4 Recommendations

This document is the Institute's formal guidance on maternal and child nutrition. When writing the recommendations, the Programme Development Group (see appendix A) considered the evidence of effectiveness (including cost effectiveness), fieldwork data and comments from stakeholders.

The recommendations support local implementation of national policy on maternal and child nutrition.

As set out in the scope for the guidance, they do not cover the following areas:

  • population‑based screening programmes

  • complementary therapy approaches

  • national maternal and child nutrition policies that are the responsibility of the Department of Health (DH) and the Food Standards Agency (FSA), as advised by the Scientific Advisory Committee on Nutrition. These include policies on population‑based dietary recommendations, food safety, the nutritional content of infant formula and the fortification of foods.

The recommendations are relevant for all women who are pregnant (or who may become pregnant), mothers of children aged under 5 and others who care for children aged under 5. They are particularly relevant for pregnant women, mothers and children from low‑income and other disadvantaged backgrounds.

The evidence statements that underpin the recommendations are listed in appendix C.

The evidence reviews, supporting evidence statements and economic appraisal are available.

The PDG also considered whether a recommendation should only be implemented as part of a research programme, where evidence was lacking.

For the research recommendations and other gaps in the research, see section 6 and appendix D respectively.

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 the 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 (www.babyfriendly.org.uk)

    • strategies for changing people's 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.

Folic acid

Recommendation 2

Who is the target population?

Women who may become pregnant and women in early pregnancy.

Who should take action?
  • Primary care trusts (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 CG63 and antenatal care NICE guideline CG62)

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).

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?
  • 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.

Diet in pregnancy

Recommendation 5

Who is the target population?

Pregnant women and those who may become pregnant.

Who should take action?

Midwives, obstetricians, GPs, health visitors and dietitians.

What action should they take?
  • Early in pregnancy, discuss the woman's diet and eating habits and find out and address any concerns she may have about her diet.

  • Provide information on the benefits of a healthy diet and practical advice on how to eat healthily throughout pregnancy. This should be tailored to the woman's circumstances. The advice should include: eat five portions of fruit and vegetables a day and one portion of oily fish (for example, mackerel, sardines, pilchards, herring, trout or salmon) a week.

Obesity

Recommendation 6

Who is the target audience?

Pregnant women who have a pre‑pregnancy body mass index (BMI) over 30, and those with a BMI over 30 who have a baby or who may become pregnant.

Who should take action?

Obstetricians, gynaecologists, GPs, midwives, health visitors, nurses, dietitians, those working in contraceptive services or on weight management programmes (commercial or voluntary).

What action should they take?
  • Inform women who have a BMI over 30 about the increased risks this poses to themselves and their babies and encourage them to lose weight before becoming pregnant or after pregnancy. Provide a structured programme that:

    • addresses the reasons why women may find it difficult to lose weight, particularly after pregnancy

    • is tailored to the needs of an individual or group

    • combines advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 minutes on at least 5 days of the week)

    • identifies and addresses individual barriers to change

    • provides ongoing support over a sufficient period of time to allow for sustained lifestyle changes.

  • Health professionals should refer pregnant women with a BMI over 30 to a dietitian for assessment and advice on healthy eating and exercise. Do not recommend weight‑loss during pregnancy.

  • Advise breastfeeding women that losing weight by eating healthily and taking regular exercise will not affect the quantity or quality of their milk.

(See also diabetes in pregnancy NICE guideline CG63 and antenatal care NICE guideline CG62)

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 8

Who is the target population?

Pregnant women and breastfeeding mothers.

Who should take action?
  • Commissioners and managers of maternity and children's services.

  • PCTs.

What action should they take?
  • Ensure health professionals who provide information and advice to breastfeeding mothers have the required knowledge and skills.

  • Ensure support workers receive training in breastfeeding management from someone with the relevant skills and experience before they start working with breastfeeding mothers.

  • Ensure all those who work in maternity and children's services, including receptionists, volunteers and ancillary staff, are made fully aware of the importance of breastfeeding and help to promote a supportive environment.

Recommendation 9

Who is the target population?

Pregnant women and their partners.

Who should take action?

Midwives, obstetricians, GPs and health visitors.

What action should they take?
  • Midwives and health visitors should ensure pregnant women and their partners are offered breastfeeding information, education and support on an individual or group basis. This should be provided by someone trained in breastfeeding management and should be delivered in a setting and style that best meets the woman's needs.

  • During individual antenatal consultations GPs, obstetricians and midwives should encourage breastfeeding. They should pay particular attention to the needs of women who are least likely to breastfeed (for example, young women, those who have low educational achievement and those from disadvantaged groups).

  • A midwife or health visitor trained in breastfeeding management should provide an informal group session in the last trimester of pregnancy. This should focus on how to breastfeed effectively by covering feeding position and how to attach the baby correctly.

Recommendation 10

Who is the target population?

Breastfeeding mothers.

Who should take action?

Midwives, health visitors, midwifery and health visitor support workers.

What action should they take?
  • Ensure a mother can demonstrate how to position and attach the baby to the breast and can identify signs that the baby is feeding well. This should be achieved (and be documented) before she leaves hospital or the birth centre (or before the midwife leaves the mother after a home birth).

  • Provide continuing and proactive breastfeeding support at home, recording all advice in the mother's hand‑held records.

  • Provide contact details for local voluntary organisations that can offer ongoing support to complement NHS breastfeeding services.

  • Advise mothers that a healthy diet is important for everyone and that they do not need to modify their diet to breastfeed.

  • Do not provide written materials in isolation but use them to reinforce face‑to‑face advice about breastfeeding.

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.

Recommendation 12

Who is the target population?

Breastfeeding mothers.

Who should take action?

Midwives, health visitors, paediatric nurses, nurses working in special‑care baby and neonatal units, and nursery nurses.

What action should they take?
  • Show all breastfeeding mothers how to hand‑express breast milk.

  • Advise mothers that expressed milk can be stored for:

    • up to 5 days in the main part of a fridge, at 4ºC or lower

    • up to 2 weeks in the freezer compartment of a fridge

    • up to 6 months in a domestic freezer, at minus 18ºC or lower.

  • Advise mothers who wish to store expressed breast milk for less than 5 days that the fridge preserves its properties more effectively than freezing.

  • Advise mothers who freeze their expressed breast milk to defrost it in the fridge and not to re‑freeze it once thawed. Advise them never to use a microwave oven to warm or defrost breast milk.

Link workers

Recommendation 13

Who is the target population?

Pregnant women and mothers whose first language is not English, their partners and extended family.

Who should take action?

NHS trusts responsible for maternity care and GP surgeries and community health centres.

What action should they take?
  • NHS trusts should train link workers who speak the mother's first language to provide information and support on breastfeeding, use of infant formula , weaning and healthy eating.

  • Where link workers are not available, ensure women whose first language is not English have access to interpreting services and information in a format and language they can understand.

  • NHS trusts should encourage women from minority ethnic communities whose first language is not English to train as breastfeeding peer supporters.

Infant formula

Recommendation 14

Who is the target population?

Pregnant women and mothers.

Who should take action?
  • Commissioners and managers responsible for maternity, children's and primary care services.

  • GPs, midwives, health visitors and pharmacists.

What action should they take?
  • Commissioners and managers should ensure mothers have access to independent advice from a qualified health professional on the use of infant formula. This should include information on the potential risks associated with formula‑feeding and how to obtain ongoing advice at home.

  • Midwives should ensure mothers who choose to use infant formula are shown how to make up a feed before leaving hospital or the birth centre (or before the mother is left after a home birth). This advice should follow the most recent guidance from the DH ('Guide to bottle feeding' 2011)[1].

  • Avoid promoting or advertising infant or follow‑on formula. Do not display, distribute or use product samples, leaflets, posters, charts, educational or other materials and equipment produced or donated by infant formula, bottle and teat manufacturers.

(See also postnatal care NICE guideline CG37)

Prescribing

Recommendation 15

Who is the target population?

Hospital doctors, GPs, obstetricians, pharmacists, specialist nurses, dentists and PCT medicine management teams.

Who should take action?

NHS trusts responsible for maternity care and GP surgeries, community health centres, pharmacies and drug and alcohol services.

What action should they take?
  • Ensure health professionals and pharmacists who prescribe or dispense drugs to a breastfeeding mother consult supplementary sources (for example, the Drugs and Lactation Database [LactMed] or seek guidance from the UK Drugs in Lactation Advisory Service.

  • Health professionals should discuss the benefits and risks associated with the prescribed medication and encourage the mother to continue breastfeeding, if reasonable to do so. In most cases, it should be possible to identify a suitable medication which is safe to take during breastfeeding by analysing pharmokinetic and study data. Appendix 5 of the 'British national formulary' should only be used as a guide as it does not contain quantitative data on which to base individual decisions.

  • Health professionals should recognise that there may be adverse health consequences for both mother and baby if the mother does not breastfeed. They should also recognise that it may not be easy for the mother to stop breastfeeding abruptly – and that it is difficult to reverse.

Child health promotion

Recommendation 16

Who is the target population?

Parents and carers of infants and pre‑school children.

Who should take action?
  • NHS trust and PCT commissioners and managers.

  • Health visitors, community nursery nurses, the child health promotion programme (CHPP) team and children's centre teams.

What action should they take?
  • Commissioners and managers should work with local partners to ensure mothers can feed their babies in public areas without fear of interruption or criticism.

  • Health visitors should assess the needs of all mothers, parents and carers with young children. They should provide relevant, early and ongoing support at home for those with the greatest needs, including any that may be the result of a physical or learning disability or communication difficulties.

  • Health visitors and the CHPP team should:

    • support mothers to continue breastfeeding for as long as they choose

    • provide mothers and other family members with support to introduce a variety of nutritious foods (in addition to milk) to ensure the child is offered a progressively varied diet from 6 months

    • encourage and support parents and carers to make home‑prepared foods for infants and young children, without adding salt, sugar or honey

    • encourage families to eat together and encourage parents and carers to set a good example by the food choices they make for themselves

    • advise parents and carers not to leave infants alone when they are eating or drinking.

Recommendation 17

Who is the target population?

Infants and pre‑school children.

Who should take action?
  • NHS trust and PCT commissioners and managers.

  • GPs, paediatricians, midwives, health visitors and community nursery nurses.

What action should they take?
  • As a minimum, ensure babies are weighed at birth and in the first week, as part of an overall assessment of feeding. Thereafter, healthy babies should usually be weighed at 8, 12 and 16 weeks and at 1 year, at the time of routine immunisations. If there is concern, weigh more often, but no more than once a month up to 6 months of age, once every 2 months from 6–12 months of age and once every 3 months over the age of 1 year[2] [new 2011].

  • Ensure infants are weighed using digital scales which are maintained and calibrated annually, in line with medical devices standards (spring scales are inaccurate and should not be used).

  • Commissioners and managers should ensure health professionals receive training on weighing and measuring infants. This should include: how to use equipment, how to document and interpret the data, and how to help parents and carers understand the results and implications.

  • Ensure support staff are trained to weigh infants and young children and to record the data accurately in the child health record held by the parents.

(See also intrapartum care NICE guideline CG55)

Allergies

Recommendation 18

Who is the target population?

Pregnant women, mothers and their partners who have a family history of allergy (including eczema, asthma and hay fever).

Who should take action?

Midwives, health visitors, GPs, paediatricians, community dietitians and pharmacists.

What action should they take?
  • Advise mothers to feed the baby only on breast milk and to continue breastfeeding while introducing solid foods, when the infant is 6 months. For current dietary advice visit NHS Choices.

  • Advise mothers who choose not to breastfeed that there is insufficient evidence to suggest that infant formula based on partially or extensively hydrolysed cow's milk protein helps to prevent allergies.

Oral health

Recommendation 19

Who is the target population?

Parents and carers of infants and pre‑school children.

Who should take action?

Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home‑based child carers and others who work with young children.

What action should they take?
  • Encourage parents and carers to:

    • use a bottle for expressed breast milk, infant formula or cooled boiled water only

    • offer drinks in a non‑valved, free‑flowing cup from age 6 months to 1 year

    • discourage feeding from a bottle from 1 year onwards

    • limit sugary foods to mealtimes only

    • avoid giving biscuits or sweets as treats

    • encourage snacks free of salt and added sugar (such as vegetables and fruit) between meals

    • provide milk and water to drink between meals (diluted fruit juice can be provided with meals – 1 part juice to 10 parts water).

  • Discourage parents and carers from:

    • adding sugar or any solid food to bottle feeds

    • adding sugar or honey to weaning (solid) foods

    • offering baby juices or sugary drinks at bedtime.

Pre‑school settings

Recommendation 20

Who is the target population?

Parents and carers of infants and pre‑school children.

Who should take action?

Nursery nurses, home‑based child carers and others working in pre‑school day care settings such as nurseries, creches and playgroups.

What action should they take?
  • Support breastfeeding mothers by:

    • offering them the opportunity to breastfeed when they wish

    • encouraging them to bring expressed breast milk in a cool bag

    • ensuring expressed breast milk is labelled with the date and name of the infant and stored in the main body of the fridge.

  • Implement DH guidance ('Guide to bottle feeding' 2011[1]) on the preparation and use of powdered infant formula to reduce the risk of infection to infants in care settings.

Recommendation 21

Who is the target population?

Infants and pre‑school children up to the age of 5 years.

Who should take action?

Teachers, teaching assistants, nursery nurses, home‑based child carers and those working in pre‑school day care settings such as nurseries, creches and playgroups.

What action should they take?
  • Implement a food policy which takes a 'whole settings' approach to healthy eating, so that foods and drinks made available during the day reinforce teaching about healthy eating.

  • Take every opportunity to encourage children to handle and taste a wide range of foods that make up a healthy diet by:

    • providing practical classroom‑based activities

    • ensuring a variety of healthier choices are offered at mealtimes, and snacks offered between meals are low in added sugar and salt (for example, vegetables, fruit, milk, bread and sandwiches with savoury fillings)

    • ensuring carers eat with children whenever possible.

Family nutrition

Recommendation 22

Who is the target population?

Families with children aged up to 5 years.

Who should take action?
  • Commissioning agencies, local authorities, local strategic partnerships, voluntary agencies and local businesses that fund or provide community projects.

  • Public health nutritionists and dietitians.

What action should they take?
  • Public health nutritionists and dietitians should offer parents in receipt of Healthy Start benefit practical support and advice on how to use the Healthy Start vouchers to increase their intake of fruit and vegetables.

  • Provide support (both practical and financial) to develop and maintain community‑based initiatives which aim to make a balanced diet more accessible to people on a low income. Examples include: food cooperatives, 'cook and eat' clubs, 'weaning parties' and 'baby cafes'.

  • Work with local retailers to improve the way fresh fruit and vegetables are displayed and promoted.



[1] This recommendation has been amended to include the latest Department of Health guidance on bottle feeding. The original wording was as follows: ('Bottle feeding' 2006).

[2] This recommendation has been amended to be consistent with the UK World Health Organization child growth charts published in 2009. The original wording was as follows: As a minimum, ensure babies are weighed (naked) at birth and at 5 and 10 days, as part of an overall assessment of feeding. Thereafter, healthy babies should be weighed (naked) no more than fortnightly and then at 2, 3, 4 and 8–10 months in their first year.