1. What is the ideal outcome of a pregnancy? Delivery of a full-term healthy infant with a birth weight of 3.1-3.6kg Avoidance low birth weight (< 2.5kg) Prevention of maternal mortality, complications of pregnancy, labour and delivery Preventing pre- and perinatal morbidity and mortality

3. Risk factors for LBW Nutritional status of mother: short stature, low pre-pregnancy BMI, low gestational weight gain Low dietary micronutrient intake Smoking, substance abuse, hard physical work Poorer prenatal care Multiple births Psychosocial factors (stressful life events, low social support, depression) Many of these are more common among low SE groups

5. What is the evidence for a nutritional link to LBW? Low gestational weight gain in women who are underweight or normal weight before pregnancy is associated with risk of LBW The optimum weight gain for best fetal outcome has been found in studies of many women, to be 10-14kg with an average of 12kg NICE antenatal guidance (clinical guidance 62) NICE Quality Standards (QS22) in 2012

6. Obesity in pregnancy Obesity causes major difficulties throughout pregnancy and in terms of outcome Increases gestational diabetes, hypertension, pre-eclampsia, congenital defects, increases chance of abnormal labour and complications – particularly maternal death Women obese pre-pregnancy are at greatest risk Obese mothers have larger babies and babies born at >4.5kg are also at increased risk of mortality, morbidity NICE guidance (PH27, 2011) on obesity before, during and after pregnancy

7. Alcohol …. The Chief Medical Officers’ 2016 guideline is If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long- term harm to the baby, with the more you drink the greater the risk. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48 9795/summary.pdf

8. Women who find out they are pregnant after already having drunk during early pregnancy, should avoid further drinking, but should be aware that it is unlikely in most cases that their baby has been affected. https://www.gov.uk/government/uploads/system/uploads/attachment _data/file/489795/summary.pdf

9. Dietary advice in pregnancy?

10. Advice to Avoid certain foods and drinks Limit certain foods/ingredients Take some supplements Eat ‘a normal healthy diet’ – What does this look like? How much does it cost?

14. 2016 launch Lancet Breastfeeding series http://www.thelancet.com/series/breastfeeding

15. Unequivocal evidence Essential for health of the infant short and longterm Determines population development Protects mother’s health And important in terms of sustainability and health of the planet.

16. “When Britain has one of the lowest rates of breastfeeding you have to ask the question why? Are British women educated enough about breastfeeding, or are there other reasons or barriers getting in the way?’

17. Risks of not breastfeeding? Using breastmilk substitutes is associated with a number of specific health hazards to which breastfed babies are not exposed. These include: the possibility of over- or under-concentrating formula milk during reconstitution the potential for infection introduced by using substitute milk products, bottles, teats, and other vessels potential risk from ingredients and contaminants in formula/infant milks

18. UK recommendations In 2003 the UK adopted the WHO recommendation that babies should be exclusively breastfed for the first 6 months of life – 26 weeks Supported by UNICEF, WHO and all major health agencies

19. Currently 90% maternity services and 82% health visitor settings are registered with Unicef Baby Friendly.

20. Who else offers support and guidance?

22. Infant formula The Infant Formula and Follow on Formula Regulations (2007) determine the composition of infant milks. Most claims made to differentiate products are made for unnecessary ingredients – and to avoid being miseld, people should only seek independent information on infant milks.

25. Formula milk safety Powdered milks must be made up safely as they are not sterile: there are clear guideline for this published by DH/FSA/UNICEF (2011)

26. After breast milk ….. UK advice says: Introduce complementary food alongside breast milk at ‘about’ 6 months of age in the first year of life Breastfeed throughout first year and as long after that as mother wishes ‘about 6 months’ Despite current rumours, this is unlikely to change

27. Impact of poor nutrition in early life Growth stunting Poorer immune system Impaired cognitive development Childhood obesity and type 2 diabetes Tooth decay Poorer speech development related to slow development chewing Fussiness around food type and texture leading to more limited diets

28. Introducing solids Key factor is ‘readiness for solids’ www.nhs.uk/start4life/solid-foods

32. Key messages: Between 6 months and 1 year babies need to get used to lots of different flavours and textures and learn to feed themselves Simple ‘family’ foods low in salt and sugar are fine – meat, fish, eggs, pulses, fruits, vegetables, starchy roots, cereals should be main components of meals Milk or water to drink Appetites will vary day to day and week to week Keep offering foods even if not eaten Elements of baby led weaning – but needs to meet individual needs Commercial baby foods are poor value for money and are generally too soft and too sweet.

33. Fussy eating Parental attitudes to feeding children in many western countries becoming anxiety driven concern that children ‘not liking’ food is a problem, leading to medicalisation of early feeding and search for ‘solutions’ This has been stimulated by baby food industry.

34. Tiny Tastes programme Developed by psychologists at UCL (www.weightconcern.com) Uses principles of repeated exposure and familiarisation

35. Who to take nutrition advice from? Code compliant, policy based organisations/programmes. Dietitians or AfN registered nutritionists with a specialism in public health. Schemes which support eating well in early years settings should be free of commercial involvement – e.g. HENRY, Food for Life EY Award

36. Things to look out for: A ‘Healthy Weight, Healthy Nutrition’ training pack will be cascaded to HV nationally during 2016/2017 by The Institute of Health Visiting. A new report on eating well in the first year of life should be published by SACN in 2016 New guidance on Vitamin D due immminently

37. Childhood obesity strategy No-one knows when this will come out – will have to include some statements related to pre-conception to five In the meantime we have the WHO ECHO recommendations which provide a clear framework for action

38. www.firststepsnutrition.org helen@firststepsnutrition @1stepsnutrition Sign up to the newsletter for monthly updates and alerts to new information