2 Public health need and practice
The importance of ensuring mothers and their babies are well‑nourished is widely recognised. A pregnant woman's nutritional status influences the growth and development of her fetus and forms the foundations for the child's later health (Gluckman et al. 2005). The mother's own health, both in the short and long term, also depends on how well‑nourished she is before, during and after pregnancy (DH 2004a).
A child's diet during the early years also impacts on their growth and development. It is linked to the incidence of many common childhood conditions such as diarrhoeal disease, dental caries and iron and vitamin D deficiencies. It may also influence the risk in adult life of conditions such as coronary heart disease, diabetes and obesity.
Current UK policy is to promote exclusive breastfeeding (feeding only breast milk) for the first 6 months. Thereafter, it recommends that breastfeeding should continue for as long as the mother and baby wish, while gradually introducing a more varied diet (DH 2003).
Breastfeeding contributes to the health of both mother and child, in the short and long term. For example, babies who are not breastfed are many times more likely to acquire infections such as gastroenteritis in their first year (Ip et al. 2007; Horta et al. 2007). It is estimated that if all UK infants were exclusively breastfed, the number hospitalised each month with diarrhoea would be halved, and the number hospitalised with a respiratory infection would be cut by a quarter (Quigley et al. 2007).
Exclusive breastfeeding in the early months may reduce the risk of atopic dermatitis (DH 2004a). In addition, there is some evidence that babies who are not breastfed are more likely to become obese in later childhood (DH 2004a; Li et al. 2003; Michels et al. 2007). Mothers who do not breastfeed have an increased risk of breast and ovarian cancers and may find it more difficult to return to their pre‑pregnancy weight (World Cancer Research Fund 2007; DH 2004a).
The UK infant feeding survey 2005 (Bolling et al. 2007) showed that 78% of women in England breastfed their babies after birth but, by 6 weeks, the number had dropped to 50%. Only 26% of babies were breastfed at 6 months. Exclusive breastfeeding was practised by only 45% of women 1 week after birth and 21% at 6 weeks (Bolling et al. 2007).
Three quarters of British mothers who stopped breastfeeding at any point in the first 6 months (and 90% of those who stopped in the first 2 weeks) would have liked to have continued for longer. This suggests that much more could be done to support them. The British figures also contrast with data from Norway, where over 80% of mothers breastfeed for the first 6 months (Lande et al. 2003).
Acheson's independent inquiry (1998) recognised the impact of poverty on the health and nutritional status of women and children. In particular, the inquiry highlighted that mothers from disadvantaged groups are more likely than others to give birth to babies with a low birth weight. It also pointed out that breastfeeding is a strong indicator of social inequalities (that is, women who are most disadvantaged are least likely to breastfeed).
The most recent infant feeding survey 2005 (Bolling et al. 2007) confirmed that low maternal age, low educational attainment and low socioeconomic position continue to have a strong impact on patterns of infant feeding. For example, 65% of UK women from managerial and professional occupations were breastfeeding at 6 weeks compared to only 32% of those from routine and manual groups.
Less privileged mothers are also more likely to introduce solid foods earlier than recommended and their children are at a greater risk of both 'growth faltering' (that is, they gain weight too slowly) in infancy and obesity in later childhood (Armstrong et al. 2003). In addition, average daily intakes of iron and calcium are significantly lower, and rates of dental caries are significantly higher among children from manual groups compared with those from non‑manual groups (Gregory et al. 1995).
Women from disadvantaged groups have a poorer diet and are more likely either to be obese or to show low weight gain during pregnancy (Bull et al. 2003; Food Standards Agency 2007; Heslehurst et al. 2007). Mothers from these groups are also less likely to take folic acid or other supplements before, during or after pregnancy (Bolling et al. 2007).
Following scientific risk assessment by the Committee on Medical Aspects of Food and Nutrition Policy (COMA) and latterly, the Scientific Advisory Committee on Nutrition (SACN), the DH and the Food Standards Agency (FSA) have issued a portfolio of dietary advice for women and children. Of particular note are the COMA reports on: 'Dietary reference values for food energy and nutrients for the UK' (DH 1991) which addresses population dietary requirements throughout the lifecourse; 'Weaning and the weaning diet' (DH 1994a); 'Folic acid and the prevention of disease' (DH 2000); 'Nutritional aspects of cardiovascular disease' (DH 1994b). The latter recommends that by 5 years, children should be eating foods consistent with the recommendations for adults. More recently, advice on salt, oily fish and vitamin D has been updated (SACN 2004a, 2004b, 2007).
In 2000, COMA undertook a scientific review of the Welfare Food Scheme (WFS) which had been in existence in various forms since 1940. WFS provided eligible pregnant women, mothers and children with vouchers for milk or infant formula. COMA also recognised the contribution of benefits in kind made to poor families (Dobson et al. 1994; Dowler and Calvert 1995).
COMA recommended giving pregnant women and those with young children vouchers for a broader range of foods (that is, not just milk or infant formula; DH 2002). Healthy Start, which replaced WFS in 2006, implemented this and a range of other measures. An important innovation was its emphasis on the need for health professionals to give participating mothers health and lifestyle advice. This advice has to cover diet during pregnancy, breastfeeding and the importance of fresh fruit, vegetables and vitamins.
Since 1998, initiatives such as Sure Start and children's centres have created more opportunities for multidisciplinary involvement outside traditional healthcare settings. This has led to more local opportunities to offer nutritional advice to mothers and those who care for young children (DH 2004a; DH 2004b; DH 2004c; DfES 2004). The involvement of the whole family will be key: a woman's diet during pregnancy and her views on infant feeding are influenced by many people including her partner, parents, grandparents, friends and peers.
Children's eating behaviour is also influenced by the wider environment. Important factors include: parental food preferences and beliefs; the food they make available for their children; child/parent interactions related to food; the behaviour of other role models; and the media (Jeffrey et al. 2005; St Jeor et al. 2002; Summerbell et al. 2005).