnjah). Materino mleko je bilo in je še vedno najboljša hrana za skoraj vse dojenčke. Skozi zgodovino so dojilje bile najvarnejša in najpogostejša alternativa za materino mleko pred izumom steklenic, dudic ter mlečnih pripravkov za dojenčke. Čeprav so starši odgovorni za izbiro dojiti ali ne, je vloga zdravstvenih delavcev, vključno s pe- Abstract Breastfeeding is an optimal nutrition that supports the healthy growth and development of infants. Numerous indicators suggest the benefits of breastfeeding to child health during infancy and later in life. Although breastfeeding is highly recommended by European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), American Academy of Pediatrics (AAP), World Health Organisation (WHO), United Nations International Children's Emergency Fund (UNICEF) and many others, it may not be always possible, suitable or adequate (i.e. in some metabolic disorders). Human milk was and still is the best food for nearly all infants. Wet nursing was the safest and most common alternative to breastmilk before bottles with nipples and infant milk formulas were invented. Although parents are responsible for decisions on breastfeeding their infants, the role of health care workers, including pediatri- diatri, spodbujanje in podpiranje dojenja. V članku je podan zgodovinski pregled dojenja v Sloveniji ter predstavljen opis socio-ekonomskih razmer v preteklosti. cians, is to protect, promote, and support breast-feeding. In this article, a historical overview of breastfeeding in Slovenia is presented with a description of the socioeconomic situation in the past. INTRODUCTION In the past, nursing was, in most cases, tightly connected to breastfeeding. Traditionally, breast milk was the only nourishment given to infants until they were old enough to eat solid food. In the past, if a mother died during childbirth or could not breastfeed for some reason (most frequently due to malnutrition), infants had a low chance of survival unless a wet nurse was used. Over many centuries and until the 19th century when feeding bottles were introduced, the aristocracy of many cultures hired nurses to feed their babies. Breastfeeding was a common practice before the introduction of the feeding bottle and formula. PAST The welfare of children has a long tradition in Slovenia. The first indication of an orphanage in Slovenia, founded in the year 1041, is mentioned in the work of Janez Vajkard Valvazor (known as Slava Vojvodine Kranjske, in English, "Glory of the Duchy of Carniola") (1). Starting in the first half of the 13th century, the Mother of God Hospital in Ljubljana provided a shelter to orphaned children. In 1553, the Imperial Almshouse was founded. The next stage in the care of orphaned children was influenced by the mental climate of the Age of Enlightenment and the leader Empress Maria Theresa (2). In 1773, the orphanage was transferred to a newly built bourgeois hospital. During the reign of Emperor Franz Joseph (1848-1916) the care of orphans continued. The first children's hospital in Slovenia was built in Ljubljana in 1865 and named after Empress Elisabeth. The hospital was later associated with a free clinic for poor children. In 1889, a new, larger and better equipped children's hospital was built. The most common reasons for admission of children to the hospital were respiratory infections, scrofulosis, eye infections, eczema, gastrointestinal tract inflammation, measles, scarlet fever, and tuberculosis. Donations and contributions from benefactors and supporters were critical for the hospital's work. In addition, pharmacists gave the hospital free medicine. At that time, the children of Mùwlêtâffàtr •. 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Announcement of the Empress Maria Theresa establishing the Ljubljana orphanage, February, 13th 1758. wealthy parents were treated at home by selected physicians. Poor children in rural areas and in the city had parental care, and their survival depended on nursing and their diet. Although breastfeeding is as old as humanity, people who work in the field of infant nutrition agree that breastfeeding is optimal nutrition for infants. In addition, in Slovenian, the term infant (slo. dojenček) comes from breastfeeding (slo. dojenje). During the second half of the 19th century, a wave of modernization and overall social progress reached Slovenia. The development of medicine brought modern perspectives to the fields of pediatrics and child care. Physicians increasingly began to pay attention to the mortality of newborns and infants, and the importance of breastfeeding. A new generation of Vienna-trained doctors were important for the enlightenment and education of the uneducated population in rural and urban areas. During those times, poor personal hygiene, ignorance of one's own body, poor housing conditions and an impoverished diet were common. A Vienna-trained doctor who left a strong impression on the Slovenian pediatrics was Professor Dr. Bogdan Derč. In 1907, in his "endorsement for education, protection and general welfare of the youth," he wrote: "Breast milk is the only natural, the best, cheapest, always ready and suitable food for children." Therefore, he advised mothers to breastfeed, and devoted energy to this cause. In 1943, his study on breastfeeding entitled Slovenian mother, breastfeed! was published as a book (3). Nurses are important for caring for mothers, newborns and infants. The first nurses with a diploma from Vienna started working in Slovenia, Ljubljana in the beginning of the 20th century. During their field work, they often encountered inadequate house and hygienic conditions, mothers' ignorance and a high infant mortality rate. Nurses founded the first counseling services for mothers and babies and organized lectures about infant care. The new profession of medical nurses was unknown during that time in the social context, which caused difficulties for the nurses regarding the implementation and positioning of this profession in the field of health care. Despite these difficulties child-rens' nurses were working for protection of infants and young children and counseling mothers in this way they contributed significantly to improving health and reducing morbidity and mortality (4). Slovenska mati, doji! PRISPEK F. h K PROPAGAND! ZA DOJENJE i Fi TA \ (L DR- BOG DAX D ERČ i' i ■ u h ! 7 L >i u I Ih frfc m I K\'jlPiWX i TWCOI'.Vi Ji i/J-ifj. r-cfi" Figure 4. First page of Dercs book, Slovenia mother, breastfeed! An interesting and specific phenomena that reflects the economic and social importance of breastfeeding was the migration of the Alexandrine at the end of the 19th century and the first half of the 20th century. The opening of the Suez Canal in the year 1869 allowed many European entrepreneurs to travel to Egypt. Many found a better life there and settled in the cities of Alexandria and Cairo. During the same period, peasants and middle-class girls, mostly from the Goriška region (Gorizia), traveled to Egypt to work for rich Egyptian families as cooks, maids, nannies, wet nurses, governesses, or dressmakers. The severe economic position of the Slovenian peasants in the second half of the 19th century, caused by industrialization and high taxes, was the reason for the mass emigration. Most single women came to Slovenia to visit. Married women and mothers, who left infants a few months old at home, went to Egypt as well-paid wet nurses. In the Goriška region, the expression 'Aleksandrinke" ("Alexandrian Women") is used for these women. They were named after Alexandria, where the majority of the Slovenian women and girls got jobs in well-paid professions. The earnings the Alexandrian women sent home by post or at times through relatives and friends, enabled their family to survive. Usually, the women returned home once they had earned the necessary money. The phenomenon started to decrease soon after the Second World War. The last women from the Goriška region returned home by the end of the 1960s (5, 6). After the Second World War, a change in the political system began to also change the public health system. At hospitals, employed nuns were gradually replaced by nursing professionals. Because of a lack of physicians, nurses started educating mothers about healthy nutrition for babies. During the postwar time, the decision to breastfeed was not a dilemma because of food shortages and the low supply of cow's milk. Milk had to originate from healthy cows that had a calf. The most common obstacle to a successful establishment of breastfeeding at the time was the standard practice of a late first breastfeeding and first contact of the mother and child following birth, usually after 24 hours. At maternity wards, mothers and babies were separated and feeding took place on schedules. Newborns were often given chamomile tea to alleviate thirst. Babies whose mothers did not have enough milk were fed by mothers in the room who had enough milk. Later, the main reason for the abandonment of breastfeeding was mothers quickly returning to work. Most mothers returned to work after 6 weeks of maternity leave and rarely after 3 months. Only unemployed mothers were able to breastfeed for 6 months (7). As a consequence of the strong impact of milk-substitute manufacturers in the 1960s and 1970s in Slovenia, the number of lactating women sharply declined. In Slovenia in 1973, only 50% of children were exclusively breastfed at the age of 1 month. At the age of three months, this percentage decreased to less than 10% (8). PRESENT At the meeting of the WHO and UNICEF on breastfeeding on July 30 and August 1, 1990 at the hospital Ospedale degli Innocenti in Florence, participants from many countries adopted and later published the "Innocenti Declaration." The Declaration stated that breastfeeding is a unique process with many well-known benefits for children and mothers. It recommends exclusively breastfeeding for 4 to 6 months with the addition of appropriate complementary food along with breastfeeding up to 2 years or possibly longer (9). To realize these principles, creating appropriate awareness, support and environment was necessary. In many countries, strengthening the culture of breastfeeding was needed to protect against a culture of bottle feeding. At all sections of society, urgent social mobilization and political will occurred. The Ministry of Health Republic of Slovenia developed a national breastfeeding policy by establishing a national system for monitoring achievement of breastfeeding promotion goals. In 1991, WHO and UNICEF launched the joint campaign "Baby friendly hospital initiative" (BFHI) to enforce breastfeeding worldwide. In the majority of European countries, breastfeeding begins in a maternity hospital. In Slovenia in 1996, the Slovenian National Committee for the Promotion of Breastfeeding was established under the Slovenian Committee for UNICEF, which brings together experts with different profiles (pediatricians; neonatologists; nurses; health educators; epidemiologists; representatives of the Ministry of Health, Ministry of Labour, Family and Social Affairs; representatives of WHO, and others). The Slovenian Committee for UNICEF adopted the introduction of "Initiatives for the Baby-Friendly Hospital" as a priority (10). Maternity hospitals that wish to receive this international recognition and the title of "Baby-Friendly Hospital" must comply with strict rules, summarized in two documents: "Ten steps to successful breastfeeding" published in 1989 in Geneva, and "Code of marketing of breast milk substitutes" adopted in 1981 (9). The essence of both documents is strict and consistent promoting, supporting and maintaining of breastfeeding. The process of achieving international recognition for medical institutions includes staff training and self-assessment tests. Verification lasts for several days during which the evaluation of the qualifications of medical staff and institution for promoting and maintaining breast-feeding is performed. In Europe, the largest percentage of designated Baby-Friendly maternity hospitals is in the Scandinavian countries. In just over 5 years from the beginning of the Baby-Friendly Hospital Initiative, in July 1997, among 114 countries, 12,700 of hospitals had this title (9, 11). According to the National Institute for Public Health, in 2009, when the study "Monitoring breastfeeding, nutrition of infants and young children and their nutritional status" started, 99% of children born in hospitals were breastfed, 78% were breastfed in the third month, and 62% in the sixth month. These percentages were thanks to intensive promotion of breastfeed- ing in Slovenia. (12). Slovenia has 12 Baby-Friendly Hospitals ("Novorojencem prijazna porodnišnica"): Brežice, Celje, Jesenice, Kranj, Ljubljana, Maribor, Murska Sobota, Novo mesto, Nova Gorica, Ptuj, Slovenj Gradec and Trbovlje. Studies show that breastfed babies are less likely to suffer from serious illnesses including gastroenteritis, asthma, eczema, diabetes mellitus, obesity and respiratory and ear infections, compared to bottle-fed babies (13, 14). The reported benefits from breastfeeding on children's health demonstrates that breastmilk is superior for infant feeding. Benefits for mothers include lower risk of developing heart disease, hypertension, diabetes, high cholesterol, breast cancer, ovarian cancer and hip fractures in later life (15-17). The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition advises exclusive or full breastfeeding for at least 4 months with a goal of exclusive or predominant breastfeeding for ~6 months (18). The WHO and American Academy of Pediatrics recommend that if a mother is unable to breastfeed or chooses not to breastfeed, or if her baby (often premature) shows signs of not getting enough breastmilk, a wet nurse or milk from a donor is a healthy alternative to milk formula (19, 20). Figure 6. Sign of the Slovenian Board of Lactation and Breastfeeding Consultants. The Association for Lactation Consultants and Breastfeeding of Slovenia, founded in 2006, has improved the data on breastfeeding. The purpose of the association is to promote, organize and implement all activities and interests of members in the field of consultancy. The association provides information about lactation and breastfeeding to prospective and nursing mothers in their home, and integrates and cooperates with related associations, federations, and organizations in Slovenia and abroad, as well as other legal entities and individuals. The goals of the association are high-quality, prompt work for the benefit and interest of its members based on an adopted program of work and membership in similar international associations and federations. World Breastfeeding Week is part of the activities of the International Union for Breastfeeding to attract societal attention to promote breastfeeding. This week is celebrated in more than 150 countries, mostly from August 1 to 7. However, some countries celebrate the week later because of holidays, which is the reason that Breastfeeding Week in Slovenia is celebrated from 1-7 October (21). CONCLUSION Breast milk has been the most natural food for infants throughout history. It contains living cells, hormones, active enzymes, antibodies and at least 400 other unique components, many of which are yet to be discovered. It is a dynamic fluid with many benefits for infants. Health benefits from breastfeeding are higher in developing countries than in developed countries. The rate of breastfeeding in the past and today is inversely proportional to the socioeconomic level of the population. In the past, infant survival was closely related to the availabilty of breastmilk. We have knowledge today about the positive effects of the breastfeeding that was not available in the past. Consequently, the mortality rate of children younger than 5 years was high in the past. 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