1. Maternal and child nutrition
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This slide set was updated in March 2012 to include details of NHS Evidence and the NICE Pathway, and to incorporate information on the guidance review that published in July 2011.
This presentation has been written to help you raise awareness of the NICE public health guidance on improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. In particular, this guidance aims to address disparities in the nutrition of low income and other disadvantaged groups compared with the general population. The guidance has been written for NHS and other professionals who have a direct or indirect role in – and responsibility for – the nutrition of pregnant and breastfeeding mothers and pre-school children. This includes midwives, health visitors, dietitians and pharmacists, and those working in local authorities and the community, voluntary and private sectors. It will also be of interest to members of the public.
This presentation focuses on the key priorities for implementation outlined in the NICE guidance. The quick reference guide (QRG) summarises all the recommendations into key themes for different audiences.
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. The key recommendations are also given in full. Please feel free to adapt, amend or remove these notes as you see necessary.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
2nd edition March 2012
NICE public health guidance 11

2. Guidance review
This guidance was originally issued in It was reviewed in July 2011 where it was decided it should not be updated at this time.
During the review, three recommendations were amended:
infant formula
checking babies weight
pre-school settings: infant feeding
NOTES FOR PRESENTERS:
Review:
The guidance will be reviewed again in three years, in July 2014.
The amended recommendations are number 14 (infant formula); 17 (checking babies weight); and 20 (pre-school settings: infant feeding).
Recommendations 14 and 20 were amended in line with a 2011 Department of Health new guide to bottle feeding
Recommendation 17 was amended to be consistent with advice in the UK-WHO growth charts and the personal child health record (PCHR or ‘red book’). Additional information:
The review noted that the Scientific Advisory Group on Nutrition (SACN) will be publishing a number of scientific reports over the next 2-3 years in relation to the guidance topic area which may impact on the current recommendations.
There are a number of large scale intervention trials ongoing and an evaluation of the national Healthy Start scheme, the findings from which may also impact on the current recommendations. However the results of these trials are not expected to be published before 2013 or 2014
The national policy context for the commissioning and provision of maternity, postnatal and children’s services and nutritional support services is undergoing change, but the implication of these changes is still unclear.
The expert group considered that all recommendations were still relevant and useful. They suggested there was insufficient new evidence since the finalisation of the guidance reviews that would cause a change to the existing recommendations.

3. What this presentation covers
Scope
Key priorities for implementation
Costs and savings
Discussion
NHS evidence and NICE pathway
A local practice example, and find out more
NOTES FOR PRESENTERS:
In this presentation we provide an overview of the scope of the guidance and why it is important and then outline the key priorities for implementation. The costs and savings that are likely to be incurred in implementing the guidance are summarised, followed by a suggested list of questions to help prompt discussion. Following this we will highlight the NICE Pathway and look at NHS Evidence and how this resource may help with keeping up to date with the latest evidence base.
Finally, we will end the presentation with further information about the support provided by NICE.

4. Scope
Maternal diet and nutrition: pre-pregnancy, during and post-pregnancy
Infant feeding: infant formula and breastfeeding
Diet and nutrition for babies from 6 months old
and pre-school children: including weaning, weight monitoring, allergy prevention and oral health
Addresses disparities in low-income and
other disadvantaged groups
NOTES FOR PRESENTERS:
Key points to raise:
The recommendations complement Department of Health and Food Standards Agency policy and advice on diet and nutrition as per July 2011.
Additional information:
For advice on what constitutes a healthy diet visit:
A pregnant woman’s nutritional status influences the growth and development of her foetus and forms the foundations for the child’s later health.
A child’s diet during their early years also impacts on their growth and development.
Breastfeeding contributes to the health of the mother and the child in both the long and the short term.
This NICE guidance is wide ranging with 22 recommendations, of these:
16 are aimed at health professionals. They cover nutrition advice and support for mothers who are feeding babies aged up to 6 months and for parents and carers of pre-school children over 6 months old (refer to QRG pages 4–11).
11 are for commissioners and managers. They cover breastfeeding policy and programmes, the Healthy Start scheme and training and development (refer to QRG pages 12–15).
7 are for public, community, voluntary and private sector organisations and focus on partnership working. The aim is to help improve women’s awareness of the importance of a healthy balanced diet during pregnancy and while breastfeeding, and to ensure babies and young children have a healthy, balanced diet both inside and outside the home (refer to QRG pages 16–18).

5. Key priorities for implementation
Promote the Healthy Start scheme
Train staff in maternal and child nutrition
Advise women to take folic acid and vitamin D supplements, as appropriate
Promote and support breastfeeding
NOTES FOR PRESENTERS:
Key points to raise:
The experts who wrote the guidance have chosen six out of the 22 recommendations that they think will have the greatest impact on promoting good health or preventing ill health and are the most important priorities for implementation. They cover the topics outlined on this slide and are the focus of this presentation.
They were selected on the basis of the following criteria:
impact on health inequalities
impact on health of the target population
the balance of risks and benefits
cost effectiveness
ease of implementation and speed of impact.
Additional information:
The 6 key priorities for implementation are summarised in section one of the guidance.

6. Encourage all those who may be eligible to apply: ensure forms and vitamin supplements are available
Offer Healthy Start vitamin supplements to all women and children who are eligible
Offer eligible parents tailored support and advice on using Healthy Start vouchers, on breastfeeding and on how to introduce infants to solid foods
Audit local uptake
NOTES FOR PRESENTERS:
Key point to raise: You may find it helpful to explain eligibility, go to:
Recommendation 4 in full: 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 (HS) 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 HS 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 HS 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.

7. Training
Caring for women who may become (or who are) pregnant and children under 5 requires training in:
their nutritional needs
the rationale for recommending supplements
how to provide dietary advice
breastfeeding management (BFI minimum standard)
practical ways of changing eating behaviour
NOTES FOR PRESENTERS:
Key point to raise: NICE has produced guidance that can be used as the basis for planning, delivering and evaluating public health activities aimed at changing health-related behaviours (go to:
Recommendation 1 in full:
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.

8. Vitamin D for pregnant and breastfeeding mothers
Ensure health professionals know about the importance of vitamin D supplements
Offer pregnant women information and advice at first booking appointment, on the benefits of taking a suitable daily 10 mcg supplement – such as Healthy Start
Ensure those at greatest risk of a deficiency are taking vitamin D
NOTES FOR PRESENTERS:
Key points to raise: Maternal Healthy Start vitamin supplements are considerably cheaper than commercially available alternatives and reduce the risk of women taking multivitamin supplements containing vitamin A (which is not recommended during pregnancy).
Additional information: See also NICE’s antenatal care guideline:
Recommendation 3 in full:
Who is the target population? Pregnant women and breastfeeding mothers.
Who should take action? • Dietitians, public health nutritionists, midwives, health visitors, GPs, obstetricians, community pharmacists, manufacturers of goods for pregnant and breastfeeding women.
What action should they take?
• Dietitians and public health nutritionists should educate health professionals about the importance of vitamin D supplements for all pregnant and breastfeeding women.
• During the booking appointment at the beginning of pregnancy, midwives should offer every woman information and advice on the benefits of taking a vitamin D supplement (10 micrograms [μg] per day) during pregnancy and while breastfeeding. They should explain that it will increase both the mother’s and her baby’s vitamin D stores and reduce the baby’s risk of developing rickets.
• Health professionals should take particular care to check that women at greatest risk of deficiency are following advice to take a vitamin D supplement during pregnancy and while breastfeeding. These include women who are obese, have limited skin exposure to sunlight or who are of South Asian, African, Caribbean or Middle Eastern descent.
• Midwives and health visitors should advise all pregnant and breastfeeding women about the availability of suitable vitamin D supplements such as the Healthy Start vitamin supplements. Women who are not eligible for Healthy Start benefit can obtain the vitamin supplement from their local community pharmacy.
• Manufacturers should include information with their products on the importance of vitamin D supplements during pregnancy and while breastfeeding. Relevant products may include pregnancy tests and breast pumps.

9. Breastfeeding promotion
Use a multi-faceted approach or coordinated programme of interventions across different settings
Use the Baby Friendly Initiative (BFI) as a minimum standard
Develop a written, audited and well-publicised breastfeeding policy that includes support for staff who are breastfeeding
Identify a health professional responsible for implementing this policy
NOTES FOR PRESENTERS:
Key point to raise:
Recommendation 7 is one of 6 recommendations on breastfeeding (please refer to recommendations 7–12 in the NICE guidance, p36–41) .
Additional Information:
See also NICE clinical guideline 37 on postnatal care at
Recommendation 7 in full:
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 ( 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.

10. Breastfeeding support
Peer supporters should:
receive externally accredited training
receive ongoing support as part of a multidisciplinary team
contact new mothers within 48 hours of their transfer home (or 48 hours of a home birth)
offer mothers ongoing support according to need
NOTES FOR PRESENTERS:
Key points to raise:
Provide local and easily accessible breastfeeding peer-support programmes.
Peer supporters should gain appropriate child protection clearance.
For women whose first language is not English the guidance recommends a link worker who speaks the mother’s first language should be available to provide information and support. Where not available, women should have access to interpreting services and information in a format and language they can understand (see recommendation13).
Recommendation 11 in full:
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.

11. Folic acid
Advise women who may become pregnant and those up to 12 weeks pregnant to follow a folate rich diet and take a 400 mcg folic acid supplement daily
Prescribe 5 mg a day if they have a family history of neural tube defect (NTD), have given birth to a baby with NTD or have diabetes
Ensure local initiatives stress the importance of folic acid and the availability of suitable supplements
NOTES FOR PRESENTERS:
Additional Information:
Neural tube defects (NTD) include anencephaly and spina bifida.
See also NICE clinical guideline 63 on diabetes in pregnancy at and the antenatal care clinical guideline 62 at
Recommendation 2 in full:
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.

12. Costs & savings
This guidance is unlikely to have a significant impact on costs. Locally, additional resources may be required for breastfeeding peer support, staff training and link workers, the provision of Healthy Start vitamins and family nutrition programmes. Implementing this guidance may reduce: - childhood illnesses such as gastroenteritis - the rate of obesity among adults and children - the risk of some cancers among mothers - neural tube defects
NOTES FOR PRESENTERS:
Key point to raise:
NICE has worked closely with the guidance developers and other people in the NHS to look at the major costs and savings related to implementing this guidance and found that it is unlikely to result in any significant changes, based on national assumptions. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average.
Implementing this guidance may reduce:
childhood illnesses such as gastroenteritis, otitis media and upper respiratory tract infections and hospital admissions (due to the protection that breastfeeding conveys on both mother and child)
the forecast for obesity rates among adults and children (due to family nutrition programmes and an increase in breastfeeding rates)
the risk of some cancers among mothers who breastfeed
neural tube defects (due to the intake of folic acid).
Additional Information:
Refer to the NICE costing statement for details of the national assumptions on which the resource impact estimate is based.
Correct at March Cost and savings assumptions were not updated for 2nd edition

13. Discussion: breastfeeding
To what extent have we implemented the BFI standard or its equivalent?
How do we train our peer supporters?
How well are peer supporters working as part of a multi-disciplinary team?
NOTES FOR PRESENTERS:
The questions here and on the following slide are suggestions that we have developed to help provide a prompt for a discussion at the end of your presentation. These can be edited and adapted according to your local situation.

14. Discussion: diet and nutrition
How do we encourage healthy eating among women who are (or who may become) pregnant and pre-school children?
How can we improve uptake of Healthy Start?
How can we improve awareness of the importance of vitamin D and folic acid supplements?
How can we improve uptake of vitamin D/folic acid?
NOTES FOR PRESENTERS:
Please edit and adapt these questions to suit your local situation.
Click here for an article on vitamin D deficiency on the NICE website

15. Click here to go to NICE Pathways website
This NICE Pathway covers:
strategy, policy and commissioning
training
primary, secondary and community health services
advice for pre-school settings
advice for manufacturers
NOTES FOR PRESENTERS:
Key points to raise:
If you are showing this presentation when in slideshow and connected to the internet, click on the orange button to go to the NICE Pathways overview. You will then need to select the Maternal and child nutrition Pathway option.
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
The NICE pathway can be found at
When you visit the pathway click on the recommendations which interest you – for example clicking on ‘training’ will take you to recommendations on the provision of training for health and social care professionals.
Click here to go to NICE Pathways website

16. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on maternal and child nutrition and care
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation when in slideshow and connected to the internet, click on the blue button to go straight to the NHS Evidence website search page, where you can search for resources on maternal and child nutrition. There are also topic pages on antenatal care, breastfeeding, postnatal depression and over 80 other topics.
For the home page go to

17. Kirklees local extension of the Healthy Start scheme
During , out of 3531 potential beneficiaries in Kirklees only 10 maternal and 228 children's vitamin supplements were claimed
In 2010, 52 children were diagnosed with rickets in Kirklees at an annual treatment cost of £135,200
This local extension project provided Healthy Start supplements to those not eligible for the national scheme.
NOTES FOR PRESENTERS:
The aim of the scheme was to enhance uptake to the national scheme, as well as improving the maternal and child nutrition of women and families across Kirklees.
Project results:
To date, this local scheme has had over 6000 referrals, and the national scheme has also seen an increase in those eligible applying for it.
25 Children's Centres and 23 Pharmacies across Kirklees now act as a distribution point where families can go and collect their Healthy Start vitamins.
For further details on this project please contact: Kate Parker, Health Improvement Practitioner, NHS Kirklees Phone:
Click here to go to the local practice example

18. Find out more Visit www.nice.org.uk/PH011 for: Other guidance formats
Commissioning guide: breastfeeding peer-support programme
Costing statement
Audit support
Shared learning
NOTES FOR PRESENTERS:
The focus of this presentation has been on the priority recommendations for implementation, but the maternal and child nutrition guidance is wide ranging with 22 recommendations.
The guidance is available in two formats. There is a quick reference guide, which summarises the guidance for different audiences under key themes, and the NICE guidance, which includes all the recommendation in full. You can download them from the NICE website. Recommendations are also incorporated into the NICE pathways on maternal and child nutrition and on diet.
NICE has developed tools to help organisations implement this guidance, which can be found on the NICE website. These include:
Commissioning guide on breastfeeding peer-support programmes
Costing statement
Audit support – assists NHS trusts to determine how well they meet NICE recommendations
For examples from local practice visit the NICE shared learning database at

19. What do you think?
Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice?
We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form.
If you are experiencing problems accessing or using this tool, please
NOTES FOR PRESENTERS:
Additional information:
The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice – your opinion would be appreciated.
To open the links in this slide set, right click over the link and choose ‘open link’.
To open the links in this slide set, right click over the link and choose ‘open link’.