Scottish Perspective on NICE public health guidance 11: Improving the nutrition of pregnant and breastfeeding mothers an

1. Scottish Perspective on NICE public health guidance 11: Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households July 2009

2. Introduction

3. NICE public health guidance • Produced by the National Institute for Health and Clinical Excellence, for England • Aimed at promoting good health and preventing ill-health • Evidence-informed, using a highly developed and rigorous process; also takes account of stakeholders’ views, and fieldwork • No formal status in Scotland, but a valuable source of evidence-informed recommendations

4. The Scottish Perspectives • Intended to help organisations and individuals in Scotland make appropriate use of NICE public health guidance • Do not themselves constitute formal guidance • Contain: • summary or overview of recommendations (or key action points) for Scotland • full recommendations for Scotland • information to support implementation (including Scottish contextual points)

5. Scottish Perspective on NICE public health guidance 11 • Intended for NHS/other professionals who have a direct or indirect role in – and responsibility for – the nutrition of pregnant and breastfeeding mothers and pre-school children • May also be of interest to members of the public • 22 recommendations under 15 headings • 6 of these recommendations ‘key priority’, under 5 headings: • Healthy Start • Training • Vitamin D • Breastfeeding • Folic acid

6. Overview of the recommendations for Scotland

7. Overview (1)

8. Overview (2)

9. Overview (3)

10. Summary ofkey priority action points for Scotland

11. Healthy Start (1) • Promote the Healthy Start (HS) scheme • Ensure an adequate supply of both types of HS vitamin supplements • Ensure an adequate supply of HS application forms, and regular audit of uptake of HS benefits • Advise pregnant women and parents of children under 4 years about the scheme; ensure all possibly eligible women receive an application form as early as possible in pregnancy • Offer eligible parents information, support and advice

12. Healthy Start (2) • Offer the maternal HS vitamin supplement to pregnant women who are/may be eligible • Offer children’s HS vitamin supplements to all children aged 6 months to 4 years in families receiving the HS benefit • Consider distributing the maternal HS vitamin supplement to all women who receive HS benefit for children aged 1–4 years, particularly those who may become pregnant • Ensure the HS maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge • Involve the voluntary sector in improving access to fruits and vegetables under HS

13. Training • Ensure health professionals have appropriate knowledge and skills to give advice on a range of relevant aspects of diet, nutrition (including breastfeeding) and eating behaviour • Train midwives, health visitors/public health nurses, and support workers in breastfeeding management, using Baby Friendly Initiative (BFI) training as a minimum standard • Train health professionals to promote and support breastfeeding, using BFI training as a minimum standard; offer such training to a wide range of community-based staff, e.g. nursery workers and childminders

14. Vitamin D • Educate health professionals about the importance of vitamin D supplements for all pregnant and breastfeeding women • During the booking appointment, offer every woman information and advice on the benefits of taking a vitamin D supplement during pregnancy and while breastfeeding • Check that women at greatest risk of deficiency are following advice to take a vitamin D supplement • Advise all pregnant and breastfeeding women about availability of suitable vitamin D supplements • Include information with relevant products

15. Breastfeeding (1) • Adopt a multifaceted approach or coordinated programme of interventions across different settings to increase breastfeeding rates • Implement a structured programme that encourages breastfeeding, using BFI as a minimum standard; subject it to external evaluation • Ensure a written, audited and well-publicised breastfeeding policy, with an identified health professional responsible for implementing it

16. Breastfeeding (2) • Provide local, easily accessible breastfeeding peer support programmes, with peer supporters part of a multidisciplinary team • Ensure peer supporters: attend a recognised, externally accredited training course; contact new mothers within 48 hours of transfer home/home birth; offer mothers ongoing support according to needs; can consult a health professional and have ongoing support; and 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 +

17. Folic acid (1) • Advise women who may become pregnant on reducing the risk of neural tube defect (NTD) by taking folic acid (FA) supplements; encourage women who may become pregnant and women in the first 12 weeks of pregnancy to take FA supplements and consume foods/drinks rich in FA/folate • Ensure local education initiatives for health professionals include information on the importance of FA supplements; provide the maternal HS vitamin supplements for eligible women; and ensure women who are not eligible for HS can obtain them from their local pharmacy

18. Folic acid (2) • Prescribe FA for women planning/in the early stages of pregnancy if: they (or their partner) have NTD or a family history of NTD; or they have had a previous baby with NTD; or they have diabetes • Include with relevant products information on the importance of FA supplements before and during pregnancy

19. General considerations, equality and diversity, and Scottish context

20. Some general considerations • Importance of ensuring that mothers and their babies are well-nourished: benefits to maternal health, and to child health, growth and development; and may influence the health of the child in adulthood • Various established and possible benefits of breastfeeding to the health of mother and child

21. Equality and diversity considerations (1) • Statutory duties and good practice principles • Adverse links between socioeconomic disadvantage and maternal and child nutrition • Healthy Start (Recommendation 4) is open to pregnant women and families with children under the age of 4 who qualify on welfare benefits/low income grounds, and to all pregnant women under 18 • Services need to be accessible and applicable to everyone

22. Equality and diversity considerations (2) • Shortage of evidence relating to different socioeconomic, ethnic or vulnerable groups; but evidence that dietary interventions recognising the specific circumstances facing people who are disadvantaged are likely to be more effective than generic ones • Equality and diversity dimensions: age, disability, gender (including transgender), language, marital status, race/ethnicity, religion or belief, sexual orientation, social origin/socioeconomic factors • Targeting, tailoring, etc. • Relevant recommendations for research

23. Scottish contextual points:breastfeeding (1) • NHS 'HEAT' target: Increase the proportion of new-born children exclusively breastfed at 6–8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11 • Rates for breastfeeding (exclusive and overall) relatively stable since 2001 • Provisional 2008 data – • at First Visit review, 45.0% of mothers breastfeeding: 37.0% exclusively, 8.0% both breast milk and formula milk • at 6–8 week review, 36.1% of mothers were breastfeeding, including 26.7% exclusively • younger mothers in most deprived areas least likely to breastfeed

24. Scottish contextual points: breastfeeding (2) • Just over half of births in Scotland in ‘Baby Friendly’ hospitals • Breastfeeding etc. (Scotland) Act 2005 • Scottish Government has formally adopted WHO guidance recommending exclusive breastfeeding for first 6 months; advocates introduction of solids at around 6 months

25. Scottish contextual points:vitamin D • At UK (and particularly Scottish) latitudes, limited sunlight of appropriate wavelength, especially during winter – maternal skin exposure alone may not achieve optimal vitamin D status needed for pregnancy

26. Relevant Scottish policies, etc. (1) • National Performance Framework • Equally Well: Report of the Ministerial Task Force on Health Inequalities (Scottish Government, 2008) • Better Health Better Care: Action Plan (Scottish Government, 2007) • The Early Years Framework (Scottish Government, 2008)

27. Relevant Scottish policies, etc. (2) • Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011)(Scottish Government, 2008) • CEL 36 (2008) – ‘Nutrition of women of childbearing age, pregnant women and children under five in disadvantaged areas - funding allocation 2008 - 2011’ (Scottish Government, September 2008) • Nutritional Guidance for Early Years: food choices for children aged 1-5 years in early education and childcare settings (Scottish Executive, 2006)

28. For further information….

29. Web address and contact • Scottish Perspectives on NICE public health guidance www.healthscotland.com/scotlands-health/evidence/NICE.aspx • For further information, or to give feedback, please contact Kate Woodman of NHS Health Scotland kate.woodman@health.scot.nhs.uk