OVER the past several decades, Pakistani paediatricians have been advocating mother`s milk a natural source of nourishment with the power to save countless newborns. So, when news broke recently that the government is considering reducing taxes on infant milk powder, it raised serious concerns among those on the front lines of infant care. They saw the move as a step backwards in their long, uphill effort.

This fiscal incentive mentioned by a government official, while meeting a delegation of an international food and beverage MNC, was seen as an endorsement of formula feeding at the expense of breastfeeding. It is hard to see the economic or ethical logic of the government promoting formula milk as `affordable and accessible` for the public, when breast milk the healthiest and entirely free alternative is readily available to most.

Executive director of Sindh Institute of Child Health & Neonatology, Dr Jamal Raza argues that, like tobacco, formula should face higher taxes to protect public health not tax cuts. The consequences of formula overuse and poor infant feeding practices are already evident in the country`s overwhelmed paediatric emergency rooms.

`Every third child brought in our emergencies has diarrhoea,` notes Dr Irfan Habib, director of the ChildLife Foundation. His organisation treats a huge cohort of around two million children annually newborns to age 14 through its 14 emergencies, in public hospitals across Pakistan.

Their telemedicine network across 300-plus government hospitals nationwide identifies gastroenteritis as the most common illness.

He has little doubt in his mind that the root cause is the same formula feeding. `We don`t just have a gastroenteritis crisis, a leading cause of death in children under five; we have a bottlefeeding crisis! Unicef says about 53,300 under-five deaths in Pakistan are due to diarrhoea every year, a tragedy that can easily be prevented just by giving the newborn mother`s milk.

But gastroenteritis is not the only illness the kids are brought to health facilities with. A formula-fed baby living in unsanitary condition is 10 times more likely to die of pneumonia (another leading killer among Pakistani children) than a breastfed one, say health practitioners.

Aside from diarrhoea, giving bottle to the babies can lead to malnourishment in poor families in Pakistan. Dr D.S. Akram has been seeing malnourished children for over 40 years in gov-ernment hospitals; and a majority are bottle-fed, she says. Malnutrition can cause stunting, impair development, weaken immunity, and evenlead to death.

Save the Children ranks Pakistan second among countries with over 20 per cent undernourishment for babies born into hunger. Conflict, displacement, extreme weather, and rising food costs have been flagged by the FAO as drivers of child malnutrition all the realities Pakistan is gr appling with.

In this context, breastfeeding becomes even more critical as a safe, cost-free source of nutrition. Yet aggressive formula marketing and reduced support for nursing mothers are exacerbating the problem, pushing vulnerable families towards expensive, less nutritious alternatives they often can`t safely prepare.

Once a newborn starts formula, the mother`s milk supply often drops or stops entirely, explains Dr Wasim Jamalvi, president of the Sindh chapter of the Pakistan Paediatric Association. As head of paediatrics at Karachi`s Civil Hospital, he notesthat parents often realise too late how costly formula is leading them to dilute it, which compromises the baby`s nutrition.

This problem is further compounded by unsafe water and unclean feeding equipment, which, as Dr Akram points out, put babies at serious risk of illness and infection.

With only 48pc of babies in Pakistan being breastfed (the WHO recommends exclusive breastfeeding for the first six months), many mothers and families believe often wrongly that undernourished women can`t produce enough milk. The formula industry exploits this fear with aggressive, unethical marketing, convincing vulnerable parents that formula isn`t just an option it`s essential.

The Protection of Breast-Feeding and Child Nutrition Ordinance, 2002, laid a vital foundation for safeguarding breastfeeding in Pakistan, prompting provinces to enact their own laws by2013-14 in step with the evolving International Code on Marketing of Breastmilk Substitutes.

A key step forward indeed, but much work remains. Laws are certainly never enough if there is little awareness in everyone involved whether it`s the community itself or the people who influence them.

Despite a marketing ban, manufacturers still flout rules and offer incentives to health workers.

Paediatricians say the real problem is weak enforcement. Only four months back, disclosed a senior health practitioner, a distribution company took a planeload of his fraternity to Japan on a junket. The laws now need to be given a shot in the arm through ensuring that infant-feeding boards are empowered with adequate funding and political commitment to monitor effectively.

In 2023, Sindh introduced amendments to its provincial law that other provinces may consider following. Among its key measures, the law limits infant formula sales to prescriptions and authorised outlets and pharmacies. The rebranded product, now labelled `artificial formula` will also include the word `malnutrition` in addition to the existing message that breast milk helps prevent diarrhoea and other diseases. To ensure compliance, the harshest penalty for violating the law is the cancellation of a health practitioner`s licence.

Undoubtedly, nothing matches the benefits of breastmilk, but it`s also important to remember that formula itself isn`t the enemy its misuse is.

Doctors should prescribe formula only in specific cases such as when the mother has died, undergone a double mastectomy, or has no lactating relative who can provide breastmilk for the baby.

They may also prescribe formula if the mother is on certain drugs, such as those used in chemotherapy, which can harm a newborn if passed through breastmilk though cancer itself isn`t a breastfeeding contraindication. Yet, in Pakistan, formula is sold freely without price or quality control. If it becomes a prescribed food and comes under the Drug Regulatory Authority of Pakistan, that may change.

Finally, as paediatricians emphasise, there truly is no substitute for a mother`s milk, the safest and most natural option. So, let`s ensure mothers have the support they need, including comfortable spaces to feed their babies, whether they`re in public or at work.

It is time to normalise, celebrate and support breastfeeding!• The wnter is a Karachi-based independent joumalist.