1 Key priorities

This section lists the six recommendations that have been identified as key priorities for implementation, on the basis of these criteria:

  • impact on health inequalities

  • impact on health of the target population

  • balance of risks and benefits

  • cost effectiveness

  • ease of implementation

  • speed of impact.

Healthy Start

Recommendation 4

Who is the target population?

Pregnant women and parents of infants and children under 4 years who may be eligible for the Healthy Start benefit.

Who should take action?
  • Primary care trust (PCT) commissioners and managers.

  • GPs, midwives, health visitors, obstetricians, paediatricians, and community pharmacists.

What action should they take?
  • PCTs should promote the Healthy Start scheme.

  • PCTs should ensure an adequate supply of both types of Healthy Start vitamin supplements (for women and for children from 6 months to 4 years) is available for distribution by health professionals when they see pregnant women and parents of children under 4 years.

  • PCTs should ensure an adequate supply of Healthy Start application forms is available and that the uptake of Healthy Start benefits is regularly audited.

  • Health professionals should advise pregnant women and parents of children under 4 years about the Healthy Start scheme. They should ensure all women who may be eligible receive an application form as early as possible in pregnancy.

  • Health professionals should use every opportunity they have to offer those parents who are eligible for the Healthy Start scheme practical, tailored information, support and advice on:

    • how to use Healthy Start vouchers to increase their fruit and vegetable intake

    • how to initiate and maintain breastfeeding

    • how to introduce foods in addition to milk as part of a progressively varied diet when infants are 6 months old.

  • Health professionals should offer the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D) to pregnant women who are (or who may be) eligible.

  • GPs and health visitors should offer children's Healthy Start vitamin supplements (vitamins A, C and D) to all children aged from 6 months to 4 years in families receiving the Healthy Start benefit.

  • Commissioners should consider distributing the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D) to all women who receive Healthy Start benefit for children aged 1–4 years, particularly those who may become pregnant.

  • Community pharmacists should ensure the Healthy Start maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge.

Training

Recommendation 1

Who is the target population?

Health professionals and support workers who care for children under 5 years and women who may become – or who are – pregnant.

Who should take action?

Professional bodies, skills councils and others responsible for setting competencies and developing continuing professional development programmes for health professionals, nursery nurses and support workers.

What action should they take?
  • Professional bodies should ensure health professionals have appropriate knowledge and skills to give advice on the following:

    • the nutritional needs of women and the importance of a balanced diet before, during and after pregnancy (including the need for suitable folic acid supplements)

    • the rationale for recommending certain dietary supplements (for example, vitamin D) to pregnant and breastfeeding women

    • the nutritional needs of infants and young children

    • breastfeeding management, using the Baby Friendly Initiative (BFI) training as a minimum standard

    • strategies for helping people to change their eating behaviour, particularly by offering practical, food‑based advice.

  • As part of their continuing professional development, train midwives, health visitors and support workers in breastfeeding management, using BFI training as a minimum standard.

  • As part of their continuing professional development, train health professionals, including doctors, dietitians and pharmacists, to promote and support breastfeeding, using BFI training as a minimum standard.

Vitamin D

Recommendation 3

Recommendation 3 in this guideline has been replaced by Vitamin D: increasing supplement use among at-risk groups NICE guideline PH56 (2014).

Breastfeeding

Recommendation 7

Who is the target population?

Pregnant women and breastfeeding mothers.

Who should take action?

Commissioners and managers of maternity and children's services.

What action should they take?
  • Adopt a multifaceted approach or a coordinated programme of interventions across different settings to increase breastfeeding rates. It should include:

    • activities to raise awareness of the benefits of – and how to overcome the barriers to – breastfeeding

    • training for health professionals

    • breastfeeding peer‑support programmes

    • joint working between health professionals and peer supporters

    • education and information for pregnant women on how to breastfeed, followed by proactive support during the postnatal period (the support may be provided by a volunteer).

  • Implement a structured programme that encourages breastfeeding, using BFI as a minimum standard. The programme should be subject to external evaluation.

  • Ensure there is a written, audited and well‑publicised breastfeeding policy that includes training for staff and support for those staff who may be breastfeeding. Identify a health professional responsible for implementing this policy.

(See also postnatal care NICE guideline CG37)

Recommendation 11

Who is the target population?

Pregnant women and new mothers, particularly those who are least likely to start and continue to breastfeed. For example, young women, those who have low educational achievement and those from disadvantaged groups.

Who should take action?

Commissioners and managers of maternity and children's services.

What action should they take?
  • Provide local, easily accessible breastfeeding peer support programmes and ensure peer supporters are part of a multidisciplinary team.

  • Ensure peer supporters:

    • attend a recognised, externally accredited training course in breastfeeding peer support

    • contact new mothers directly within 48 hours of their transfer home (or within 48 hours of a home birth)

    • offer mothers ongoing support according to their individual needs. This could be delivered face‑to‑face, via telephone or through local groups

    • can consult a health professional and are provided with ongoing support

    • gain appropriate child protection clearance.

  • Consider training peer supporters and link workers to help mothers, parents and carers follow professional advice on feeding infants aged 6 months and over. The advice should promote an increasingly varied diet using food of different textures in appropriate amounts (in addition to milk), in response to the baby's needs.

Folic acid

Recommendation 2

Who is the target population?

Women who may become pregnant and women in early pregnancy.

Who should take action?
  • PCTs and NHS trusts.

  • Directors of public health, planners and organisers of public health campaigns.

  • Pharmacists, GPs, hospital doctors and nurses, particularly those working in gynaecology, sexual health, contraceptive and family planning services, fertility clinics and school health services.

  • Public health nutritionists and dietitians.

  • Manufacturers of goods for women of childbearing age.

What action should they take?
  • Health professionals should:

    • Use any appropriate opportunity to advise women who may become pregnant that they can most easily reduce the risk of having a baby with a neural tube defect (for example, anencephaly and spina bifida) by taking folic acid supplements. Advise them to take 400 micrograms (μg) daily before pregnancy and throughout the first 12 weeks, even if they are already eating foods fortified with folic acid or rich in folate.

    • Advise all women who may become pregnant about a suitable folic acid supplement, such as the maternal Healthy Start vitamin supplements.

    • Encourage women to take folic acid supplements and to eat foods rich in folic acid (for example, fortified breakfast cereals and yeast extract) and to consume foods and drinks rich in folate (for example, peas and beans and orange juice).

  • PCTs should ensure local education initiatives aimed at health professionals include information on the importance of folic acid supplements. They should provide the maternal Healthy Start vitamin supplements (folic acid, vitamins C and D) for eligible women. They should also ensure women who are not eligible for Healthy Start can obtain the supplements from their local pharmacy.

  • GPs should prescribe 5 milligrams of folic acid a day for women who are planning a pregnancy, or are in the early stages of pregnancy, if they:

    • (or their partner) have a neural tube defect

    • have had a previous baby with a neural tube defect

    • (or their partner) have a family history of neural tube defects

    • have diabetes.

  • Manufacturers should include information with their products on the importance of folic acid supplements before and during pregnancy. Relevant products may include pregnancy tests, sanitary products, contraceptives and ovulation predictor kits.

(See also diabetes in pregnancy NICE guideline NG3 and antenatal care NICE guideline CG62)