NICE, 2008 cont’d Interventions to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, Maternal health Early years Health services and community settings Implement a structured programme that encourages breastfeeding, using BFI as a minimum standard (www.babyfriendly.org.uk).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. Work with local partners to ensure mothers can feed their babies in public areas without fear of interruption or criticism. Health professionals training: As part of their continuing professional development (CPD): -train midwives, health visitors and support workers in breastfeeding and management produce cost savings by reducing various childhood diseases Most LHB have/are developing BF peer-support groups Most have BF Welcome Scheme run by L.A.s North Wales also professional-led BF support groups
NICE, 2008 cont’d Interventions to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, Maternal health Early years Health services and community settings -train doctors, dietitians, pharmacists and other health professionals to promote and support breastfeeding ...using BFI training as a minimum standard. Health professionals & service managers 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. 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 that best meets the woman’s needs.
NICE, 2008 cont’d Interventions to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, Maternal health years Health services and community settings 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 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. 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
NICE, 2008 cont’d Interventions to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, Maternal health Early years Health services and community settings telephone or through local groups. Health visitors and the CHPP team should support mothers to continue breastfeeding for as long as they choose. Provide easily accessible breastfeeding peer support programmes and ensure peer supporters are part of a multi- disciplinary team. Ensure support workers receive training in breastfeeding management from someone with the relevant skills and experience before they working with breastfeeding mothers. sure peer supporters: attend a recognised, externally accredited training course in breastfeeding peer support, can consult a health professional and are provided with ongoing support, gain appropriate child protection clearance.
NICE, 2008 cont’d Interventions to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, Maternal health Early years Health services and community settings 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. Midwives, health visitors, paediatric nurses, nurses working in special-care baby and neonatal units, and nursery nurses should: -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 expressed breast milk for less than 5
Maternal health Early years generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001). Possible selection bias in 7/8 studies and attrition bias in 4/8. nationally on an ad-hoc basis Dyson, L et al, 2005 continued Interventions for promoting the initiation of breastfeeding – Breastfeeding promotion Initiation and duration of any and exclusive breastfeeding The findings from 1 suggest that hospital breastfeeding promotion packs are not the most effective use of breastfeeding promotion resources in a context of widespread use of formula company promotion items. The evaluation of hospital breastfeeding promotion packs compared to formula-company produced materials about infant feeding (Howard 2000) showed this intervention to be ineffective at increasing initiation rates of breastfeeding. This trial was of high quality. This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis G. There is some evidence suggesting that this intervention is ineffective but it is not conclusive
Lumbiganon, P et al, 2011 Antenatal breastfeeding education for increasing breastfeeding duration - routine BF education, formal BF education, printed information, video, peer counselling and lactation consultation. Cochrane Database of Systematic Reviews Maternal health Early years Duration of any BF Duration of exclusive BF Proportion of mothers BF at three & 6 months Proportion of mothers exclusively BF at 3 & 6 months Initiation rate of BF 18/19 included studies had either unclear or high risk of bias. There were wide variations in the nature of BF educational interventions as well as in type and completeness of reported outcomes between studies. Therefore the internal validity of the results of this review is limited. Because there were significant methodological limitations and the observed effect sizes were small, it is not appropriate to recommend any specific form of antenatal BF education. There is an urgent need to conduct RCTs with adequate power to evaluate the effectiveness of antenatal BF education. NB BF education is usually a formalised, defined, descriptive and goal-orientated programme with a specific purpose and target audience. BF education differs from BF support. BF support is usually aimed at the individual person as the need arises and is defined as a 14 studies involving 6932 women contributed data to the analyses Five studies compared a single method of BF education with routine care. Peer counselling significantly increased BF initiation. studies compared one form of BF education versus another. No intervention was significantly more effective than another intervention in increasing initiation or duration of BF. Seven studies compared multiple methods versus a single method of BF education. Combined BF educational interventions were not significantly better than a single intervention in initiating or increasing BF duration. However, in one trial a combined BF education significantly reduced nipple pain and trauma. One study compared different combinations of interventions. There was a marginally significant increase in exclusive BF at six months in women Elements of the intervention are funded for national implementation, but implementation is dependent on local components which are variable C. There is some evidence supporting the use of this intervention but it is not conclusive
person, a group or an organisation providing support in many ways. receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video only. Two studies compared multiple methods of BF education versus routine care. The combination of BF booklet plus plus LC was significantly better than routine care for exclusive BF at three months. Renfrew, MJ et al, 2012 Support for healthy breastfeeding mothers with healthy term babies Cochrane Database of Systematic Reviews Maternal health Early years Primary outcomes Stopping breastfeeding before 6 months postpartum. Stopping exclusive breastfeeding before 6 months postpartum. Stopping any breastfeeding before 4 to 6 postpartum. Stopping exclusive Effective Postnatal hospital stay • Skilled breastfeeding support, peer or professional, proactively offered to women who want to breastfeed • Preventing the provision of discharge packs containing formula-feeding information and samples • Unrestricted feeding from birth onwards • Unrestricted mother-baby contact from birth onwards • Unrestricted kangaroo care/skin-to-skin care from birth onwards • Avoiding supplementary fluids for babies unless medically indicated 52 studies contributed outcome data to the review (56,451 mother-infant from 21 countries. All forms of extra support analysed together showed an increase in duration of ’any breastfeeding’ (includes partial and exclusive breastfeeding) (risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% CI 0.88 to 0.96). All forms of extra support together also had a positive effect on duration of exclusive breastfeeding (RR at 6 months 0.86, 95% CI 0.82 to 0.91; RR at four to six weeks 0.74, 95% CI 0.61 to 0.89). Extra support by both lay and professionals had a positive Some of the interventions are funded for national implementation (Baby Friendly Initiative), but implementation is dependent on components which are variable A. These interventions are supported by good evidence of effectiveness and are recommended for use in the UK trial
Hospital and community setting breastfeeding before 4 to 6 weeks postpartum. Secondary Stopping breastfeeding before 2, 3, 9 and 12 months postpartum. Stopping exclusive breastfeeding before 2,3 9 and 12 months postpartum. Maternal satisfaction with care. Maternal satisfaction with feeding method. All-cause infant or neonatal morbidity • Regular breast drainage/ continued breastfeeding for mastitis • Antibiotics for infective mastitis Postnatal care in the community • Skilled breastfeeding support, peer or professional, proactively offered to who want to breastfeed Ongoing care in the community • Skilled breastfeeding support, peer or professional impact on breastfeeding outcomes. Maternal satisfaction was poorly reported. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support should be tailored to the needs of the setting and the population group Renfrew, MJ et al, 2012 cont’d As above “Promising or well-grounded in theory” 52 studies contributed outcome data to the review (56,451 Elements of the interventions are C. is some
Support for healthy breastfeeding mothers with healthy term babies In pregnancy • Group, interactive, education sessions • Group education sessions on positioning and attachment • Antenatal education individually tailored to the needs of low-income women Immediate postnatal care • Basing prevention and treatment of sore nipples on principles of positioning and attachment • Cabbage leaves/extract for treatment of engorgement • Systemic antibiotics for infected nipples Postnatal care in the community • Self-monitoring daily log for women from higher economic groups Combination of supportive care, teaching breastfeeding technique, rest and reassurance for women with ‘insufficient milk’ • Division of the frenulum in infants with signs of congenital ankyloglossia [tongue tie] and breastfeeding difficulties mother-infant from 21 countries. All forms of extra support analysed together showed an increase in duration of ’any breastfeeding’ (includes partial and exclusive breastfeeding) (risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% CI 0.88 to 0.96). All forms of extra support together also had a positive effect on duration of exclusive breastfeeding (RR at 6 months 0.86, 95% CI 0.82 to 0.91; RR at four to six weeks 0.74, 95% CI 0.61 to 0.89). Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Maternal satisfaction was poorly reported. Support is likely to be more effective in settings with high initiation so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies funded for national implementation (Baby Friendly Initiative), but implementation is dependent on components which are variable evidence supporting the use of these interventions but it is not conclusive
Wider social/political issues • National policy of encouraging maternity units to adhere to the UNICEF Baby Friendly Initiative (BFI) • Regionally/nationally determined targets with supporting activities, and/or penalties and/or incentives Multifaceted interventions (across time periods and of interventions) • Tailored antenatal education combined with proactive postnatal support in hospital and the community • Combining antenatal education with partner support, postnatal support and incentives for in low income groups that rely mainly on face-to-face support are more likely to succeed. Support should be tailored to the needs of the setting and the population group Renfrew, MJ et al, 2012 cont’d Support for healthy breastfeeding mothers with healthy term babies As Potentially ineffective In pregnancy • Self-help manual used alone • Antenatal education by a paediatrician • Providing materials produced by formula milk companies on infant feeding in early pregnancy As above Elements of the interventions are funded for national implementation, but implementation is dependent on local components G. is some evidence suggesting that these interventions are ineffective
Immediate postnatal care • Separating mothers and babies for treatment of jaundice Postnatal care in the community • Written educational materials used alone • GP clinic at one week postpartum • Single home visit by community nurse following early discharge • Dopamine antagonists for ‘insufficient milk’ Ongoing care in the community • Dopamine antagonists for ‘insufficient milk’ which are variable but it is not conclusive Renfrew, MJ et al, 2012 cont’d Support for healthy breastfeeding mothers with healthy term babies As above Ineffective In pregnancy • Conditioning nipples in pregnancy • Hoffman’s exercises for inverted and non-protractile nipples in pregnancy • Breast shells for inverted and non-protractile nipples in pregnancy As above This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is H. is moderate to good evidence that these interventions are unlikely to be effective
Immediate postnatal care • Restricting the timing and/or frequency of breastfeeds • Restricting mother/baby contact from onwards • Routine use of supplementary fluids • Provision of discharge packs containing samples or information on formula feeding • Topical agents for the prevention of nipple pain • Breast pumping before the establishment of breastfeeding in women at risk of delayed lactation Multifaceted interventions • Combined antenatal education and limited postnatal telephone support for high-income women and women who intend to breastfeed (existing high rates suggest resources are better spent elsewhere) implementation nationally on an ad-hoc basis
nationally on an ad-hoc basis Jepson J et al., 2006 Continued Interventions to promote healthy eating in preschool children Dietary change: reducing the intake of total and saturated fat, increasing the intake of fruit and vegetables, and increasing the intake of fibre. Traditional, video or computer-based teaching methods were successful at increasing nutrition knowledge, and their effectiveness was enhanced by including parents. However, there is insufficient evidence available to predict the format of successful healthy eating interventions that are likely to be effective at improving the nutritional well-being of UK pre-school children. One moderate quality systematic review of study types (1&2+, A) evaluated the effectiveness of interventions to promote healthy eating in preschool children aged 1 to 5 years (Tedstone et al, 1998). This intervention may be implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach Lack of evidence Jepson J et al., 2006 Continued Interventions to promote to children aged 4-10 Dietary change: reducing the intake of total and saturated fat, increasing the intake of fruit and vegetables, and increasing the intake of fibre. The results of the revealed that these kinds of interventions have a small, but significant positive effect. Pooled estimates from the nineteen studies suggest that implementation of these interventions will, on average, increase children’s fruit intake by one-fifth of a portion per day and their vegetable intake by a little less than One moderate quality SR of mixed study types (1&2+, A) evaluated interventions to promote healthy eating in order to evaluate the barriers to, and facilitators of, healthy eating amongst children aged four to 10 years old (Thomas et al, 2003). This review combined both qualitative and quantitative studies. The types of interventions evaluated by these studies were largely school-based, and often This intervention may be implemented locally in some areas but does not have a consistent B. This intervention is supported by moderate to good quality evidence of its effectiveness
one-fifth of a portion per day. The results of the suggest that it is easier to increase children’s consumption of fruit than vegetables. combined learning about the health benefits of fruit and vegetables with ‘hands-on’ experience in the form of food preparation and taste-testing. The majority targeted parents and/or involved them in intervention delivery alongside teachers and health promotion practitioners. Some included environmental modification involving, for example, changes to the foods provided at school. national programme Jepson J et al., 2006 Continued Healthy eating interventions in young people aged 11-16 years Dietary change: reducing the intake of total and saturated fat, increasing the intake of fruit and vegetables, and increasing the intake of fibre. Several multi-component interventions complementing classroom activities with school wide initiatives + involving parents were found to have positive effects. A moderate quality SR of study types (1&2+, A) evaluated healthy eating interventions in young people aged 11-16 years (Shepherd et al, 2002). This intervention may be implemented locally in some areas but does not have a consistent national programme B. This intervention is supported by moderate to good quality evidence of its effectiveness Jepson J et al., 2006 Continued Dietary interventions Dietary change: reducing the intake of total and saturated fat, increasing Dietary interventions in the workplace can achieve effects (<0.5 portions/day). 6. One moderate quality SR of mixed study types (1&2+, A) identified two studies of interventions with adults in the workplace (Ciliska et al, 1999).4 The results of the first trial indicated that the intake of fruits This intervention may be implemented locally in B. This intervention is supported by moderate to good quality
in the workplace the intake of fruit and vegetables, and increasing the intake of fibre. and vegetables increased from 2.6 to 2.8 servings/day in the intervention group, compared with 2.58 to 2.6 servings/day in the control group (p<0.001). The results of the second trial showed that there was no post-test difference in the mean servings per month of fruit. The intervention group also experienced significant mean reduction in the servings/week of margarine and butter. some areas but does not have a consistent national programme evidence of its effectiveness Jepson J et al., 2006 Continued Interventions to promote healthy eating in older people. Dietary change: reducing the intake of and saturated fat, increasing the intake of fruit and vegetables, and increasing the intake of fibre. is limited evidence of the effectiveness of interventions to promote healthy eating in older people. A strategy of individual feedback and tended to be associated with a positive intervention. One moderate quality SR of mixed study types (1&2+, C) evaluated 23 studies of interventions aimed at promoting healthy eating in older people (Fletcher & Rake, 1998). The interventions included: nutrition education targeted at the individual or the community; individual counselling; and policies to facilitate healthy eating behaviour, but not the provision of a meal. There was limited evidence for effectiveness of healthy eating interventions in this age range. This intervention may be implemented locally in some areas but does not have a consistent national programme B. This intervention is supported by moderate to good quality evidence of its effectiveness Jepson J et al., 2006 Continued Non-worksite healthy eating Dietary change: reducing the intake of total and saturated fat, increasing Giving tailored information was ineffective as was having a Healthy Heart Coalition. A moderate quality SR of mixed study types (1&2+, B) evaluated three non-worksite interventions with adults (see above Ciliska et al, 1999) (only 2 met inclusion criteria U. status is unknown G. There is some evidence suggesting that this intervention is ineffective but
interventions in adults the intake of fruit and vegetables, and increasing the intake of fibre. for Jepson review). No details of what interventions were. it is not conclusive Jepson J et al., 2006 Continued Interventions to promote healthy eating in the general population Dietary change: reducing the intake of total and saturated fat, increasing the intake of fruit and vegetables, and increasing the intake of fibre. The authors concluded that they found clear evidence in 15/25 recent controlled studies that, despite difficulties inherent in achieving dietary change in the general population, healthy eating interventions were effective in a variety of settings and populations. The greatest magnitude in change in diet was seen in studies with highly motivated volunteers in intensive programmes. The majority of interventions in supermarket and catering settings showed a positive effect on food purchases in the short term, that is, while the intervention was in place. One moderate quality SR of study types (1&2+, A) evaluated health promotion interventions to promote healthy eating in the general population (Roe et al, 1997). There was a range of settings in the studies including school/ university, workplaces, primary care, and communities. Seventy six studies were included (over 100000 participants in total). Most good quality studies, which reported a dietary outcome measure, showed a benefit of intervention (15 studies out of 25). Long-term interventions in the population achieved reductions in dietary fat of 1 to 4% of energy intake. A substantial number of studies showed no effect of the intervention on the main outcomes measured, compared with controls. This intervention may be implemented locally in some areas but does not have a consistent national programme D. The evidence is inconsistent and it is not possible to draw a conclusion but is some evidence of effect 8. NICE (2008) National Institute for Nutrition during pregnancy & outcome Guidance recommends: Health professionals training Some elements A. This intervention is supported by good evidence
ensuring a variety of healthier choices are offered at mealtimes, and snacks offered between meals are low in added sugar and salt, ensuring carers eat with children whenever possible. D’Souza et al., (2007) Dietary counselling Pregnant Improving access to healthy foods Advice about food hygiene Advice on how to avoid allergies Home support for dietary change Birth outcomes, dietary change, improved nutrition Dietary change, improved nutrition Evaluation of the role of dietary counselling in improving the diets of pregnant women is held back by the lack of high quality studies. --------------------------------- Studies on improvement in access to healthy foods, food shopping, storage and preparation are lacking. -------------------------------- There was no evidence to answer questions about the best way to provide advice about food hygiene or the best way to provide advice about how to avoid allergies. --------------------------------- Only one case control was found about the intake of oily fish or omega-3 supplements (Odent 1996 +). This study could not demonstrate any differences in birth outcomes between controls and women given tailored advice to eat more fish. A review by van Teijlingen reported that there was some evidence to suggest that educational interventions have a modest effect but much of this evidence was flawed. The van Teijlingen review concluded that there was a dearth of research in this area and that high quality research was needed. Only one study was found that evaluated advice or information on its own (Anderson 1995+). This study undertaken in Scotland found that dietary advice and information alone helped improve knowledge about diet but did not improve dietary behaviour. This suggests Some elements implemented locally in some but does not have a consistent national programme or a co-ordinated approach Lack of evidence
at birth. It seems likely that in many populations, particularly in developed countries, that it would be difficult to for a dietary intervention in pregnant women to achieve statistically significant changes in birth outcomes. It was also notable that none of the studies evaluating different aspects of food support programmes during pregnancy had long term follow up. Therefore the long term impact of such programmes on development is unknown. 10. NICE (2006) National Institute for Health and Clinical Excellence. Obesity: prevention, identification, assessment and management. Dietary change Local authorities and NHS workplaces: should ensure on-site catering promotes healthy food and drink choices (for example by signs, posters, pricing and positioning of products). Community Local authorities should engage with the local community, to identify environmental barriers to healthy eating. This should involve: • an audit, with the full range of partners including PCTs or local health boards, See guidance for details. Some elements implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
11. Rees, R et al. (2012) EPPI-Centre SR Interventions to introduce adults to home cooking. Adults Community Cooking skills, knowledge, confidence, behaviours and health status, as well as participant costs. Only 1/5 studies (Food [people >65 in sheltered housing in a deprived area] Moynihan et al 2006) was used to judge effectiveness after assessment for bias. The reviewers agreed with the study’s authors that there was no evidence that the Food Club had an effect a year after its delivery on any other aspects of diet measured. Thirteen studies were included. All 13 of the home cooking courses aimed to teach cooking skills to low income groups in order to improve diet and health. The courses were all similar and introduce participants to practical cooking skills, with some courses emphasising food safety and hygiene, and others shopping on a budget. Five studies that used a comparison group design were used to evaluate effectiveness. in some areas but does not have a consistent national programme or a co-ordinated approach F. The evidence is inconsistent and it is not possible to draw a conclusion but it tends towards no effect 12. Schwann et al 2010 National Institute of Health and Clinical Excellence of health systems and services: at national, regional and local levels Dietary change Generic message multi-component interventions are commonly more effective than interventions • more intensive interventions tend to be more effective • school-based and workplace-based interventions can be effective in the short term, but benefits are less clear Results from review of 12 NICE evidence reviews: Community/whole population Promotional campaigns, including media interventions, can increase awareness of what constitutes a healthy diet and may subsequently improve dietary intakes. There is little evidence of benefit from locally implementable city- and state-wide interventions to prevent CVD in relation to diet and/or physical activity outcomes. Some elements implemented in some areas but does not have a consistent national programme or a co-ordinated approach A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
that promote and support health-related behaviour change. Early years School children Adults of working age population Pre-school settings School Workplace Primary care • involving parents and carers is important in effecting behaviour change for children • family-based interventions focusing on obesity prevention are effective • programmes focusing on CVD risk factors show the strongest effect in dietary change and body mass index (BMI) • policy related to the physical environment and transport systems makes a difference to physical activities such as walking, although the size of the effect varies across studies • mass media campaigns can be effective in increasing levels of awareness and knowledge, but there is less evidence on their effects on behaviour, and the evidence that exists is mixed • methods such as telephone counselling and postal prompts can be effective • incentives to participants (not financial incentives) seem to work Interventions may be ineffective unless fundamental issues are addressed, such as individual confidence to change behaviour, cost and availability; pre-existing concerns such as poorer taste of healthier foods and confusion over mixed messages; the perceived ‘irrelevance’ of healthier eating to young people. Tailoring dietary advice to address potential barriers (taste, cost, availability, views of family members, time) is key to the effectiveness of interventions and may be more important than the setting. Point-of-purchase schemes in shops, supermarkets, restaurants and cafés can be effective in improving dietary intake, at least in the short term, particularly if accompanied by supporting education, information and promotion. There is some evidence that longer-term, interventions may show greater effects. Early years