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Advice on maternal nutrition aims to cut health inequalities

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New guidance focuses on improving maternal and child nutrition in low-income and other disadvantaged groups through the Healthy Start scheme. NerysHairon reports

NICE has published new guidance on improving maternal and child nutrition, particularly in low-income groups (NICE, 2008a). It advises healthcare professionals on helping pregnant women and mothers to make decisions about their diet and lifestyle. The guidance calls for national consistency in the quality and quantity of support available to help address disparities in the nutrition of mothers and young children from disadvantaged groups compared with the general population. Its recommendations are relevant to all pregnant women, those planning to become pregnant, and mothers and other carers of children under five. Two key priorities focus on promoting the Healthy Start scheme and folic acid supplements.

NICE (2008b) has also published new guidance on managing diabetes in pregnancy, and has updated its guidance on antenatal care (NICE, 2008c), which includes revised advice on alcohol consumption in pregnancy (see box, p50).

Folic acid

The recommendations on taking folic acid supplements apply to women who may become pregnant and those in early pregnancy. The advice is particularly important for those in groups found to be less likely to take folic acid around pregnancy, which include younger women and those with low levels of formal education.

Healthcare professionals should use any appropriate opportunity to advise women who may become pregnant to take folic acid supplements. They should explain that this reduces the risk of giving birth to a baby with a neural tube defect such as spina bifida. Women should be advised to take 400mcg daily before pregnancy and throughout the first 12 weeks, even if they are already eating foods fortified with folic acid or those naturally rich in folate.

All women who may become pregnant should be advised about a suitable folic acid supplement, such as the maternal Healthy Start vitamin supplements. They should be encouraged both to take supplements and to eat foods that are rich in folic acid, such as fortified breakfast cereals and yeast extract, as well as those that are naturally rich in folate. These include dairy products, green leafy vegetables such as broccoli and Brussels sprouts, peas, chickpeas, oranges and bananas.

Diet in pregnancy

NICE says up to 50% of pregnancies are likely to be unplanned, so all women of childbearing age need to be aware of the importance of a healthy diet. Nutritional interventions for women who are or plan to become pregnant are likely to be most effective if delivered before conception or in the first 12 weeks of pregnancy.

Healthcare professionals should discuss women’s diet and eating habits early in pregnancy and find out and address any concerns. They should offer information and practical advice on how to eat healthily throughout pregnancy, which should be tailored to individual circumstances. The advice should include eating five portions of fruit and vegetables a day and one portion of oily fish a week.


Women who are overweight or obese before they conceive have an increased risk of complications during pregnancy and birth. This poses health risks for both mother and baby in the longer term. NICE also cites evidence that maternal obesity is related to health inequalities, particularly socioeconomic deprivation, inequalities within ethnic groups and poor access to maternity services.

Recommendations on obesity are aimed at pregnant women with a pre-pregnancy body mass index over 30, and those with a BMI over 30 who have a baby or who may become pregnant. They should be informed about the increased risks obesity poses to their own health and that of their babies and be encouraged to lose weight before or after pregnancy, through a structured diet and exercise programme.

Pregnant women with a BMI over 30 should be referred to a dietitian for assessment and advice on healthy eating and exercise, although they should not be advised to lose weight during pregnancy. Breastfeeding women should be reassured that losing weight through healthy eating and exercise will not affect the quantity or quality of their milk. Practitioners should also consult NICE guidelines on antenatal care and obesity (NICE, 2008c; 2006).

Healthy start scheme

A healthy diet is important for both mother and baby throughout pregnancy and after birth. However, 39% of people in low-income groups report that they worry about having enough food to last until they receive money to buy more. Similarly, 36% report that they cannot afford to eat balanced meals (NICE, 2008a).

To improve maternal and child nutrition, healthcare professionals should advise pregnant women and parents of children under four about the Healthy Start scheme. They should ensure all women who may be eligible for the scheme receive an application form as early as possible in pregnancy, and use every opportunity to offer eligible parents practical information and advice on:

  • How to use Healthy Start vouchers to increase their fruit and vegetable intake;
  • How to start and maintain breastfeeding;
  • How to introduce foods in addition to milk as part of a progressively varied diet when babies are six months old.

Pregnant women who are (or may be) eligible for the scheme should be offered the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D). For further details on the scheme and supplements for children, see

Other issues

The guidance on maternal and child nutrition covers a wide range of issues, including vitamin D, breastfeeding, link workers for pregnant women and mothers whose first language is not English, infant formula, prescribing, child health promotion, allergies and family nutrition.
On vitamin D, NICE recommends that midwives should offer every woman information and advice on the benefits of taking a vitamin D supplement (10mcg a day) during pregnancy and while breastfeeding. Healthcare professionals should take particular care to check that women at the greatest risk of deficiency are following this advice.

Those responsible for providing maternity services should set up easily accessible breastfeeding peer support programmes to ensure women receive skilled and practical guidance in feeding their babies.

Diabetes in pregnancy

Approximately 650,000 women give birth in England and Wales each year, and 2–5% of pregnancies involve women with diabetes (NICE, 2008b). The guidance recommends that women with pre-existing diabetes should access specialist services before conception and be given advice on the importance of planning their pregnancy.

NICE stresses that women with diabetes planning a pregnancy should be offered preconception care and advice before they stop using contraception. They should be informed that establishing good glycaemic control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death. It is important to explain that, while risks can be reduced, they cannot be eliminated.

Starting from adolescence, healthcare professionals should give information about the benefits of preconception glycaemic control at each contact. The diabetes care team should also record women’s intentions regarding pregnancy and contraceptive use at each consultation, while the importance of avoiding unplanned pregnancy should be an essential element in diabetes education.

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