Eating for Health: a Diet Action Plan for Scotland

6. PREGNANCY AND PRE-SCHOOL CHILDREN

6.1 This section considers diet during pregnancy; the nutritional needs of the infant and very young child; and the role of schools in influencing the diet of school children.

PREGNANCY

6.2 Pregnancy is a key time for nutrition for both the mother and the expected child. It is vital that expectant mothers eat healthily during pregnancy, not only for their own well-being but also for that of their baby. Inadequate nutrition in pregnancy can lead to ill health not only for the mother but also for her baby who risks being left permanently predisposed to hypertension, diabetes and coronary heart disease. But a healthy diet is a continuing process. It is equally important that mothers continue to eat an appropriate diet themselves after the birth of their baby and that they introduce, from birth, healthy eating practices to their child, because of the potential for lifetime eating patterns to begin to be established at a very early stage.

6.3 Mothers should, therefore, have readily available to them, either before a planned pregnancy or early in their pregnancy, comprehensive information and guidance on nutrition and diet. This should cover the mother's diet both during and after pregnancy; the need to remain alert to the potential for iron deficiency during pregnancy; and the necessity of taking the recommended levels of vitamins from foods and appropriate folate supplements, including those from fortified bread and cereals, both prior to and during the first 12 weeks of pregnancy. It is important, therefore, that the Health Education Board for Scotland and the Health Boards themselves should ensure that their health promotion activity includes regular campaigns to alert potential parents to the need for good nutrition prior to, as well as during, pregnancy. In addition GPs, obstetricians, nurses, midwives and health visitors should ensure that arrangements are in place to provide mothers with the requisite information and Health Boards should monitor the quality of the information provided against their breastfeeding policies. (The guide for health professionals on this topic prepared by Stracathro Hospital and the Post-Graduate Nutrition Dietetic Centre at the Rowett Research Institute provides a helpful reference service.)

6.4 Health professionals need to be sensitive to the influence of culture and religion on the diet of some families. Parents may choose a meat-free diet and for some cultures a vegetarian diet is the norm. A proportion of the population also now eats a vegetarian diet. Where pregnant women (and infants) are taking a diet which may be restricted in animal protein, health professionals should consider appropriate and culturally sensitive ways of ensuring that the dietary needs of mother and child are met.

6.5 For some women living on a low income it may prove difficult to ensure a diet adequate to meet their own nutritional requirements and that of their unborn child. The Report of the Policy Review on Coronary Heart Disease in Scotland, published in January 1996, highlighted the evidence that poor foetal growth and poor nutrition in infancy both appear to increase an individual's subsequent risk of CHD and hypertension 2 or 3 fold. It is important, therefore, that the advice given to pregnant women living on a low income is relevant and appropriate to their needs. Health Boards should try to ensure that Trust and primary care staff receive specific training for this purpose and that, in conjunction with the Health Education Board for Scotland, relevant responses and health education materials are developed.

6.6 In view of the significance of nutrition in pregnancy for the future health of the child, innovative ways of providing practical support to women on low incomes at such a time should be considered. Such support might include making available low cost, quality foodstuffs through community action such as food co-operatives or community cafŽs and encouraging uptake of entitlement to milk vouchers and vitamins. Information on needs assessment and good practice could be co-ordinated and disseminated centrally through the national project officer (see also paragraph 5.14).

Action Points

The Health Education Board for Scotland and Health Boards should ensure that their health promotion activity includes regular campaigns to alert potential parents of the need for good nutrition prior to, as well as during pregnancy. GPs, obstetricians, nurses, midwives and health visitors should provide dietary information to expectant mothers about their own nutritional needs as well as those of their babies. It will be important to ensure that this information and advice are tailored to meet the individual needs of expectant mothers. Health Boards should monitor the quality of the information so provided.

THE INFANT AND VERY YOUNG CHILD

Breastfeeding

6.7 The Committee on Medical Aspects of Food Policy (COMA) has consistently recommended that breastfeeding is preferable to feeding with infant formula. Even so the rate of breastfeeding by Scottish women is very low. In 1993, the latest year for which figures are available (Source: Guthrie Card System data), the average breastfeeding rate in Scotland at the end of the first week was 38%. In the 4 main cities, the percentages were Glasgow 32%, Dundee 41%, Edinburgh 45% and Aberdeen 50%. These figures conceal, however, that the rate was as low as 9% in some areas of Glasgow. And by one month of age very few babies are being breastfed. Those benefiting from a full 4 months' breast feeding are rare. Yet breast milk provides children with a healthy start to life by lessening the risk of gastrointestinal and respiratory illness in infancy and by providing protection against childhood diabetes.

6.8 The principal reason why women choose not to breastfeed is the generally unsupportive and critical attitude of partners, family and friends towards the practice. For some women, the adverse reaction by the general public towards breastfeeding in the workplace and in public places can also be an inhibiting factor. Inconsistent advice from health professionals and inadequate social advice and support, as well as perceived loss of freedom, also contribute substantially to women's decisions not to breastfeed.

6.9 The solution lies not in one course of action but rather in a multi-faceted approach. This should embrace measures to stimulate a shift in public attitudes to accept breastfeeding in the workplace and in public places, particularly in large stores and catering establishments; to provide education and training to all health professionals to better equip them to persuade women to breastfeed; and to give sound and consistent advice to pregnant women. It will also be important for health professionals, where the opportunity presents itself, to encourage the partners and/or family of women who do wish to breastfeed to support them. Health education in schools could also usefully include material on breastfeeding and the feasibility of this should be explored by the education sector, the Health Education Board for Scotland and Health Boards. Schools themselves should be encouraged to promote the advantages of breastfeeding at appropriate points within health education and personal and social education programmes. These approaches are essentially long-term but such information, carefully and sensitively presented, could encourage future generations of parents to regard breastfeeding as accepted practice.

6.10 Much has been done in recent years to address the low rates of breastfeeding. The Scottish Joint Breastfeeding Initiative, funded by The Scottish Office, was set up in 1991. Supported by a multi-agency steering group and a breastfeeding co-ordinator, the Initiative's objectives were to promote breastfeeding and to improve support for breastfeeding women and their babies. A measure of success has been achieved by the project in raising professional and public awareness of the benefits of breastfeeding through a wide range of activities, including the establishment of 22 local Joint Breastfeeding Initiatives across Scotland.

6.11 The Initiative has been complemented by the work of the Health Education Board for Scotland which plays an important part working with others to achieve the breastfeeding target. In 1995 the Board published and distributed widely a breastfeeding facts pack for professionals. This resource material should help to ensure the consistency of advice to women.

6.12 The Scottish Needs Assessment Programme's Report has also contributed by providing information designed to assist purchasers of health services to determine their needs in relation to support for breastfeeding women. And, following the introduction of the national breastfeeding target, the NHS Management Executive invited Health Boards to set local targets and to put in place arrangements to monitor these. Most Boards have now set targets and Scotland's Chief Medical and Chief Nursing Officers have taken steps to encourage professional support for breastfeeding and to improve professional practice. The Group recommends that Boards should continue to work towards attainment of their local targets and, within this context, promote with hospitals the breast-feeding criteria specified by the World Health Organisation and UNICEF as appropriate to a cBaby Friendly Hospital. Many hospitals in the rest of the UK are seeking to meet these criteria which require action at a hospital level by managers, the medical profession and other health care personnel.

6.13 Running concurrently with much of this activity has been the National Infant Feeding Audit undertaken in Scotland between 1992 and 1994. Results show that the intention to breastfeed and the initiation of breastfeeding both increased by 5%, an increase not known to have been achieved elsewhere in the UK.

6.14 The Scottish Joint Breastfeeding Initiative project was completed in 1995 but in order to maintain the momentum which it achieved the Scottish Breastfeeding Group was established in October 1995 to build on the Initiative's work. The Action Group welcomes the priority which is being given to the breastfeeding target and the continued focus which the Scottish Breastfeeding Group will provide. Monitoring of progress will be undertaken by means of the Infant Feeding Surveys commissioned by the UK Health Departments.

6.15 The action currently being pursued is largely concentrated within the NHS and undertaken by the NHS itself. However, this action will not necessarily be wholly effective in tackling the cultural and societal attitudes which constrain women from breastfeeding. There is, therefore, a complementary role for health education interests in breaking down the attitudinal barriers.

Action Points

The education sector, the Health Education Board for Scotland and Health Boards should jointly examine the potential for school health education curricula to include material directly on breastfeeding in order to inform children about its positive benefits to mother and child. Scottish hospitals should continue to develop the initiatives being taken to encourage professional support for breastfeeding and to improve professional practice so that, within a defined period, they comply with the World Health Organisation and UNICEF guidelines for designating a hospital as "Baby Friendly". In order to address the cultural and societal issues which influence women's willingness to breastfeed the Health Education Board for Scotland should identify the action required to encourage a more sympathetic attitude by the general public towards breastfeeding.

THE UNDER FIVES

6.16 Nutrition in the early years of life is a major determinant of growth and development. It also influences adult health. Below the age of 2 toddlers' diets are determined wholly by their parents or other carers. It is, therefore, vital that they recognise the importance of an appropriate diet to the future well-being of their children.

6.17 In 1994 the Committee on Medical Aspects of Food Policy (COMA), produced its Report on Weaning and the Weaning Diet which was issued to health professionals in Scotland by the Chief Medical and Nursing Officers. It recommended that the majority of infants should not be given solid foods before the age of 4 months and that, thereafter, a varied diet containing iron rich food (to protect against iron deficiency anaemia,) and food and drinks with good sources of vitamin C should be provided. Sugar, if offered at all, should be used only sparingly because of its effect on dental health. Currently, however, excess sugar consumption is still the most important shortcoming in toddlers' diets. This is largely because of children's inherent liking for sweet foods and drinks and parents' willingness to provide these in ignorance of the damaging nutritional and dental health pattern being set. In response, food manufacturers and processors have developed a range of very sweet foods for weaning and for toddlers in the knowledge that they will sell well. We recommend in paragraph 3.6 that this process should be reversed.

6.18 From the age of 2, children begin to make their own choices. They can also be generally receptive to advertising. Sugary drinks and confectionery are heavily marketed in this way and they are the major factors in children's dental caries because of their accessibility and frequency of intake. Much "pester power" is exerted by young children to gain these products. Parents and other adults frequently yield to this pressure, thus consolidating the poor dietary pattern. As a consequence, Scottish children have exceptionally poor dental health - 1993/94 data indicate that some 62% of the under fives had already developed dental decay. Fluoridation of water supplies would greatly help to combat such high levels of dental decay. In the current absence of fluoridation schemes in Scotland, the use of fluoride toothpaste must become an essential component of children's dental hygiene; and the Group notes with approval the emphasis placed on this in the Oral Health Strategy for Scotland published in December 1995.

6.19 Medicines sweetened with sugars also contribute to dental caries in young children, especially if given at night when reduced salivary flow lowers resistance to caries. Sugar free formulations of several paediatric medicines, though available, are still little used. Action is needed to accelerate the introduction of sugar free, or low sugar, paediatric medicines.

6.20 Sugar is not the only problem in what under fives eat. By five, their diet has too much fat and salt and too little fruit, vegetable, fish and carbohydrate. The Group is clear that - if there is to be any prospect of introducing healthy eating to successive generations of Scots - healthy eating messages must reach the under fives and their parents. Staff in nurseries and play groups, child minders, and health professionals who work with small children, in particular health visitors, can and should deliver that message. They need to understand, first, the basics of good diet. That will mean good information and in some cases training. To this end local authorities, in consultation with the Care Sector Consortium, whom we understand is currently reviewing vocational training, should ensure that the standards and competencies for Scottish Vocational Qualifications in care should take full account of the importance of nursery and play group staff and child minders having the ability to understand and apply knowledge about diet and nutrition.

6.21 Special initiatives to encourage the under fives to eat healthily should also be explored by local authorities. Such initiatives might usefully include employing the services of home economists and/or dietitians to provide advice and support on diet and nutritional matters to families with young children.

6.22 In relation to the provision of day care by independent and voluntary interests, local authorities in Scotland have a statutory responsibility for the registration and inspection of the services being provided for children under the age of 8 years. Guidance issued in 1991 to local authorities by The Scottish Office suggests that snacks and meals, where provided, should be varied and nutritious and should be chosen to reflect not only the background of the children but parents' wishes as well. The Scottish Office should, therefore, consider with local authorities the development of national dietary guidelines which day carers should be encouraged to adopt. Examination of dietary practices should be covered in the annual inspection of day care facilities. In the context of the Government's pre-school education initiative providers in the independent and voluntary sectors who wish to enter the pre-school education voucher system will be asked to complete a "Profile of Education Provision" which will request, inter alia, information about the steps to be taken by the applicant "to ensure that the nursery/centre has a positive ethos with attention to healthy living through diet and exercise". HM Inspectors of Schools will be scrutinising the Profiles which will inform the decision on who should be admitted to the voucher scheme. The Group welcomes this component of the application procedures and is confident that HM Inspectors will evaluate responses carefully and give due weight to the dietary and nutrition factors.

Action Points

The Scottish Office Department of Health, through the Chief Pharmacist, should identify the action necessary to accelerate introduction of low or sugar free paediatric medicines. Health Boards and local authorities should ensure that health professionals and residential and day care staff with care responsibilities for children under 5 have a working knowledge of the dietary and nutritional needs of young children and that they put such knowledge to practical effect. In this context, local authorities, in consultation with Care Sector Consortium, should ensure that in relation to their care responsibilities, the standards and competencies for Scottish Vocational Qualifications in care should recognise this requirement. Health Boards should encourage health professionals who work with small children, in particular health visitors, to provide dietary and nutritional advice and guidance to the parents of children under five years of age. Local authorities should similarly encourage staff in nurseries and playgroups and childminders. Special initiatives to encourage the under fives to eat healthily should be explored by local authorities, including the value of employing the services of home economists and/or dietitians to provide advice and support on diet and nutritional matters to families with young children. The Scottish Office should consider, with local authorities, the development of national dietary guidelines which day carers in the independent and voluntary sectors should be encouraged to adopt. The establishment of good dietary practice should be an important component of the annual inspection procedures required under the Children Act, 1989. HM Inspectors of Schools should give due weight to the requirement on applicants under the pre-school education voucher scheme to demonstrate an appropriate appreciation of the dietary and nutritional needs of the children in their care.