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.
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
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
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? 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
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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
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
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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 19–64 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 30–50% 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).
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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
(www.nice.org.uk/page.aspx?o=248187), 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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4.1.1 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
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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
4.2 Areas that will be covered
The guidance will have a bearing upon the following areas:
? Diet/ nutrition pre-pregnancy, including folic acid
supplementation, food safety, weight management and
? 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.
? 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 0–5
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 – 0–6 months
o Infant feeding – 6–12 months
o Young child feeding – 12–24 months
o Young child feeding - 2–5 years
? Vitamin supplementation including vitamin D.
? Early dietary strategies that reduce the risk of food allergies
? 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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