Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years

Why the committee made the recommendations

Evidence on interventions to improve the uptake of folic acid supplementation before and during pregnancy showed mixed findings. Overall, information provision and education interventions compared with usual care helped to improve uptake when provided face-to-face as well as in printed materials, and when delivered by healthcare professionals. Qualitative evidence also highlighted the importance of making information about folic acid supplementation before and during pregnancy available in different healthcare settings that people who may become pregnant visit, to raise awareness of its importance. This could be in the form of, for example, posters or leaflets, as well as online.

In addition to having information readily available, the committee agreed that folic acid supplementation should be proactively discussed with anyone who is likely to become pregnant, planning to become pregnant or is already pregnant. Qualitative evidence showed that barriers to taking folic acid supplements include misinformation or confusion about the impact of folic acid, including a belief that it causes nausea. The committee agreed the importance of providing information in line with government advice, and reassuring people that folic acid supplementation is well tolerated and low cost or, in some cases, free.

No evidence was identified on high-dose (5 mg or more) folic acid during preconception and pregnancy, although 5 mg is the current recommended dose for those with an increased risk of conceiving a child with neural tube defects or other congenital malformations.

There was evidence that women with a history of births affected by neural tube defects who took 4 mg of folic acid before conception and during pregnancy had a lower risk of having a baby with a neural tube defect in the current pregnancy. No evidence was available for other known 'at-risk' groups so these were based on committee consensus. Based on the evidence, the committee would have recommended 4 mg of folic acid as the high dose for the 'at-risk' populations; however, 5 mg is recommended, partly for practical reasons, and it reflects current practice. This is because the only formulations available are 0.4 mg (400 micrograms) and 5 mg, so it is not feasible for people to take 4 mg. Folic acid is generally well tolerated even in high doses, and there is no known evidence of harm in different populations (evidence for other populations than those in the preconception period or during pregnancy was not reviewed by the committee). There is also likely to be little difference between a 5 mg and 4 mg dose because folic acid does not have a narrow therapeutic index. The recommendation reflects current practice because 5 mg is the current recommended dose for those with increased risk of having a baby with neural tube defects or other congenital malformations. The committee also made a recommendation for research into the safest and most effective dose of folic acid supplementation for this population.

There was no evidence to support high-dose folic acid for those with a body mass index (BMI) that is within the overweight or obesity weight categories. The committee agreed that the standard dose of 400 micrograms is sufficient, unless there are other factors that increase the risk of having a baby with neural tube defect or congenital malformation. For those at risk of pre-eclampsia, the evidence, while limited, did not show that high-dose folic acid would prevent pre-eclampsia. The committee agreed that people who have had bariatric surgery may need specific advice about folic acid and other micronutrients before and during pregnancy.

The committee also agreed the importance of additional discussions and support for people who do not take folic acid supplements as recommended.

The evidence on the role of digital technologies to improve uptake of folic acid supplementation before and during pregnancy was limited, so the committee made a recommendation for research on the clinical and cost effectiveness of such technologies, including subgroup analysis (for example, by age, ethnicity and socioeconomic status) to enable exploration of health inequality issues.

How the recommendations might affect practice

Overall, the recommendations should reinforce best practice. Providing targeted information and reminders may have a small resource impact but this should be offset by the benefits of improving folic acid uptake. The recommendations on high-dose folic acid generally reflect current best practice. However, there will be a change in practice because people with a BMI that is within the obesity weight category will no longer be advised to take high-dose folic acid unless they have other risk factors. The recommendation to advise people to contact their bariatric surgery unit for individualised, specialist advice about folic acid and other micronutrients if they have had bariatric surgery and are planning a pregnancy or are pregnant might result in some changes in practice and have resource implications.

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Why the committee made the recommendations

Overall, there was limited evidence on interventions to improve the uptake of vitamin supplements. Qualitative evidence showed that people sometimes lacked information about the benefits of vitamin D supplementation or found the information confusing. Tailored information provided in different appointments, settings and opportunities was preferred. The committee agreed that healthcare professionals should provide current government advice about vitamin supplementation at various opportunities and in different settings.

There was some evidence that information provision, together with a supply of vitamin D drops, improved vitamin D uptake in babies aged 3 months. The committee agreed that it is important to make people aware of the Healthy Start scheme so that those eligible can access free vitamins. Qualitative evidence showed that even those eligible for the free Healthy Start vitamins sometimes struggle to obtain them for various reasons, emphasising the importance of information from healthcare professionals. Because the Healthy Start scheme is not universally available, the committee agreed that providing free vitamin supplements to those at an increased risk of vitamin D deficiency could prevent vitamin D deficiency and associated outcomes. According to the UK government advice, young children are at an increased risk of vitamin D deficiency. There was evidence that free vitamin D supplementation during pregnancy and for children up to 4 years of age with dark or medium tone skin (who are at higher risk for vitamin D deficiency) is cost effective.

Evidence on the appropriate dose of vitamin D during pregnancy for people with a BMI that is within the overweight or obesity weight categories was limited and inconclusive, so the committee made a recommendation for research on the optimum dose of vitamin D for people with a BMI that is within the overweight or obesity weight categories.

How the recommendations might affect practice

The recommendations on information provision reinforces current best practice. Free Healthy Start vitamins are already available in some areas for everyone who is pregnant or breastfeeding and children under 5, regardless of their eligibility for the wider Healthy Start scheme. Where this is not available, provision of free vitamin supplements for those at an increased risk of deficiency may have some resource impact but this should be balanced by preventing vitamin D deficiency.

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Why the committee made the recommendations

The recommendations are based on quantitative and qualitative evidence and the committee's expertise.

Evidence from randomised controlled trials showed that information provision and education on healthy eating and drinking during pregnancy (compared with usual care) had some beneficial effects on eating practices.

Qualitative evidence suggested that people value personalised discussions with midwives about healthy eating. Feeling accepted and understood were considered important. There was qualitative evidence that young pregnant people lack trust in healthcare professionals because of a perceived lack of support and understanding of their situation.

There was evidence that overall, dietary advice from healthcare professionals leads to better understanding for the person and their unborn baby, and influences uptake of healthy cooking and dietary habits in the long term. Qualitative evidence also showed that, in addition to discussions, people value other written information, particularly in digital formats, and want these to be trustworthy. The committee agreed that information sources should be evidence-based and non-commercial.

A major barrier for healthy eating identified in qualitative research is the cost of healthy food. The committee agreed that practical support and advice about accessing free or affordable foods and financial help are essential in supporting pregnant people to eat healthily. In addition, people may lack confidence and skills in cooking healthy meals, so classes where people can learn to cook healthy, affordable meals were highlighted as an example of how to overcome this.

How the recommendations might affect practice

The recommendations reinforce current best practice. In some areas, the recommendations may have small resource implications relating to the additional healthcare professional time needed to discuss healthy eating in pregnancy, particularly with young people and those from low income or disadvantaged backgrounds. Commissioners and service providers in some areas may need to improve training for healthcare professionals about healthy eating in pregnancy. Interventions to improve people's skills and confidence related to healthy eating, such as local cookery classes or groups, may not be available in all areas so establishing these may have resource implications but promoting healthy eating can, in turn, bring long-term benefits.

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Why the committee made the recommendation

Overall, evidence on physical activity-based interventions during pregnancy showed no impact on weight change during pregnancy, but showed some benefit in terms of other outcomes such as reducing the rate of gestational diabetes and babies being large for gestational age. The committee agreed that starting or maintaining moderate physical activity during pregnancy is important for both the pregnant person and their unborn baby. They recommended that discussion around physical activity is individualised and based on a discussion about the person's usual habits and preferences, because this will help encourage physical activity during pregnancy.

How the recommendation might affect practice

The recommendation reinforces current best practice. In some areas, the recommendation may have small resource implications relating to the additional healthcare professional time needed to discuss physical activity in pregnancy.

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Why the committee made the recommendations

The committee were aware that discussions around weight are often perceived as judgemental and insensitive. This can prevent people from engaging, and creates distrust and negative feelings towards healthcare professionals.

BMI is currently calculated at the antenatal booking appointment, in line with current practice and NICE's guideline on antenatal care. This enables risk assessment and determines the need for further tests or referral. The committee agreed that a referral to a specialist obesity service or a specialist practitioner should be discussed with people with a pre-pregnancy BMI of 40 kg/m² or over because of the higher risk of complications and other considerations during the pregnancy.

Evidence from randomised controlled trials was not able to show that dietary and physical activity interventions are particularly helpful in managing weight in pregnancy; however, they did show some other benefits, for example, on gestational hypertension and pre-eclampsia.

The committee agreed that the evidence does not support weighing everyone throughout pregnancy and this should only be offered when there is a clinical need. They also acknowledged that some people may want to monitor their weight themselves throughout pregnancy. Quantitative evidence was unable to determine the optimal weight change during pregnancy; however, there are estimates of healthy total weight change in a singleton pregnancy according to the pre‑pregnancy BMI that healthcare professionals can refer to, although these estimates do not account for trimester-specific healthy weight change (note that separate estimates exist for twin pregnancies).

There was evidence that both low weight gain and excessive weight gain during pregnancy lead to an increased chance of some adverse outcomes. Excess weight gain, in particular, is associated with adverse outcomes such as gestational hypertension, gestational diabetes and the baby being large for gestational age. Those with a pre-pregnancy BMI in the overweight and obesity weight categories are most affected, although an impact was also seen in those with a pre-pregnancy BMI in the healthy weight category.

How the recommendations might affect practice

The recommendations reinforce current best practice. In some areas, the recommendations may have some resource implications relating to the additional healthcare professional time needed to discuss weight in pregnancy.

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Why the committee made the recommendation

There was evidence that low weight gain during pregnancy is associated with the baby being small for gestational age across all pre-pregnancy weight categories. The committee agreed that there may be various reasons for low weight gain during pregnancy, for example, nausea and vomiting in pregnancy, mental health issues, or clinical interventions that have been recommended for the person, for example, after a diagnosis of gestational diabetes.

How the recommendation might affect practice

The recommendation reinforces current best practice. In some areas, the recommendation may have some resource implications relating to the additional healthcare professional time needed to discuss weight in pregnancy.

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Why the committee made the recommendation

There was evidence that excessive weight gain during pregnancy is associated with gestational diabetes in people with a pre-pregnancy BMI in the healthy, overweight and obesity weight categories. Excessive weight gain is also associated with the baby being large for gestational age. The committee agreed that there may be various underlying reasons for excessive weight gain during pregnancy, and a holistic exploration of the person's wellbeing is important.

How the recommendation might affect practice

More people may be considered for gestational diabetes testing, but resource implications are not expected to be significant, and any potential additional cost is likely to be offset by the benefits of early identification of gestational diabetes. It is current practice to offer people with a pre-pregnancy BMI in the obesity weight category testing for gestational diabetes. In some areas, the recommendation may have some resource implications relating to the additional healthcare professional time needed to discuss weight in pregnancy.

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Why the committee made the recommendations

Dietary change is the first-line intervention for gestational diabetes. However, the evidence did not show any particular diet to be better than another for outcomes such as weight change during pregnancy, gestational hypertension, mode of birth, baby being born large for gestational age and the need for pharmacological interventions. The committee agreed that a healthy diet that is appropriate and preferable for the individual should be discussed. They also made a recommendation for research to determine what type of diet is most beneficial for those with gestational diabetes.

How the recommendations might affect practice

The recommendations reflect current best practice.

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Why the committee made the recommendations

The UK Scientific Advisory Committee on Nutrition (SACN), UNICEF and the World Health Organization recommend 6 months of exclusive breastfeeding, and continuing breastfeeding to their second year and beyond. The committee agreed that appropriate support before birth and during the first weeks after birth will enable continued breastfeeding for longer. The committee acknowledged the importance of discussing babies' feeding at every healthcare contact to support continued breastfeeding, or safe and appropriate formula feeding, support informed decision making and to address any problems or concerns with feeding. There are various reasons why people may consider stopping breastfeeding or starting supplementing with formula, and the committee agreed that every face-to-face health contact is an opportunity to support continued breastfeeding (whether exclusive or not). The committee emphasised the importance of these discussions being sensitive and non-judgemental. The committee agreed to list different discussion points that can help with this, based on qualitative evidence and their knowledge and experience.

Qualitative evidence showed that in order to maintain breastfeeding, it is important to build the confidence and motivation to breastfeed. The evidence also highlighted the important impact that partners, family members and friends have in either discouraging or supporting breastfeeding. The positive impact that peers can have was also evident. The evidence also highlighted that breastfeeding is sometimes experienced as embarrassing or not socially acceptable. Evidence showed that receiving inconsistent or conflicting information about breastfeeding, often in a rushed encounter with a healthcare professional, contributes to the challenges in continuing breastfeeding. Sometimes people felt that discussions on breastfeeding were judgemental or intrusive, rather than supportive.

From their knowledge and experience, the committee agreed about the importance of maintaining a healthy and balanced diet for anyone who is breastfeeding but agreed that it is not necessary to follow a special diet to meet the nutritional requirements of the baby.

Breastfeeding rates are known to be lower among people in lower socioeconomic groups, so in line with NICE's guideline on postnatal care, the committee acknowledged that more support to continue breastfeeding may be needed for parents from low income or disadvantaged backgrounds.

Using medicines can sometimes be, or may be perceived to be, a contraindication for breastfeeding, so the committee included a recommendation about clinicians using appropriate sources for safe medicine use and prescribing during breastfeeding so that breastfeeding can continue despite the need to take medicines. The committee were aware that the Breastfeeding Network's Drugs in Breastmilk Service is often used in practice for advice on safe use of medicines during breastfeeding.

The committee agreed that face-to-face contacts with a healthcare professional after the baby is 8 weeks old are usually infrequent, so opportunities to provide support and advice are considered beneficial.

There was evidence from an analysis of randomised controlled trials that group interventions aimed at promoting breastfeeding are effective in increasing breastfeeding rates. Economic analysis showed that group interventions delivered by a mixture of healthcare professionals and peer supporters in addition to standard care provides additional benefits and reduced costs compared with standard care alone, making additional group interventions highly cost effective.

How the recommendations might affect practice

Support for breastfeeding exists but is not consistently available in primary care and community services. There may be some costs associated with improving breastfeeding support services through enhancing face-to-face discussions, virtual or remote contacts, and drop-in group sessions. However, improving breastfeeding rates could bring cost savings to the healthcare system as a whole because breastfeeding is associated with the prevention of breast and ovarian cancer, diabetes and obesity in breastfeeding people, as well as prevention of infections and obesity in babies.

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Why the committee made the recommendations

The recommendations are based on qualitative evidence and the committee's expertise. The committee agreed that healthcare professionals and breastfeeding peer supporters can play an important role in supporting people to continue breastfeeding after returning to work or study. They can discuss the different topics that the person may need to think about, and encourage them to talk to their employer or education provider before their return. The committee also agreed that employers and education providers can facilitate continuation of breastfeeding by exploring how their setting, policies and arrangements can better support those returning to work after having a baby.

The evidence identified various barriers to continue breastfeeding. It showed that people worry that breastfeeding at work is perceived as unprofessional and feel embarrassed, isolated or judged when trying to maintain breastfeeding while working or studying. Many reported that they did not know about a policy on breastfeeding in their workplace or university, or what facilities were available for them to use. Even if a breastfeeding policy was in place, implementation tended to vary from office to office and in practice, often depending on supervisors' and colleagues' attitudes towards breastfeeding. The evidence also reported that some women experience difficulties accessing breastfeeding spaces, even if they were available. Sometimes the breastfeeding spaces were considered to be unclean and unsuitable, lacking privacy or lacking important features such as power plugs, a sink or fridge to store breast milk safely.

The evidence also highlighted issues that could encourage the person to continue with breastfeeding after they return to work or study. The evidence emphasised the value of raising awareness of breastfeeding in workplaces or universities, having clear policies, and the need to assess each person's needs individually. The evidence showed that people value proactive and supportive communication and conversations that began before their return to work or study. The evidence also reported on the benefits of peer support. Having childcare near the workplace or campus area is a key factor in maintaining breastfeeding according to the evidence. The evidence described how workplaces that show flexibility through, for example, flexible hours, flexible breaks, part-time work or working from home arrangements can help ease the struggle of maintaining breastfeeding while working.

How the recommendations might affect practice

Healthcare professionals and peer supporters may need to spend more time discussing how to enable people to continue breastfeeding after returning to work or study.

There is great variation in how workplaces and education settings support breastfeeding, so the recommendations may lead to improved support and greater consistency.

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Why the committee made the recommendations

The recommendations are based on qualitative evidence and the committee's expertise. The evidence showed that support and advice on safe and appropriate formula feeding from healthcare professionals is often felt to be limited, inconsistent and confusing, so people seek information from various other sources that are often inconsistent or unreliable. There was evidence that people perceive healthcare professionals to be reluctant to discuss formula feeding and people reported feeling judged.

There was also evidence about the power that the marketing of infant formula brands can have on people's choices. The committee discussed that people feel confused about the information in formula brand labels and the differences between different brands, and can perceive the most expensive brands to be the best quality while being hesitant to buy cheaper options. At the same time, the cost of infant formula as a barrier for safe formula feeding was reflected in the qualitative evidence. This was confirmed by the committee's experience that because of cost, people regularly have to dilute infant formula, give less infant formula than recommended, or substitute infant formula with other drinks that are not suitable for babies. These practices can lead to adverse outcomes for the babies. To better understand parents' experiences related to formula feeding within the context of poverty and food insecurity, the committee made a recommendation for research on the facilitators and barriers for safe and appropriate formula feeding.

The committee discussed the importance of healthcare professionals providing independent, non-commercial, evidence-based and consistent advice and additional resources as well as providing information about the Healthy Start scheme and other initiatives that give advice and financial support to access infant formula. In addition to the resources listed in the recommendation, the committee were also aware that the First Steps Nutrition Trust provides useful, evidence-based and non-commercial advice on formula feeding.

How the recommendations might affect practice

The recommendations should improve support for safe formula feeding and reinforce current best practice. Commissioners and service providers in some areas may need to improve training for healthcare professionals about advice on safe and appropriate formula feeding.

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Why the committee made the recommendations

Evidence from randomised controlled trials about which interventions improve appropriate and timely introduction to solid foods for babies was inconclusive. However, providing information to parents (either face-to-face or in a telephone call), in addition to leaflets, was shown to have some benefit on the appropriate timing of introducing solid foods (at around 6 months).

The committee agreed that advice about introducing solid foods should start in late pregnancy and continue in the first months after the birth. An appointment to discuss this in more detail before the baby is 6 months old will allow practical advice and support to be given. The committee agreed that the best timing for this would be when the baby is around 4 to 5 months. Qualitative evidence showed that group sessions help parents understand how to provide variable and nutritional food for the baby, how to adapt family meals to be appropriate for the baby, and the differences between commercial and homemade foods. Qualitative evidence suggested that parents are confused about marketing information in commercial baby foods that conflict with feeding guidelines, such as introducing solids before 6 months of age. Parents also expressed worry and concern over their baby's feeding. Overall, parents found information, even from healthcare professionals, to sometimes be confusing or inconsistent, emphasising the importance of healthcare professionals being appropriately trained and knowledgeable about evidence-based best practice, which can then be shared with parents.

The committee agreed, based on their experience, that knowledge and expertise around the introduction of solids varies between healthcare professionals. They discussed how those with expertise could act as 'champions' to promote and share knowledge among other staff about the safe and appropriate introduction of solids, which can then be shared with parents.

Qualitative evidence showed that affordability of healthy foods can be a barrier. The committee agreed that healthcare professionals should discuss sources of support to access healthy foods.

The committee agreed that healthcare professionals should continue to check on the baby's feeding when there is an opportunity to do so, and that they should reinforce and remind parents about the advice given so that appropriate and safe feeding practices are followed.

How the recommendations might affect practice

The recommendations will largely reinforce current best practice. However, not all areas offer a session to discuss introduction of solids at 4 to 5 months, so there may be some resource implications in these areas. Commissioners and service providers in some areas may need to improve training for healthcare professionals about introducing solid foods to babies, in line with the recommendations and government advice.

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Why the committee made the recommendations

Qualitative evidence among parents of young children highlighted the importance of sensitively considering the family's individual circumstances and needs when discussing healthy eating. The evidence highlighted the barriers that people face in providing their children with healthy foods. People from low income or disadvantaged backgrounds face particular barriers if they cannot afford food or have living conditions that prevent them from preparing healthy meals.

Evidence from randomised controlled trials on what type of interventions might improve healthy eating in children was inconclusive. There was some evidence that providing information about children's healthy eating for parents from low income or disadvantaged backgrounds had some beneficial impact on healthy eating behaviours and parents' confidence. There was also some evidence that providing information about healthy eating combined with offering children healthy foods improved their vegetable and fruit intake. This was supported by qualitative evidence on parents' views and experiences. Qualitative evidence also showed that parents' lack of skills or confidence in preparing healthy meals prevents them from offering such foods to their children.

The committee agreed that healthy eating in children can be improved in various ways, including providing information through individualised discussions with families supplemented by printed or online resources, improving access to healthy food through, for example, welfare schemes, and building parents' skills and confidence through, for example, group cooking sessions.

The committees discussed the topics to discuss with families in line with government guidance, including providing information about financial or practical support in accessing healthy foods.

Quantitative and qualitative evidence also touched on the role of early years settings. Based on the evidence and their expertise, committee recommended ways in which these settings can promote healthy eating and drinking in children.

How the recommendations might affect practice

The recommendations reinforce current best practice. In some areas, the recommendations may have small resource implications relating to the additional healthcare professional time needed to discuss healthy eating and drinking for children, particularly with families from low income or disadvantaged backgrounds. Interventions to improve people's skills and confidence related to healthy eating, such as local cookery classes or groups, may not be available in all areas so establishing these may have resource implications but promoting healthy eating can, in turn, bring long-term benefits.

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