IMPACT OF NUTRITIONAL EDUCATION ON PHYSICAL STATUS/NUTRITIONAL

STATUS OF LACTATING MOTHER AND INFANT

I. Introduction

According to Maso et al . (2021) and Gila Diaz et al. (2021), adequate nutrition is essential for
optimal health during lactation. Furthermore, according to the research by Johnson et al. (2017)
and (Bartick et al., 2017) breastfeeding provides standardized and specific feeding and is
associated with long-term health benefits for the mother and her baby.

Breastfeeding is a time when lots of energy and important nutrients are needed. Thus, women are
particularly vulnerable to nutrition during this period. Lactating mothers have been found to still
be able to produce adequate milk in quantity and quality even if their nutritional status is
inadequate, although this may ultimately lead to their deterioration Women's milk content is in
fact affected by a wide range of variables. The mother’s diet, body type, and amount of stored fat
are all greatly influenced by this (Gila Diaz et al., 2021; Rasmusen, 1992). In addition, research
has shown the influence of socioeconomic, cultural and geographic variables on milk nutrition
(Michealsen et al., 1994). These factors are clearly illustrated by differences in milk production
between breastfeeding mothers in less developed countries and those living in industrialized
areas Malnutrition is common among breastfeeding women who economic status is poor, and
can have a negative impact on their health (Ahmed et al., 2012). It should therefore be noted that
although women tend to have access to an adequate and varied diet, the nutritional status of
breastfeeding mothers in developed countries is not always optimal and, moreover , evidence of
an unbalanced diet and insufficient nutrients is evident, leading to many issues (blood pressure,
obesity) , heart disease). (Crozier et al., 2009), (Cuco et al., 2006), (Dos Santos et al. al., 2014).
In addition, the nutrition of breastfeeding women receives relatively little attention during this
time, with the major focus being on neonates. (Gila Diaz et al., 2021).

The best method for giving energy and nutrients to neonates and babies for their best possible
growth, development, and health is breastfeeding. In 2012, Nakhaie et al. A nutritious diet
benefits mothers' and children's health in the short- and long-term, according to a research done
on breastfeeding mothers. (do Cormo et al., 2001). Mothers are more likely to experience
nutritional deficiencies, particularly during breastfeeding, as a result of poor eating habits,
physiological changes, and a variety of sociodemographic variables. (Gay. 2018) According to a
recent study, iodine, essential fatty acids, vitamins B1, B2, B6, B12, A, and D, and iodine are
necessary nutrients for the best possible breast milk production. (Valentin and Wagner. 2013).
Malnutrition in children can result from a prolonged deficiency in calories, which can also
impact the quality and amount of breast milk produced. (Kong. 2016)

Breastfeeding causes a large increase in nutritional demands since breast milk has to supply all
the nutrients a kid requires for healthy growth and development in sufficient levels (Doran and
Evers, 1997). In addition to the daily caloric needs for non-pregnant women, breastfeeding
women require an additional 500 kcal (Kominiarek and Rajan, 2016). Thus, it's critical that
nursing mothers get enough wholesome food at this time (WHO, 2009). Nursing moms who are
malnourished not only have problems with the composition and supply of milk, but also with
their own and their children's health. Poor quality and quantity of nutrients will be given to the
infant if the mother is undernourished when nursing. (Sanusi and Falana. 2009). Dietary
diversity, or the variety of foods or food categories ingested during a specific time period, is a
proxy for nutritional sufficiency in lactating mothers. (Arimond et al., 2009).

Women's and children's nutritional status, which reflects socioeconomic conditions, general
health, and home security, is a good predictor of the community's general well-being. Alemaehu
and colleagues, 2014). It is consequently essential to continuously evaluate the food intake and
nutritional condition of lactating women, particularly in environments with limited resources.
(George et al.,, 2005). Another study, carried out in Khorramabad as well, discovered that
breastfeeding mother's were getting enough calories and macronutrients, but that there was a
shortage of certain trace elements (vitamins A, D, B2, B9, and C; calcium, iodine, magnesium,
phosphorus, and zinc). (HorMozi and Khaghani, 2002). The majority of the published research
solely looked at prenatal nutrition; nursing women's nutritional needs were not taken into
account. (Moghasemi et al., 2014). Research conducted in several nations has also observed
inadequate nourishment and inadequacies in nutrients among women who are breastfeeding. (Do
Carmo et al., 2001), (Wang et al., 2017), (Sanusi and Falana. 2009).

According to Flanagan et al. (2012), malnutrition is a clinical condition marked by weight loss
coupled with a notable decrease of muscle mass and fat reserves. Maternal and child malnutrition
rates are still too high worldwide. Women's health, their children's survival, growth,
development, and future productivity are all at risk when they are malnourished before their
second birthday (UNICEF, 2009). Over 90% of teenage females globally who begin nursing do
so in underdeveloped nations, accounting for an estimated 14 million new breastfeeding starts
each year (Hundera et al., 2015). Women who are malnourished are likely to have significant
health consequences for both herself and their offspring. The leading cause of death for women
and children under five in developing nations is malnutrition, which claims the lives of almost
3.5 million of them annually. [Biteu and Tellake. 2010). According to Bhutta et al. (2013),
800,000 newborn fatalities from small-for-gestational-age deliveries are caused by malnourished
mothers, who also give birth to ill and cognitively damaged children. A malnourished woman
produces less breast milk than a well-nourished woman, and underweight women in
underdeveloped nations are at a higher risk of illness and death (Alemayehu et al., 2015).
Additionally, underweight women have lower milk production volumes and quality. According to
Mtumwa et al. (2016), there is proof that women who have a body mass index (BMI) of less than
18.5 kg/m2 are more likely to experience morbidity and death. There exists a tight relationship
between the general health and nutritional state of the population and the health and nutritional
status of women. (Khan and khan. 2012).

Low body weight children are more likely to be born to women who are unhealthy and who do
not eat well. They are also less likely to be able to provide their kids enough food and attention.
Ultimately, the financial stability of a family is impacted by a woman's health, since
undernourished women tend to be less productive in the workforce (Rao et al. 2010). The
majority of pregnant women (58.38%) were under 20 years old and had mild anaemia. Khan and
associates (2014). These include anaemia from iron deficiency, vitamin and calcium deficiencies,
inadequate diet, and some allergy illnesses that might harm breastfeeding mother. Lactating
women should incorporate these foods into their everyday routine to prevent deficient disorders.
(Bose, 2010). In order to evaluate the food and nutritional health of lactating Saharia tribe
women, a National Institute of Nutrition (NIN) study was carried out in October–November
2004. The mother must meet high nutritional requirements when breastfeeding. The diet that
women consume throughout pregnancy and nursing has an impact on the health of their unborn
children as well as the effectiveness of breastfeeding. The mother's diet is crucial when she is
nursing. The mother's diet has an impact on the amount and quality of milk she produces.
Breastfeeding causes malnutrition in lactating women because the nutritious demands of
lactating mother's are higher than those of pregnant women. If these increased nutrient needs are
not satisfied by diet, breastfeeding results in malnutrition.

For parents, increasing their calorie and nutritional intake is one of the most important
adjustments at this time. Numerous factors, including age, exercise level, and size, influence how
much an individual should eat. (USDA, 2020). However, it is typically advised that nursing
moms take in an extra 330 calories per day during the first six months of lactation. If
breastfeeding lasts for an additional six months, this rises to an additional 400 calories. (Institute
of Medicine. 2005) Nutrient-dense meals—that is, those high in vitamins and minerals and low
in added sugars, saturated fat, and sodium—are the greatest sources of those additional calories.
(USDA, 2020). Adhering to the overall healthy eating pattern that the Dietary Guidelines for
Americans prescribe is the best method to accomplish this aim. Eating a range of colourful
vegetables, whole fruits, whole grains, lean proteins, low-fat dairy products, and minimising
added sugars, saturated fats, and salt are all advised by these guidelines. (USDA, 2020). Though
this advice may seem straightforward, assessments of American incomes now indicate that many
people are not fulfilling these objectives. Breastfeeding mother's are known to consume high
amounts of protein, refined grains, added sugars, saturated fat, and salt, and low amounts of
vegetables, whole grains, fruits, and dairy products. (USDA, 2020). Parents who abide by these
suggestions will have improved health as well as better outcomes for the kids they raise. For
instance, the diet of the breast milk producer provides aromatic chemicals. It turns out that
compared to breastfed newborns, formula-fed babies are less accepting of unfamiliar flavours. In
one trial, breast milk was used to provide cumin flavouring to newborns. Compared to a control
group of bottle-fed newborns, these babies later took more purees flavoured with cumin
(Hausner et al., 2010). Therefore, after solid meal introduction, children may become less fussy
eaters if parents adhere to nutritional standards that suggest a diversified diet.

The subdistricts of Ciomas and Darmaga in Bogor were the sites of the research. A maximum of
sixteen posyandus (Integrated Health and Nutrition Services) that satisfied the criteria for the
study were chosen. In all, 240 moms took part in the posyandus and were part of the study. Each
sub-district's posyandus was randomly assigned to an intervention and control group. The
influence of nutrition education on response factors, such as mothers' nutritional knowledge,
attitude, and practice, and the nutritional status of children under five based on Z-score, was
investigated through an experiment. Nutrition instruction was given once every two weeks for
the duration of the five-month project. The nutritional status of children under five years old, as
determined by the Z-score of body weight for age, and mothers' nutritional knowledge, attitudes,
and behaviours were significantly impacted by the nutrition education intervention, according to
the General Linear Model analysis. (Sukandar et al., 2015)

Numerous studies have indicated that feeding instruction for mothers improves the nutritional
condition of their offspring significantly, particularly when the tactics are applied in the local
contexts for which they are intended. In a systematic review (Dewey et al., 2008), Dewey and
Adu-Afarwuah assessed the various forms of educational interventions in different developing
countries (educating the public, providing food offering extra energy (with or without
micronutrient fortification), micronutrient fortifying complementary foods, increasing the energy
density of complementary foods through simple technology) during the period from 1996 to
2006. They discovered that, while the outcomes varied depending on the availability of food in
the environment, educational interventions generally had positive effects in Asia and Africa..
Imdad et al. (2011) assessed the weight and growth of young children in a follow-up systematic
review based on whether feeding programmes had been implemented with or without guidance
on supplemental feeding for infants under the age of two for mothers from poor nations. They
noted that even while both groups' weight and height gains were comparable, additional data was
required before any inferences could be made in this area.

There is little data to determine how nutrition education affects the physical and nutritional
health of mothers who breastfeed and their infants. Thus, the goal of the current study is to assess
how nutrition education affects the physical and nutritional health of nursing moms and their
babies in the District Kurram.

I.2. Aims and Objectives of the study

The current study will focus on the following few objectives

1. To assess the nutritional status of lactating mothers.

2. To determine the physical status of the infant
 3. To evaluate the impact of nutrition education on nutritional and physical status of
lactating mothers and their infants
II. REVIEW OF LITERATURE

Nyamasegi et al. (2021) investigated whether the frequency of stunting varied between
intervention and control groups and found characteristics linked with linear growth in children.
This was a follow-up study of mother-child couples who took part in a cluster randomised
controlled trial between 2012 and 2015. Linear mixed-effects models were used to model and
identify the causes of children's linear growth. The investigation was place in two Nairobi slums.
Throughout pregnancy and infancy, the intervention group received monthly nutritional
education and advice (NEC). A cohort of 1004 children was tracked every three months after
birth until they were 13 months old. Due to attrition, only 438 mother-infant couples participated
in the 55-month follow-up. There was no difference in the loss of baseline attributes to follow-up
between the characteristics that were included of the study. When comparing the height z-score
between birth and 13 months, the control group (33.5%) reported a substantially greater
prevalence of stunting than the intervention group (28.6%), with an average drop of −1.42 (SD
2.04). When compared to the intervention group (8.3%), considerably more males (16.5%) in the
control group experienced growth retardation at month 55, when scores increased by a mean of
−0.89 (SD 1.04). The following factors were shown to be adversely linked with linear child
growth: being in the control group, having a male kid, frequent vomiting/regurgitation, mother
height <154 cm, and early weaning.

Thakur et al. (2018) evaluated the level of exclusive breastfeeding knowledge among nulliparous
and multiparous moms and examined the influence of nutrition education on it. The awareness of
breastfeeding techniques among pregnant and postpartum mothers was also assessed. Thirty-two
pregnant women who visited Anganwadi facilities in an urban slum in New Delhi and twenty
primiparous women made up the sixty pregnant women (>30 weeks' gestation) involved in the
research. Using purposive sampling, the individuals were selected. The influence of nutrition
education on pregnant women's knowledge levels was evaluated using a point questionnaire. The
statistical analysis was performed using paired and independent t-tests. Both postpartum and
multiple pregnant women, particularly those who were pregnant, seemed to lack basic
knowledge regarding exclusive breastfeeding. There was a noteworthy distinction between the
knowledge ratings of women who had given birth to many pregnancies and those who had given
birth to their first pregnancy (t=-2.476; p<0.05). The understanding of exclusive breastfeeding
among pregnant mothers has improved as a result of nutrition education delivered through
pamphlets and videos. Pregnant women's knowledge of exclusive breastfeeding before and after
showed a significant (t = -17.8; p<0.0001) difference in the total knowledge score. Women's
understanding and exclusive breastfeeding practices will increase if they get engaging,
comprehensive prenatal and postnatal nutrition education..

Singh et al. (2018) examined EBF knowledge, attitudes, and behaviours among lactating moms.
A structured interviewer-administered questionnaire was used to conduct a focus group research
with 350 women utilising the birth-to-return technique. Methodical random sampling was
employed to choose research participants, and descriptive statistics were computed. Of the 350
lactating women, the majority (31.4%) were between the ages of 26 and 30. The majority
(71.7%) hailed from nuclear families. 320 lactating mothers (91.4% of research participants)
were aware of EBF. Most mothers were aware of EBF and had a good attitude towards it,
although most were unsure of the suggested length or if six months was enough. Health
practitioners should support breastfeeding and nutritional health education.

Zerihun et al. (2016) examine malnutrition and associated characteristics among mothers who
were breastfeeding in rural Ambo District, West Shewa Zone, Oromia Region, Ethiopia, in 2016.
A community-based cross-sectional study was conducted on a random sample of people. There
are 619 mothers that nurse their children. Sociodemographic data was gathered using a pre-tested
and standardised questionnaire. We determined weight, height, and upper arm circumference.
The body mass index was utilised to estimate nutritional status. The results were described using
descriptive statistics. Each independent and dependent variable's connection was determined
using binary logistic regression. In multivariate logistic regression, adjusted odds ratios with
95% confidence intervals were used to discover characteristics that were associated with
outcomes. Malnutrition (BMI < 18.5 kg/m2) was detected in 21.5% of patients. Breastfeeding
mothers in the 17–25 age range were more likely to be malnourished than mothers in the 36–49
age range (AOR=6.82, 95% CI: 1.84, 25.27). Furthermore, mothers lacking literacy were more
likely to be undernourished (AOR=2.45, 95% CI: 1.22, 494) and had a worse mental well-being
score (AOR=1.76, 95% CI: 1.05, 2.95). Rich mothers and official education One-fifth of mothers
who were breastfeeding were malnourished. Therefore, special attention should be paid to health
education on the necessity of enough sustenance while breastfeeding as well as optimal nutrition
for mother and child. Enhancing the health and nutrition of nursing women also requires strong
cross-sectoral coordination with the goal of raising women's status in society.

Almeyehu et al. (2015) investigated malnutrition characteristics in lactating women who

participated in a home-based food production and child-oriented extension project in the
Kebeles, Dado, and Seka-Chekorsa Districts of Jimma Zone, South West Ethiopia, from
February 3 to March 3. From February 3 to March 2, 2014, a community-based cross-sectional
survey was conducted among 355 nursing moms who received assistance from a home food
production programme and a child-centered counselling project. A structured interview was
utilized to assess demographic data and nutritional risk factors, while anthropometric
measurements were employed to estimate nutritional status. Data was entered into Epi-data
version 1.4.4.0, then exported to SPSS (Statistical Package for Social Science) version 20 for
analysis. The study population was described using percentages, mean values, and standard
deviations. Among the explanatory factors, logistic regression was utilized to find underweight
predictors. The research participants' dietary variety scores had a mean of 4.9 and a standard
deviation of 1.9, respectively. 24 hours before to data collection, the majority of research
participants ate morning cereal. Other than the customary family supper, 92% of research
participants did not eat anything. Of nursing moms, 40.6% were underweight. Malnutrition was
shown to be predicted by maternal ratings of dietary variety. The research participants exhibited
inadequate eating practices, and malnutrition was highly prevalent among them. Consequently,
initiatives to produce food at home and provide advice to children, Verda health authorities,
healthcare professionals, and other relevant stakeholders should give improving the situation
their full attention.

Hundera et al. (2015) investigated the nutritional status and associated characteristics of
breastfeeding mothers at Nyakemte Hospital and Health Centre in Wollega East, Ethiopia. The
institutional research was conducted between January and June of 2014. The Body Mass Index
was calculated by measuring the height and weight of nursing moms using standard procedures.
All breastfeeding women who received postnatal care at health facilities and participated in the
EPI programme were asked to give information on their sociodemographic characteristics,
maternal nutritional status, and other factors. Descriptive statistics, binary and multiple logistic
regression models were used to examine the link between nutritional status and socioeconomic
and demographic factors. According to the study, 292 women (91.3%) were enrolled in school,
and the majority of the 260 women (81.3%) were between the ages of 17 and 25. Underweight,
normal weight, overweight, and obesity were prevalent in 65 (20%), 240 (75%), 20 (4.7%), and
0.3% of the population, respectively. The results of multiple logistic regression analyses showed
a significant relationship between the study participants' nutritional condition and family size
(AOR=4.604, 95%CI=1.903-11.140) and family income (AOR=0.250, 95%CI=0.100-0.623).
and were in compliance with global standards. To enhance nutritional intake during breastfeeding
and thereby enhance the health and nutrition of expectant mothers, it is therefore advised that
breastfeeding mothers, their families, and communities receive ongoing nutrition education.
Appropriate nutritional knowledge, appropriate family planning, and breastfeeding mothers
themselves should also be encouraged. The appropriate organisation has to come up with a plan
to boost their revenue.

Sukander et al. (2015) investigated the impact of nutrition education on mothers' nutritional
knowledge, attitudes, and habits, as well as the nutritional status of children under the age of
five. This research was conducted in Bogor's Siomas and Darmaga districts. The study's
requirements were satisfied by sixteen Posiandus (integrated health and nutrition services). This
research involved 240 mothers. Posiandus is allocated to either the control or intervention group
at random in each sub-area. An experiment was conducted to explore the impact of nutrition
education on response characteristics such as mother knowledge of nutrition, attitude and
practice, and the nutritional status of children under the age of five, as determined by Z-score.
Nutritional data were sent biweekly for five months during the trial.Nutrition education
programmes had a substantial impact on mothers' nutritional knowledge, attitudes, and
behaviours as well as the nutritional health of their under-five children based on body weight-
for-age Z-score, according to general linear model analysis.

Ogechi (2014) studied nutritional requirements of lactating women in Umuahia, Nigeria. This
cross-sectional study comprised of 240 randomly selected women with infants (0-6 months) who
went to postnatal clinics at four health facilities in Umuahia North Local Government Area
(LGA), Abia State, Nigeria. A structured, validated, and pre-tested questionnaires was used to
collect socioeconomic data. The body mass index (BMI) was calculated by measuring height and
weight using standard methods. Dietary intake was determined using a repeatable and confirmed
24-hour food frequency questionnaire. The average nutritional intake was calculated and shown
as a percentage of the FAO/WHO recommended values. The data were analysed using
descriptive statistics, and the relationship between nutrient consumption and BMI was
determined using Pearson's correlation coefficient. Of the women, 71.30 percent were between
the ages of 26 and 35, and 85% of them made more than 20,000 nan per month in their
households. Of the cases, 18.30 percent were obese, and 52.10% were overweight. The amount
of vegetables, both leafy and non-leafy, was consumed more frequently (1,430) and cereals and
grains (1,079) than legumes each day. The amount of calories consumed was lower than
recommended, with protein at 50.02±12.23 g, calcium at 339.21±186.35 mg, and vitamin A at
698.52±615.50 µg RE. Some vital nutrients were not consumed to the necessary level. To
promote health and nutrition, special focus should be given to measures such dietary
diversification and nutrition education throughout the pregnancy and breastfeeding period.

Bhutta et al. (2013) conducted a thorough review of treatments to address malnutrition and
micronutrient deficiencies in women and children, using standardised methodologies to assess
developing evidence for delivery platforms. We estimated the savings and costs of these
treatments in 34 countries where 90% of children are stunted. additionally they investigated the
effectiveness of several platforms and delivery choices that employed community health
professionals to engage disadvantaged communities and encourage behaviour, attitude, and
intervention changes. Our findings indicate that if the population had access to 10 evidence-
based nutrition treatments with 90% coverage, the current total number of fatalities among
children under the age of five could be decreased by 15%. Furthermore, iodine deficiency can be
corrected and health outcomes improved by consuming and having access to iodized salt. If
access is enhanced in this way, there might be potential advantages immediately and a fifth of the
present stunting load could be averted. In the 34 target nations, increasing access to these 10
direct nutrition interventions is expected to incur yearly expenditures of $9.6 billion. A major
impact may be achieved by maintaining funding for specific nutrition programmes that target the
poorest and most vulnerable groups in the community and use community participation and
delivery methods to avoid micronutrient deficiencies and malnutrition in mothers and children.
In nations with the highest rates of maternal and child malnutrition and mortality, this improved
approach can greatly accelerate progress when paired with nutrition-sensitive approaches, such
as those pertaining to women's empowerment, agriculture, food systems, employment, education,
and social protection policies.

Gilmore et al. (2013) evaluate the efficacy of community health workers' preventative
interventions for mother and child health in low- and middle-income countries. From June 8 to
11, 2012, a systematic search was conducted in the following databases: CINAHL, Embase,
Ovidius Nursing Database, PubMed, Scopus, Web of Science, and POPLINE. The search
strategy was developed in accordance with the recommendations of the Evidence for Policy and
Practice Information and Coordination Centre (EPPI Centre). Google, Google Scholar, and WHO
were also searched, as were pertinent systematic reviews and included articles' reference lists.
The following requirements must be met in order to be eligible: i) The targeted beneficiaries
must be women who are pregnant or who have recently become pregnant; ii) The intervention
must be preventative and provided at the home level by community health professionals, as well
as children under the age of five and/or carers for such children. There were no exclusion
standards given for the results or comparisons/controls. Data tables and peer-reviewed quality
evaluation were used to gather the study features of the included papers. To summarise results
and make inferences, a descriptive synthesis of the included research was carried out using
descriptively coded articles. 17, publications detailing 19, studies out of the 10,281 research that
were initially found were included in the screening process. Randomised controlled trials, cluster
randomised controlled trials, before-and-after studies, case-control studies, and cross-sectional
studies were among the ten nations in which the research were carried out. The evidence's overall
quality was assessed as moderate. Preventive interventions have been divided into five primary
categories: health education, breastfeeding assistance, basic infant care, psychosocial support,
and prevention of malaria. While community health professionals proved to be particularly
successful in promoting maternal interventions (skin care and exclusive breastfeeding), evidence
of their efficacy was present in all categories. In low- and middle-income countries, community
health workers have been demonstrated to provide a variety of preventive maternal and child
health interventions, with some evidence of effective strategies. However, for the majority of
interventions, there is not enough data to make conclusions, and more research is needed.
Thakur et al. (2012) evaluated the effect of nutrition education on the growth of low birth weight,
prematurely born, exclusively breastfed newborns compared to a control group. A total of 184
low birth weight infants and their mothers from the Maternal Training and Health Institute and
the Dhaka Medical College Hospital were randomly assigned to either the intervention or control
groups. Recruitment for the research population began in May 2008 and finished in October
2008. Mothers got nutritional education instruction twice a week for two months after starting
one hour of lactation, switching to exclusive breastfeeding, and increasing feeding. Every two
weeks, the nutritional status of low birth weight infants was examined by measuring their height
and weight. The data were analysed with SPSS/Window version 12. The data means were
compared using the conventional Student's t test. Children with NMB had similar starting body
weights and heights in both groups (2261±198 g vs. 2241±244 g, P=0.535 and 43.0±1.3 cm vs.
43.0±1.7 cm, P=0.535) (77). At two months, children receiving NMM saw significant increases
in body weight and height (3620±229 g vs. 3315±301 g, P<0.001 and 50.2±1.3 cm vs. 48.7±1.6
cm, P<0.001). The intervention group reported fewer respiratory infections than the control
group (39% vs. 66%, P<0.001). With the dietary intervention, the proportion of individuals who
breastfed at an early age significantly increased (59.8% vs. 37.2%, P<0.001). In the intervention
group, the rate of exclusive breastfeeding was much higher (59.8% vs.37%, P = 0.004). The
study found that breastfeeding and nutrition education significantly increased weight and height
in low birth weight babies. Consequently, breastfeeding instruction appears to be a powerful
strategy for reducing low birth weight children's increased risk of starvation and mortality.

Limonen et al. (2012) looked at the existing practice of nutritional advising, nutritional
understanding, and the need for nutritional education for nurses in mother-child clinics.
Nutritional guidance for young families is a crucial tool for avoiding lifestyle-related chronic
illnesses. Nurses are stationed in medical clinics to provide preventative work that needs
knowledge of current nutrition research as well as counselling. Nurses have little knowledge of
current nutritional counselling methods and the need to enhance their counselling skills. A
computer-generated questionnaire was distributed to 650 nurses at maternal and paediatric clinics
nationwide via email connections. Respondents who did not answer were contacted again,
resulting in a 50% response rate (n=327). Nurses perceived nutritional advising in clinics as an
essential but difficult responsibility. In addition to health promotion, they provided advice to
customers on a wide range of illnesses, including constipation and celiac disease. Nurses'
acceptance of nutritional advice varied. Better collaboration with families and health
professionals, as well as additional resources like as counselling time, updated educational
materials and clinical recommendations, and enhanced nutrition education, have been proposed
as ways to improve counselling. The findings revealed nurses' need and desire to implement
nutritional counselling in clinics. Given the potential health advantages of nutritional
counselling, investments in operational counselling, including expertise and training in health
clinics, are obviously justified.

Chen et al. (2012) investigated the impact of dietary modifications and nutrient consumption
during the first three months of nursing on the risk of disease and overall health. At 2, 15, 45, and
90 days postpartum, 200 healthy lactating women participated in in-person interviews to
complete a 24-hour dietary questionnaire; 59 healthy non-pregnant women served as the control
group. Daily energy consumption in nursing women was 12%-18% and 34%-11% less than the
Chinese recommended nutritional intake (RNI, 2600 kcal, 357.5-422, 5g); (2) fat intake went up
from 4% to 14%, surpassing the RNI (58-87.7 g) by 9-76%; and (3) protein intake was 33-53%
more than the RNI of 86 g. (4) Proteins (20%–23%), fats (34%–42%), and carbohydrates (39%–
44%) as a percentage of total calories consumed do not meet the Chinese RNI (5) vitamin C, B1.
Intakes of iron, selenium, vitamin B2, vitamin B3, vitamin E, and fibre were 20% to three times
higher than the RNI, whereas intakes of calcium, zinc, fibre, and folic acid were 5% to 73%
lower. The RNI was not met by the control group's dietary consumption for any given nutrient.
Self-choice diets can have an effect on the nutritional composition of breast milk and,
consequently, the future health of mothers and babies, as they fail to meet the Chinese RDA for
many critical nutrients. RNI needs to consider local customs and eating patterns. China is too
large to be covered by a single national RNI. Society needs to be more educated about nutrition.

Kamran et al. (2012) used the Health Belief Model (HBM) to investigate the influence of
breastfeeding instruction on new moms. In a quasi-experimental case-control research, 88
participants were divided into two groups: control and experimental. During their prenatal
period, subjects in the experimental group were given a programme that included HBM-based
group instructions. The researchers created the data collecting method, which was then
standardised using the Dennis and Fox Breastfeeding Self-Efficacy Scale (BSES). Baseline
interviews were done prior to delivery, follow-up interviews 30 days and 4 months later. SPSS
(version 16) was used to conduct data analysis using c2, independent sample t-test, and paired t-
tests. The pregnant women in the research had a mean age of 22 ± 3.29 years. In terms of
knowledge, attitude, and self-efficacy at the program's conclusion, the experimental group
outperformed the control group statistically considerably. During the fourth month of life, there
was a significant difference in the mean baby weight between the experimental and control
groups (P = 0.001) as well as a significant difference in the exclusive breastfeeding rate (P =
0.007). This study demonstrated the effectiveness of HBM-based prenatal education by
increasing knowledge, attitudes, self-efficacy, and associated metrics. It is deemed imperative to
institute a uniform curriculum and health professional training for pregnant mothers, particularly
in the event of their first pregnancy.

Kabhenda (2006) analysed children's eating behaviour and nutritional status before implementing
an intervention to establish the effects of a nutrition education programme on carers' eating
habits and their young children's nutritional status. According to a cross-sectional baseline
survey, malnutrition is a public health issue at the research locations. Of the 204 children studied,
24.4% were stunted, 9.9% were underweight, 39.8% were anaemic, and 37.9% were vitamin A
deficient. Bananas were the most popular food, and beans were the best source of flavour and
protein. The children's diet had minimal diversity and was most likely insufficient to promote
optimal development. The intervention intended to influence carers' dietary preferences in order
to guarantee that young children received enough calories and nutrients. The intervention
involved two sets of caretakers and their children. A control group stitched for five weeks
concurrently with the carers in one group that received dietary training. For a year, the kids'
weights and measurements were taken each month. Participants in the intervention group
reported choosing a greater variety of grains, fats and sweets, legumes, meat, fruits, and
vegetables than those in the control group one month (2 times) and nine months (3 time) after the
intervention. The intervention group offered kids more snacks than the control group at Time 2
(mean: 1.26 vs. 0.35, p = 0.000) and Time 3 (mean: 1.22 vs. 0.58, p = 0.001), although there
were no changes in the number of meals. Additionally, the children in the intervention group
shown improvements in their vitamin A status (mean change in retinol binding protein
concentration = 0.24 μmol/l vs 0.04 μmol/l) and growth (mean weight for age: 0.61 ± 0.15
compared to 0.99 ± 0.16, p = 0.038).. The intervention proved effective in improving the
children's development and nutritional quality overall, as well as the caretakers' meal planning
and food selection practices. Gains in growth and nutritional status, however, could have been
jeopardized by the high frequency of illnesses, seasonal food shortages, and the severe pressure
on caretakers.
 III. MATERIAL AND METHODS
3.1. Design of the study

A community based randomized control trial will be used to conduct the entire research
study.

3.2. Study location

The entire research study will be carried out in different areas of district Kurram
3.3. Population
The study will consist of lactating mother with infants of 6 to 12 months
3.4. Sample size
The study will comprise of total 100 lactating mothers and their childrens
3.5. Research Questionnaire (tool)
To begin collecting information, a pre-planned questionnaire will be constructed.
3.6. Collection of data
Data will be gathered on socio-demographic variables, maternal and child anthropometric
parameters, health condition, feeding methods, and nutritional consumption.
a. Socio demographic data
Data regarding name of mother, age, number of children, family type,
residence, mother education, mother job status, father/husband job, monthly
income of the family will be collected
b. Anthropometric measurement of mother
Data on weight, height, waist, hip, waist to hip ratio, and body mass index will
be obtained.
Weight will be measured using a weighing machine. The reading will be
reported to the closest 0.1 kilogram
Height will be measured using a standiometer. The readings will be taken to
the closest 0.1 cm.
Waist and hip circumference will be measured using a measuring tape.
The waist to hip ratio will be found by dividing the waist circumference by the
hip circumference.
 Body mass index will be calculated by dividing weight (kg) by height (cm).
The Body mass index will be categorized into four categories.
Underweight= <18.5
Normal= 18.5 to 24.9
Overweight= 25.0 to 29.9
Obese= 30 or >30
c. Anthropometric measurement of infant
This portion of the questionnaire will consist of weight, height and weight
for height z score of the child
d. Health Status
This section of the questionnaire will consist of data regarding
hypertension, diabetes, heart problem, other non-communicable disease
and use of supplements.
e. Feeding practices
Data regarding different feeding practice including initiation of breast
feeding, exclusive feeding, duration of feeding, type of feeding and night
feeding will be collected
f. Dietary intake
Data regarding 24 hour dietary recall will be collected from all the
mothers. The subjects will be asked to remind all the food items they have
consumed in the last 24hrs
3.7. Research methodology
The enrolled participants will be divided into two groups of 50 participants each.
Group 1 will be given no nutrition education whereas group 2 will be given some
nutrition education at first meeting, then after 1 month including 3 consecutive
followed up. The anthropometric measurement and dietary intake data will also be
taken at baseline and after 3 months of follow up.
3.8. Ethical consideration and consent letter
To perform the complete research project, formal clearance will be required from
the board members of the Department of Human Nutrition at the University of
Agriculture. In addition, participants will sign a permission form indicating their
 desire to participate in the present study. The subject will also learn about the
study's goal and outcome.
3.9. Statistical analysis
The full data set will be gathered and put into SPSS (Statistical Package for Social
Science) Version 28 for statistical analysis. Descriptive statistics will be used to
the data to identify the means and frequencies of different variables, while one-
sided ANOVA, chi square test, independent t test, paired t test, and correlation test
will be used to evaluate the link between the variables.
 CONSORT FORM
Socio anthropometry Socio
feeding
demographic of child demographic
preactice
Group 1 no data
intervention
(n=50) health status of Anthropmetry
anthropometry of mother
of mother mother dietary intake

anthropometry
of child
Baseline
health status of
mother

feeding
practices

dietary intake
ENROLLMENT
(N=100)
Anthropometry
of mother

anthropometry
of child
After 60 days
feeding
practices

dietary intake
of mother
Group 2
intervention
(n=50)
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 APPENDIXES

A. SOCIO DEMOGRAPHIC DATA

1) Name: _________________
2) Age:__________________
3) Family type
a) Nuclear b) Joint
4) Husband education
a) Illiterate b) Middle c) Matriculate
d) Intermediate e) Graduate f) Post Graduate
5) Husband job
a) Government b) non government c) labor
6) Children’s
a) 1-3 b) 4-6 c) More than 6
7) Respondent educational level
a) Illiterate b) Middle c) Matriculate
d) Intermediate e) Graduate f) Post Graduate
8) Respondent status
a) Working Lady b) House wife
9) Income level
a) Less than 20000 b) 20000-35000 c) 35000-450000 d) More than 50000

ANTHROPOMETRIC MEASUREMENT

a. Weight (Kg)…………………………
b. Height (cm)…………………………..
c. Waist circumference……………………….
d. Hip Circumference……………..
e. Waist-to-hip ratio
f. BMI………………………………
ANTHROPOMETRIC MEASUREMENT OF CHILD
 a. Weight______________
b. Height _____________
c. Weight for height z score
FEEDING PRACTICE

1. Initiation of breastfeeding after birth

a. 1sthour b. 2nd hour c. 3rd hour d. late
2. frequency of breast feeding in a day
a. 1 hour b. 2 hour c. 3 hour d. on demand
3. Time of breast feed
a. 15 min b. 20 min c. 30 min d. more
4. Right breast used
a. 05 min b. 10 min c. 15 min d. 20 min
5. Left breast
a. 05 min b. 10 min c 15 min d. 20 min
6. Night feeding
a. Yes b. No.
7. Exclusive feeding
a. 3 months b. 4 months c. 6 months d. more then 6
TWENTY-FOUR-HOUR DIETARY RECALL METHOD

1. BREAKFAST

Food Portion Amount Carbohydrate Protein Fat Energy

size

2. SNACK

Food Portion Amount Carbohydrate Protein Fat Energy

size
 3. LUNCH

Food Portion Amount Carbohydrate Protein Fat Energy

size

4. SNACK

Food Portion Amount Carbohydrate Protein Fat Energy

size

5. DINNER

Food Portion Amount Carbohydrate Protein Fat Energy

size

6. BEDTIME

Food Portion Amount Carbohydrate Protein Fat Energy

size

HEALTH STATUS

Hypertension

a. Yes
b. No
Diabetes

a. Yes
b. No
Appetite

a. Yes
b. No
Heart problem

a. Yes
b. No
Other disease

a. Yes
b. No
Use of medicine

a. Yes
b. No