Pakistan, one of the most populous countries in the world; currently ranks 26th in the world for under-five child mortality. Poor nutrition and maternal education are major factors affecting mortality rates. Demographic and health surveys have highlighted that under-five mortality in children born to mothers with no education is twice that of children born to mothers with secondary education and three times higher than children of mothers with more than a secondary education. (Health Research Policy and Systems BMC 2015).

Pakistan is among the countries in the world with the highest rates of child malnutrition (stunting 38 percent, wasting 15 percent and underweight 31 percent) and its progress in child nutrition and health has remained slower than other South Asian countries.

Malnutrition in children under five years of age is an important problem around the globe but particularly so in low and middle-income countries. Key factors include: maternal education, knowledge, perception and misconceptions about breast milk and various other food items. If mothers do not have knowledge about a healthy balanced diet or if they perceive healthy food as harmful, they will not incorporate these foods into their child’s regular diet even if they are easily available.

Colostrum, yellowish-white or bluish white milk rich in proteins, is the first secretion from the mammary gland, which starts expressing in the third trimester. Studies have shown that the negative attitude about colostrum feeding contributed to its lack of use.

So what information do we have about feeding practices among mothers of children under five years of age? A local study comparing maternal education levels with the use of colostrum or ‘first milk’ showed that 42 percent of mothers who had no schooling/ education perceived it as ‘not clean’ as opposed to 9.5 percent of those with higher education. It was, however, interesting to note that the percentage of mothers with higher qualification who did not use colostrum due to parents/ family elders’ advice against its use was greater than those with no education (28.5 percent vs 15.8 percent).

In another study, 81 percent of mothers with college/ university degree stated their overall food choices for their kids was influenced by family elders. When specific food items were looked at it appeared that the use of banana and eggs were mostly avoided due to some misconceptions.

Community-based interventions to promote maternal health education can be cost-effective and can be used long-term. Even in underprivileged areas, with high ratio of poverty and malnutrition, a structured community-based intervention in areas of food economics, healthy diet and food safety can have successful outcomes.

Consumption of bananas, eggs, rice and butter all year round, was noted among children belonging to mothers with higher qualification compared to their less educated counterparts. It was noted that bananas and dates were included in a child’s diet all year round where mother’s choice was affected by older members of the family.

One of the leading reasons for use of supplemental feeds, also called additional or top feed (which is a feed given to child in addition to breast milk) was maternal belief that they were not producing enough breast milk to adequately feed their child. Depending upon affordability either diluted cow’s/ buffalo’s milk or formula milk was used as top feed. Approximately 80 percent of mothers were unaware of the fact that bovine milk can lead to iron deficiency anaemia in children below 12 months of age.

There is a need to educate mothers and families about the importance of breast feeding, especially benefits of colostrum.

The information about the benefits of colostrum and exclusive breast feeding on media rather than promotion of breast milk substitutes can help primary care providers deal with the current knowledge gap.

Information on nutritional advantages of foods like banana, eggs, rice, dates, ghee and butter must be introduced to mothers. This will promote inclusion of these items in infants and toddler’s diet.

For a successful transition to healthy diet, myths and misconceptions have to be dealt with systematically. Nutritionists, healthcare professionals must be aware of frequent misconceptions and address them promptly during consultations.

Higher maternal education leads to better understanding of paediatric anaemia, which affects more than half of pre-school children in developing countries.

Community-based interventions to promote maternal health education can be cost-effective and can be used long-term. Even in underprivileged areas, with high ratio of poverty and malnutrition, a structured community-based intervention in areas of food economics, healthy diet and food safety can have successful outcomes.

I would like to appreciate the work of two family physicians: Drs Khudija Amna Arif and Marriam Sheraz in the above-mentioned studies.

The writer is an assistant professor in family medicine at the University of Health Sciences, Lahore