# *Detailed SUMMARY of the article “Relief for formula” by Zofeen T. Ebrahim, Published in Dawn on May 30th, 2025:* The article addresses concerns raised by Pakistani pediatricians over the government’s consideration of tax reductions on infant formula milk, which they view as undermining decades of efforts to promote breastfeeding. The proposed fiscal incentive, mentioned by a government official during a meeting with a multinational food and beverage company, is seen as endorsing formula feeding over breast milk, which is free, natural, and healthier. Dr. Jamal Raza of the Sindh Institute of Child Health & Neonatology argues for higher taxes on formula, akin to tobacco, to protect public health. Dr. Irfan Habib of ChildLife Foundation links formula feeding to a “bottle-feeding crisis,” noting that *one in three children* in their *14 emergency rooms* (treating *2 million children* annually) suffers from *gastroenteritis*, a leading cause of *53,300 under-five deaths* yearly in Pakistan, per *Unicef*. Formula-fed babies in unsanitary conditions are *10 times more likely* to die from *pneumonia*, another major killer. Dr. D.S. Akram highlights that formula use in poor families leads to *malnutrition* and *stunting*, with *Save the Children* ranking Pakistan second globally for *undernourishment* (*over 20%*). Breastfeeding, critical amidst *conflict*, *displacement*, and *rising food costs*, is hindered by aggressive formula marketing and inadequate maternal support. Only *48%* of Pakistani babies are breastfed, far below *WHO*’s six-month exclusive breastfeeding recommendation, partly due to myths about undernourished mothers’ milk supply. The *Protection of Breast-Feeding and Child Nutrition Ordinance, 2002*, and provincial laws align with the *International Code on Marketing of Breastmilk Substitutes*, but weak enforcement allows violations, such as manufacturers offering incentives to health workers. *Sindh*’s 2023 law amendments, limiting formula sales to prescriptions and adding *“malnutrition”* warnings, are a model, but enforcement needs funding and political will. The article stresses that formula should be prescribed only in rare cases (e.g., maternal death or chemotherapy) and regulated under the *Drug Regulatory Authority of Pakistan*. It advocates normalizing and supporting breastfeeding through public and workplace facilities. # *Easy/Short SUMMARY*: Pediatricians oppose the government’s plan to reduce taxes on infant formula, arguing it undermines breastfeeding, which is healthier and free. Formula feeding causes *gastroenteritis* (*53,300 under-five deaths yearly*), *pneumonia*, and *malnutrition*, with *48%* breastfeeding rates in Pakistan. Weak enforcement of laws like the *2002 Breastfeeding Ordinance* allows unethical formula marketing. *Sindh*’s 2023 law limits formula sales, but stronger enforcement and breastfeeding support are needed. # *SOLUTIONS of The Problem*: ## *1. Increase Formula Taxes* Raise taxes on infant formula to discourage overuse, as suggested by Dr. Jamal Raza. ## *2. Strengthen Law Enforcement* Empower infant-feeding boards with funding and political support to enforce *2002 Breastfeeding Ordinance*. ## *3. Adopt Sindh’s Model* Implement *Sindh*’s 2023 law nationwide, restricting formula sales to prescriptions and adding *“malnutrition”* warnings. ## *4. Regulate Formula Sales* Place formula under *Drug Regulatory Authority of Pakistan* for price and quality control. ## *5. Promote Breastfeeding Support* Establish public and workplace breastfeeding facilities to normalize and encourage the practice. ## *6. Counter Formula Marketing* Ban unethical incentives by formula companies to health workers, with strict penalties like license cancellation. ## *7. Educate Communities* Launch campaigns to dispel myths about breastfeeding and highlight its benefits, targeting vulnerable families. ## *8. Improve Maternal Health* Enhance nutrition and mental health support for pregnant and nursing mothers to boost milk supply. ## *9. Address Sanitation Issues* Improve access to clean water and sanitation to reduce formula-related infections. ## *10. Align with Global Standards* Adhere to *International Code on Marketing of Breastmilk Substitutes* to protect breastfeeding. # *IMPORTANT Facts and Figures Given in the article*: - *53,300 under-five deaths* in Pakistan annually due to *diarrhea*, per *Unicef*. - *One in three children* in *ChildLife Foundation*’s *14 emergency rooms* has *gastroenteritis*. - *ChildLife Foundation* treats *2 million children* yearly across *14 emergencies* and *300+ telemedicine hospitals*. - Formula-fed babies are *10 times more likely* to die from *pneumonia* in unsanitary conditions. - *Save the Children* ranks Pakistan second for *undernourishment* (*over 20%* of babies). - Only *48%* of Pakistani babies are breastfed, below *WHO*’s six-month exclusive breastfeeding recommendation. - *Sindh*’s 2023 law limits formula sales to prescriptions and adds *“malnutrition”* warnings. - The *Protection of Breast-Feeding and Child Nutrition Ordinance, 2002*, supports breastfeeding. # *IMPORTANT Facts and Figures out of the article*: - *40%* of Pakistani children are underweight, and *50%+* are stunted (*National Nutrition Survey*, 2018).[](https://www.dawn.com/news/1840159) - *50 deaths per 1,000 live births* is Pakistan’s infant mortality rate (*SUNCSA Pakistan*, 2025).[](https://www.thenews.com.pk/print/1313934-govt-urged-to-scrap-tax-relief-on-infant-formula-milk) - *41.7%* of women of reproductive age are anemic (*National Nutrition Survey*, 2018).[](https://www.thenews.com.pk/print/921754-17pc-gst-on-local-formula-milk-to-hinder-nutrition-goals) - *10 million* children suffer from stunting in Pakistan (*Unicef*, 2022).[](https://www.aaj.tv/news/30276360/) - *Sindh Protection of Breastfeeding and Child Nutrition Bill* passed in *2013*.[](http://www.humanrights.asia/opinions/AHRC-ETC-010-2013/) - *84%* of mothers were advised to use formula by healthcare providers (*Save the Children*, 2018).[](https://tribune.com.pk/story/613582/doctors-promoting-formula-milk-at-expense-of-babies-lives-islamabad-city) # *MCQs from the Article*: ### 1. *What annual under-five death toll from diarrhea is cited in the article?* A. 25,000 *B. 53,300* C. 75,000 D. 10,000 ### 2. *What percentage of Pakistani babies are breastfed, per the article?* A. 75% *B. 48%* C. 38% D. 60% ### 3. *What illness is linked to formula feeding in unsanitary conditions?* A. Malaria *B. Pneumonia* C. Tuberculosis D. Cholera ### 4. *What does Sindh’s 2023 law require for infant formula sales?* A. Public advertising *B. Prescription-only sales* C. Price reduction D. Free distribution ### 5. *What is the harshest penalty for violating Sindh’s breastfeeding law?* A. Fine *B. License cancellation* C. Imprisonment D. Warning # *VOCABULARY*: 1. *Advocating* (وکلات کرنا) – Promoting or supporting a cause 2. *Fiscal* (مالی) – Related to government revenue or taxes 3. *Endorsement* (توثیق) – Official support or approval 4. *Gastroenteritis* (معدے کی سوزش) – Inflammation of the stomach and intestines 5. *Cohort* (گروہ) – A group with shared characteristics 6. *Malnourishment* (غذائی قلت) – Lack of proper nutrition 7. *Stunting* (رشد کی کمی) – Impaired growth due to malnutrition 8. *Exacerbating* (بڑھانا) – Making a problem worse 9. *Compounded* (پیچیدہ کرنا) – Made worse by additional factors 10. *Unethical* (غیر اخلاقی) – Not morally correct 11. *Junket* (تفریحی سفر) – A trip funded by others, often for influence 12. *Compliance* (تعمیل) – Adherence to rules or laws 13. *Contraindication* (ممانعت) – A condition making a treatment inadvisable 14. *Normalise* (عام کرنا) – Make something standard or acceptable 15. *Readily* (آسانی سے) – Easily or without difficulty 16. *Overwhelmed* (دباؤ میں) – Overpowered by volume or intensity 17. *Vulnerable* (کمزور) – Susceptible to harm or influence 18. *Prescription* (نسخہ) – A doctor’s order for medication 19. *Empowered* (بااختیار) – Given authority or power 20. *Safeguarding* (تحفظ) – Protecting from harm or loss 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 bottle-feeding 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 government hospitals; and a majority are bottle-fed, she says. Malnutrition can cause stunting, impair development, weaken immunity, and even lead 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 grappling 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 notes that 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 by 2013-14 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 writer is a Karachi-based independent journalist. Published in Dawn, May 30th, 2025 *CSS CORNER PLATFORM*