Maternal and child nutrition scope - National Institute for

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Choosing a better diet: a food and health action plan (DH 2004c) highlights that breastfeeding can make a major contribution to improving the public's

    National Institute for Health and Clinical Excellence

    Public health programme guidance


    1 Guidance title

    Guidance to improve the nutrition of pregnant and breastfeeding mothers and

    children in low income households for midwives, health visitors, pharmacists

    and other primary care services.

1.1 Short title

    Maternal and child nutrition.

    2 Background

    a) The National Institute for Health and Clinical Excellence (‘NICE’ or ‘the

    Institute’) has been asked by the Department of Health (DH) to develop

    public health programme guidance on maternal and child nutrition as

    th1part of its 11 Wave. The guidance will provide recommendations for

    good practice.

    b) The guidance will be based on the best research evidence available

    from a range of methodological traditions including quantitative,

    qualitative and economic analyses. It is designed for implementation by

    those working in the NHS. It will also be relevant to local authorities

    and the wider public, private and voluntary sectors.

    c) The guidance will also support the implementation of:

1 A wave announces the referral of new NICE guidance topic areas

    Maternal and child nutrition final scope 1 of 19

    ? The national service framework for children, young people

    and maternity services (DH 2004a)

    ? Every child matters: change for children programme

    (Department for Education and Skills/DH 2004)

    ? Choosing health: making healthy choices easier and

    Choosing a better diet: a food and health action plan paper

    (DH 2004b; 2004c).

    3 The need for guidance

    3.1 The importance of maternal and child nutrition

    There is a recognised need to optimise nutritional status before pregnancy,

    during pregnancy, the post partum period and breastfeeding, and in the early

    years of life. The nutritional status of the pregnant women influences the

    growth and physical and mental development of the fetus. It has a major

    impact on infant mortality, growth and development and forms the foundations

    of health in later life. Folic acid supplementation, both before pregnancy and in

    the first 12 weeks of pregnancy, is particularly important as it significantly

    reduces the risk of neural tube defects (NTD).

    Optimising nutritional status before, during and after pregnancy is important to

    the mother herself, both in the short term and the long term. She needs to

    have sufficient energy and nutrient supply from diet and reserves to maintain

    her own health as well as to provide for the fetus and the breastfed infant.

    There are Department of Health (DH) recommendations on nutrient

    requirements and healthy eating for women before, during and after

    pregnancy by (DH 1991; 2000).

    Women also often make decisions on diet for the whole family and play a key

    role in ensuring that their children establish healthy eating patterns.

    The Independent inquiry into inequalities in health (Acheson 1998) found that

    a child’s long term health was related to the nutrition and physique of his/her

    mother. Infants whose mothers were obese had a greater risk of subsequent

    coronary heart disease. Low birth weight (under 2500 g) was associated with

    Maternal and child nutrition final scope 2 of 19

increased risk of death in infancy and with increased risk of coronary heart

    disease, diabetes and hypertension in later life. Accordingly, the Inquiry

    recommended, improving the health and nutrition of women of childbearing age and their children, with priority given to the elimination of food poverty and

    the reduction of obesity. Choosing a better diet: a food and health action plan (DH 2004c) highlights

    that breastfeeding can make a major contribution to improving the public’s

    health and reducing health inequalities. Breastfeeding provides clear short

    and long term health gains for both the infant and mother. Breastfed babies

    are five times less likely to be admitted to hospital with infections such as

    gastroenteritis in their first year, and seem to be less likely to become obese

    in later childhood. These benefits of breastfeeding remain even after

    adjustment for confounders such as socio-economic status. Exclusive

    breastfeeding in the early months also appears to reduce the risk of allergies

    and atopic conditions (for example, eczema). Mothers who do not breastfeed

    have an increased risk of developing breast cancer and may be less likely to

    regain their pre-pregnancy weight.

    Ensuring children are well nourished in the early years is very important. It is

    fundamental for proper growth and development, can modify the risk of

    chronic adult diseases (for example coronary heart disease and obesity) and

    prevent some of the more commonly found short term diet-related conditions

    (such as dental caries and iron deficiency anaemia). The pre-school years are

    also a crucial time for establishing dietary patterns and food intake. The DH

    provides recommendations on nutrient requirements and healthy eating (DH

    1991; 1994).

    3.2 Maternal and child nutrition concerns

    Choosing a better diet: a food and health action plan (DH, 2004c) reported

    that, ‘while many people in England eat well, a large number do not,

    particularly among the more disadvantaged and vulnerable in society. In

    particular, a significant proportion of the population consumes less than the

    recommended amount of fruit and vegetables and fibre and more than the

    recommended amount of fat, saturated fat, salt and sugar.’ Concerns about

    Maternal and child nutrition final scope 3 of 19

    maternal and child nutrition in lower socio-economic and vulnerable groups

    include the following.

    a) Short stature, low pre-pregnancy body mass index and low weight gain

    during pregnancy are more common among women from lower socio-

    economic groups. The relationship between pregnancy, nutritional

    status and fetal growth has been described as ‘deceptively complex’

    (Kramer, 1987). However there is now retrospective and prospective

    evidence that poor nutritional status at conception and during

    pregnancy is associated with low birth weight (Kramer 1987). b) In the UK, a higher proportion of low birth weight babies (less than

    2500 g) are born to families where the father is in unskilled or semi-

    skilled manual work, or are registered by the mother alone. Between

    1991 and 1995 in England and Wales, the percentage of low birth

    weight babies was 5.4% in professional social class I, compared with

    8.2% in unskilled social class V, and 9.3% of births registered by the

    mother alone (Macfarlane et al. 2000). Furthermore, teenage mothers

    are 25% more likely than average to have a low birth weight baby.

    c) The national diet and nutrition survey (Hoare et al. 2004) found that

    adults aged 1964 years who were living in households in receipt of

    benefits had a lower average intake of energy, compared with those in

    non-benefit households. A significantly higher proportion of women in

    benefit households also had lower intakes of vitamins and minerals

    from food sources. A low consumption of fruit and vegetables among

    low income families is also a recognised problem in the UK. d) In the UK, the quality of a woman’s diet during pregnancy tends to fall

    with income. Teenage girls, who have higher nutritional requirements

    associated with completion of the adolescent growth spurt, are at

    greater risk of deficiencies during pregnancy. In addition, research has

    shown that mothers from low income households are nutritionally

    vulnerable and may go short of food in order to feed their children

    (Dobson et al. 1994; Dowler and Calvert 1995).

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    e) The preventable proportion of NTDs is greatest among women of

    lowest socio-economic status, probably because they consume less

    dietary folate and are less likely to take folic acid supplements. (It is

    estimated that approximately 3050% of pregnancies in England and

    Wales are unplanned, as are 75% of teenage pregnancies). Women

    from higher socio-economic groups are more than twice as likely to

    follow the advice to take folate supplements before pregnancy, and

    women over 25 years of age are more likely to follow this advice than

    younger women (Health Education Authority 1998).

    f) There are also inequalities in the rates of breastfeeding. Mothers

    classified as being in higher occupations are much more likely to

    breastfeed at birth than are mothers classified as being in lower

    occupations. The Infant feeding survey (Hamlyn et al. 2002) showed

    that mothers most likely to initiate breastfeeding are those who reach

    higher educational levels, are aged over 30 years, and are feeding their

    first baby. Mothers in low income groups are up to 25% less likely to

    breastfeed than those in higher income groups.

    g) In the UK, levels of breastfeeding drop sharply in the weeks following

    birth, especially among lower socio-economic groups. The Infant

    feeding survey 2000 found that 69% of mothers breastfed at birth. Of

    these, 52% were still feeding after 2 weeks, 42% after 6 weeks, 28%

    after 4 months and 21% at 6 months (Hamlyn et al. 2002). There is a

    strong relationship between the duration of breastfeeding and the

    mother’s socio-economic status, with mothers from higher occupational groups breastfeeding for longer. In 2000, 75% of mothers classified as

    being in higher occupations were still breastfeeding at 6 weeks,

    compared with 53% of mothers classified as being in lower occupations.

    By 6 months, the equivalent figures were 41% and 27%, respectively

    (Hamlyn et al. 2002).

    h) There are important differences in disease patterns and health status

    between different minority ethnic groups and the general population.

    For example, South Asian and Pakistani women are more likely to have

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    low birth weight babies than white British women, even when the mothers are born in the UK (Bull et al. 2003) and poor iron status is common among pregnant women of South Asian origin in the UK (Thomas 2002).

    i) Furthermore, cultural differences affect breastfeeding rates. Mothers

    from minority ethnic groups are considerably more likely to breastfeed at birth compared with white mothers. Hamlyn and co-workers (Hamlyn et al. 2002) found the incidence of breastfeeding was 95% among black ethnic groups, 87% among Asian ethnic groups and 86% among women of mixed ethnic origin. This compared with 67% among white groups. However, although mothers from black and minority ethnic groups have higher initial breastfeeding rates, they are more likely to introduce mixed milk feeding. After 4 months, only 50% of mothers from mixed ethnic origin and 46% from black ethnic groups were still breastfeeding. Asian and white mothers had an even higher rate of breastfeeding cessation, with only 28% still breastfeeding at 4 months (Hamlyn et al. 2002).

    j) However, there is a dearth of relevant research on nutritional health

    promotion among minority ethnic groups in the UK. A review of the effectiveness of interventions to promote healthy eating in people from these groups identified only two studies from the UK, both of which focused on supplementation of infant or toddler diets (White et al.


    k) The prevalence of obesity is increasing among adults, children and

    young people. Around 16% of 2 to 15 year olds and 23% of women are obese (Joint Health Surveys Unit 2004). Children who are overweight or obese in childhood have a much greater chance of remaining so in adulthood, particularly if at least one parent is overweight and/or they are from a lower socio-economic group (Parsons et al. 1999). The prevention of obesity in both children and adults is important because it is linked with ill health, including hypertension, heart disease, and type 2 diabetes (including the onset of type 2 diabetes in childhood).

    Maternal and child nutrition final scope 6 of 19

l) Women with body mass index (BMI) over 30 kg/m? take longer to

    conceive, compared with women with a lower BMI, even after adjusting

    for other factors such as menstrual irregularity. Obesity and excess

    weight during pregnancy are linked to increased rates of gestational

    diabetes, pre-eclampsia and difficulties during birth, which may lead to

    increased rates of caesarean section. Excessive weight gain during

    pregnancy and poor weight loss postnatally has also been identified as

    a critical period for the development of obesity in the life cycle. m) Iron deficiency anaemia is common in young children. Average daily

    intakes of iron and calcium are significantly lower in children from

    manual groups than those in non-manual groups. Children in manual

    groups have lower blood ferritin status; 84% of children under 4 years

    old have below recommended iron intakes, with 16% having very low

    intakes (Gregory et al. 1995).

    4 The guidance

    NICE issued a consultation draft of a process for the development of NICE

    public health guidance (The operating model for the Centre for Public

    Health Excellence) in March 2005. A final process manual is being

    developed taking into account the responses received during consultation.

    The consultation draft is available from the NICE website

    (, and the final draft will be posted

    on the website when it is available.

    a) This document is the final scope. It defines exactly what this guidance

    will (and will not) examine, and what the guidance developers will

    consider. The scope is based on a referral from the Department of

    Health (see appendix).

    b) The areas that will be addressed are described in the following sections.

    c) The term ‘intervention’ is used throughout this scope. It encompasses a

    range of delivery mechanisms such as interventions, programmes,

    policies, approaches and strategies.

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4.1 Population

    4.1.1 Groups that will be covered

    This guidance will support and inform local practice with both women and

    children in low income households and groups and will cover the following


    a) Women of childbearing age (regardless of body weight):

    ? pre-conception (or planning a pregnancy)

    ? during pregnancy (from conception to birth) including multiple


    ? post-pregnancy (up to 1 year following birth), including the

    nutritional needs of all mothers.

    b) Infants from birth and pre-school children, typically up to 5 years old

    (regardless of body weight) including multiple births and infants and

    children with physical and/or learning disabilities.

    Particular attention will be given to:

    ? lower socio-economic groups

    ? vulnerable groups, including young teenage mothers,

    refugees and asylum seekers

    ? black and minority ethnic groups

    ? cultural and religious practices. In relation to health inequalities, this guidance will investigate the

    effectiveness of interventions across the broader social gradient, rather than

    focusing on those in the poorest circumstances and those in the poorest

    health (Graham and Kelly 2004).

    4.1.2 Groups that will not be covered

    The guidance will not cover the nutritional status and care of women and

    children with clinical conditions that require specialist advice, secondary

    dietary management, or clinical therapeutic advice, for whom normal care

    would be inappropriate. For example, the guidance will not cover women and

    Maternal and child nutrition final scope 8 of 19

children with diabetes, epilepsy or HIV, the management of food allergies and

    intolerance, or the care of low birth weight babies (defined by the World

    Health Organization as a birth weight less than 2500 g). However, where

    appropriate, the guidance will cross-reference to other NICE guidance, such

    as the clinical guidelines on diabetes during pregnancy, antenatal care,

    routine postnatal care, antenatal and postnatal mental health, fertility, and

    eating disorders.

    4.2 Areas that will be covered

    The guidance will have a bearing upon the following areas:

    a) Women

    ? Diet/ nutrition pre-pregnancy, including folic acid

    supplementation, food safety, weight management and

    alcohol consumption.

    ? Diet/nutrition during pregnancy, including folic acid and

    vitamin and mineral supplementation (including vitamins A

    and D, iron and calcium), food safety, weight management

    (that is, appropriate gestational weight gain), oral health,

    physical activity and alcohol consumption.

    ? Diet/nutrition for all post partum women and mothers of

    babies and children, including weight management, healthy

    birth intervals and breastfeeding.

    ? Influencing whole family dietary patterns.

    b) Children

    ? Infant feeding including exclusive breastfeeding, partial

    breastfeeding, hygienic preparation and storage of

    expressed breast milk and formula feeds (that is, for infants,

    older babies and young children).

    ? Introducing supplementary feeds and solids.

    ? Optimal dietary management of pre-school children aged 05

    years, both within the home and in child care and pre-school


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    ? The diet and nutrition of infants and children will be split into

    the following age groups:

    o Infant feeding 06 months

    o Infant feeding 612 months

    o Young child feeding 1224 months

    o Young child feeding - 25 years

    ? Vitamin supplementation including vitamin D.

    ? Early dietary strategies that reduce the risk of food allergies

    and intolerance.

    ? Prevention of dental caries, tooth loss and dental erosion.

    c) Father/partner, carers and family

    ? The role of the father/partner, carers and family in influencing

    the diet of women, infants and children. 4.3 Areas that will not be covered

    The guidance will not cover the following areas.

    ? Population-based screening programmes

    ? Complementary therapy approaches

    ? National maternal and child nutrition policies that are already under the

    remit of the Department of Health and the Food Standards Agency

    (advised by the Scientific Advisory Committee for Nutrition), such as

    the establishment of population-based dietary recommendations,

    national advice on food safety, the nutritional content of infant formula

    and the fortification of foods.

    4.4 Key questions

    The overarching question will be: what nutritional interventions are effective in

    improving the health of pre-conceptual, pregnant and post partum mothers

    and children (up to 5 years) and reduce nutrition-related health inequalities?

    Ten elements of each intervention will be examined (as appropriate).

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