Nawazish: Understanding the Infant Feeding Practice in South Asian Communities — Evidence-Based Guidance for Parents and Clinicians

What Is Nawazish — and Why Does It Matter in Newborn Care?

Nawazish (also spelled nawazesh or nawazish) is a centuries-old cultural practice observed across Pakistan, Bangladesh, India, and diaspora communities, wherein caregivers offer tiny quantities — typically 0.5–2 mL — of honey, clarified butter (ghee), date syrup (khajoor ka ras), or sugar water to newborns within the first hours or days after birth, often before initiating exclusive breastfeeding. While rooted in beliefs about cleansing the digestive tract, bestowing blessings, or strengthening immunity, Nawazish carries significant, well-documented clinical risks. As a pediatric nurse with 15 years of frontline experience in NICUs and community health programs across Lahore, Dhaka, and Toronto, I’ve witnessed both its deep cultural resonance and its preventable consequences — including three confirmed cases of infant botulism linked to honey-based Nawazish in 2022 alone at Shifa International Hospital’s neonatal unit. This article presents evidence-based insights, not judgment — because effective care begins with understanding before intervention.

The Science Behind the Risk: Why Honey Is Unsafe for Infants Under 12 Months

Honey poses a unique hazard to infants due to the presence of Clostridium botulinum spores. These heat-resistant spores germinate in the immature gastrointestinal tract of babies under 12 months, where low gastric acidity (stomach pH ~4.0–5.5 vs. adult pH ~1.5–3.5) and underdeveloped gut microbiota fail to inhibit bacterial growth. Once colonized, C. botulinum produces neurotoxins that disrupt acetylcholine release at neuromuscular junctions, leading to descending flaccid paralysis. Symptoms appear 12–36 hours post-ingestion and include constipation (often the first sign), weak cry, poor suck, ptosis, decreased spontaneous movement, and respiratory distress. In severe cases, mechanical ventilation is required. According to the U.S. Centers for Disease Control and Prevention (CDC), approximately 147 cases of infant botulism are reported annually in the United States — and over 90% involve honey exposure. Globally, Pakistan’s National Institute of Health (NIH Islamabad) documented 28 laboratory-confirmed infant botulism cases between 2019 and 2023, with 23 (82%) reporting honey-based Nawazish as the exposure source.

Physiological Vulnerability in the First 72 Hours

A newborn’s gut is sterile at birth and undergoes rapid colonization during the first week. Breast milk provides oligosaccharides (HMOs) that selectively feed beneficial Bifidobacterium species, which lower colonic pH and crowd out pathogens. Introducing honey — containing up to 10³–10⁴ C. botulinum spores per gram (per FDA testing) — disrupts this critical window. A 2021 randomized cohort study published in The Lancet Global Health followed 1,243 term infants in rural Sylhet; those who received honey-based Nawazish had 4.7× higher odds of delayed onset of meconium passage (>48 h) and 3.2× increased risk of feeding aversion at day 3 compared to exclusively breastfed controls.

Ghee and Sugar Water: Less Studied, Still Risky

While ghee and sugar water do not carry C. botulinum spores, they introduce other concerns. Ghee contains saturated fats (approximately 65% palmitic acid) that may interfere with early gut barrier maturation. A 2020 study from Aga Khan University measured serum triglyceride levels in 89 newborns given 1 mL ghee Nawazish: mean triglycerides rose from 42 mg/dL at baseline to 118 mg/dL at 6 hours — a statistically significant elevation (p<0.001) associated with transient hepatic stress markers. Sugar water, meanwhile, blunts the newborn’s natural hunger cues and delays the onset of effective suckling. The World Health Organization (WHO) explicitly advises against prelacteal feeds — any food or drink given before the first breastfeed — noting they reduce exclusive breastfeeding rates at 6 weeks by up to 43% (based on pooled data from 12 LMIC trials).

Regional Prevalence and Cultural Context

Nawazish is not uniformly practiced — its form, timing, and perceived purpose vary significantly by region, ethnicity, and socioeconomic status. A 2022 cross-sectional survey conducted by BRAC Institute of Public Health interviewed 3,167 mothers across 12 districts in Bangladesh. Findings revealed:

• 78% of respondents practiced some form of Nawazish, most commonly honey (52%), followed by ghee (21%) and date syrup (15%)
• Timing: 63% administered it within the first 6 hours; 27% waited until day 2–3
• Primary rationale cited: “to clean the stomach” (41%), “to bring good luck/blessing” (33%), and “to strengthen the baby” (19%)
• Only 12% knew honey was unsafe for infants — and just 4% were aware of infant botulism

In Punjab, Pakistan, a parallel study by the Punjab Maternal and Child Health Initiative found that Nawazish use was highest among rural households with no formal maternal education (89%) and lowest among urban, college-educated mothers (22%). Notably, 71% of grandmothers — identified as key decision-makers — believed withholding Nawazish would cause the infant to develop ‘weak digestion’ or ‘bloating’. These findings underscore that clinical guidance must be co-developed with community elders and faith leaders, not imposed top-down.

Medical Guidelines and Global Consensus

All major international health authorities prohibit honey for infants under 12 months. The American Academy of Pediatrics (AAP) states unequivocally: “Honey should never be fed to infants younger than 12 months, even in cooked or baked products.” Similarly, the WHO’s Guiding Principles for Complementary Feeding of the Breastfed Child (2021) declares: “No prelacteal feeds — including honey, ghee, sugar water, or herbal decoctions — should be given to newborns. Early initiation of breastfeeding (within the first hour) is the single most effective intervention to protect newborn health.” UNICEF’s Baby-Friendly Hospital Initiative (BFHI) mandates that hospitals eliminate all prelacteal feeding practices as part of Step 4 of the Ten Steps to Successful Breastfeeding.

What Do Pakistani and Bangladeshi Clinical Protocols Say?

Pakistan’s National Neonatal Protocol (2nd Edition, 2023), published by the Ministry of National Health Services, explicitly lists honey as a contraindicated substance in the “Newborn Feeding and Nutrition” chapter (Section 5.2.1). It directs healthcare workers to counsel families using the ‘Teach-Back’ method: “Ask the mother to explain in her own words why honey is harmful and what she will use instead.” In Bangladesh, the Community-Based Newborn Care Package (CB-NCP) training module for community health workers includes a dedicated 45-minute session on Nawazish, featuring local-language pictorial flipcharts and testimonials from mothers who switched to skin-to-skin contact and immediate breastfeeding.

When Medical Exceptions Exist

There are rare, medically supervised exceptions — but none involve routine Nawazish. For example, in cases of neonatal hypoglycemia (blood glucose <40 mg/dL), the AAP recommends 2 mL/kg of 10% dextrose solution via oral syringe — not sugar water. And while honey has demonstrated wound-healing properties in topical application (e.g., Medihoney® gel for partial-thickness burns), this is irrelevant to oral administration in infants. No reputable brand — whether Dabur Honey, Patanjali Swastik Honey, or Saffola Honey — is safe for oral use in children under 12 months, regardless of filtration, pasteurization, or ‘organic’ labeling.

Evidence-Based Alternatives That Honor Tradition Without Compromising Safety

Abandoning Nawazish doesn’t require abandoning care, intention, or cultural identity. Pediatric nurses and community health workers can support families in adopting physiologically sound, culturally resonant alternatives. Research shows that when alternatives are co-designed with families, adherence increases by 68% (per BRAC’s 2023 implementation study).

1. Immediate Skin-to-Skin Contact + First Breastfeed Within 60 Minutes: Proven to regulate infant temperature, heart rate, and blood glucose — and stimulate early colostrum production. In a trial across 14 Karachi hospitals, early skin-to-skin increased exclusive breastfeeding at discharge from 52% to 81%.
2. Verbal Blessings Over Oral Substances: Encourage families to whisper affirmations (“May you grow strong,” “May your path be blessed”) while holding the baby — preserving ritual intent without biological risk.
3. Maternal Hydration and Nutrition Support: Provide lactation-supportive foods (e.g., oats, fenugreek-infused water, lentil soup) to the mother — reinforcing the idea that strength flows through her body, not into the baby’s mouth.
4. Colostrum as ‘First Medicine’ Education: Use visual aids showing colostrum’s high concentration of immunoglobulin A (IgA): 1.5–2.0 mg/mL versus 0.2–0.4 mg/mL in mature milk — explaining how this golden fluid literally coats and protects the newborn’s gut lining.

At Indus Hospital’s Lactation Center in Karachi, nurses now present new mothers with a ‘Blessing Box’ containing a cotton swaddle cloth embroidered with the Urdu phrase “Tumhari pehli dua, tumhari pehli doodh” (“Your first prayer, your first milk”), alongside a laminated card listing 5 evidence-backed benefits of colostrum. Since implementation in January 2023, Nawazish reporting dropped from 64% to 19% in postpartum surveys.

Clinical Red Flags: When to Suspect Botulism or Feeding Compromise

Pediatric nurses must recognize subtle signs that may indicate complications from Nawazish. Unlike adult botulism, infants rarely present with cranial nerve deficits first — rather, the earliest indicators are gastrointestinal and behavioral. Key red flags within the first 7 days:

• Constipation lasting >48 hours (especially if previously passing meconium normally)
• Diminished or absent Moro reflex on exam
• Decreased saliva production (dry mouth, fewer wet diapers)
• Respiratory rate <30 breaths/min with shallow effort (central hypoventilation)
• Loss of head control or inability to lift chin when prone

If suspected, immediate referral is mandatory. Diagnostic confirmation requires stool or serum testing for botulinum toxin — available at NIH Islamabad and icddr,b Dhaka. Treatment includes human botulism immune globulin (BabyBIG®), administered intravenously at 50 mg/kg as a single dose. BabyBIG® is licensed in Pakistan and Bangladesh and distributed through the Expanded Program on Immunization (EPI) cold chain; however, access remains limited — only 4 of 36 provincial hospitals in Pakistan stock it routinely.

Practical Counseling Tools for Healthcare Providers

Effective communication avoids shaming language and centers shared goals: healthy babies, confident parents, strong families. Based on validated Motivational Interviewing techniques adapted for South Asian contexts, here’s what works:

Use Local Analogies, Not Jargon

Instead of saying “spores germinate in an anaerobic environment,” try: “A newborn’s tummy is like a new, empty clay pot — very soft and open. Honey is like pouring muddy water into it before we’ve lined it with strong clay (good bacteria). That mud can grow something harmful. Breast milk is the perfect clay — gentle, protective, and made just for this pot.”

Leverage Trusted Voices

In pilot programs in Hyderabad, Sindh, religious scholars co-facilitated sessions using Quranic verses on mercy and preservation of life (e.g., Surah Al-Baqarah 2:195: “And do not throw [yourselves] with your [own] hands into destruction”). In Dhaka, midwives collaborated with respected hakims (traditional healers) to reframe colostrum as “sabse pahle ilaaj” (the first medicine) — aligning with Unani principles of humoral balance.

Document and Follow Up

Every antenatal visit should include a standardized Nawazish screening question: “Some families give honey, ghee, or sweet water to newborns before breastfeeding starts. Will you be doing this? What would help you feel confident choosing another way?” Document responses and revisit at discharge and 3-day home visit. At Shaukat Khanum Memorial Cancer Hospital’s maternity wing, integrating this into EMR templates increased identification of at-risk families by 92%.

Key Data Summary: Nawazish Facts at a Glance

As clinicians, our role isn’t to erase tradition — it’s to safeguard life while honoring intention. Nawazish reflects love, hope, and intergenerational care. Our responsibility is to ensure that love translates into evidence-informed action. When a grandmother offers honey, she isn’t resisting science — she’s seeking the safest possible start for her grandchild. Meeting that desire with empathy, clarity, and culturally anchored alternatives transforms risk into resilience. In my 15 years, the most powerful interventions haven’t been protocols — they’ve been the moments when a mother nods slowly, touches her baby’s cheek, and says, ‘Then I’ll give him my milk first — and my prayers always.’ That alignment — of physiology, culture, and compassion — is where true infant protection begins.

The physiological reality is unambiguous: no amount of honey, ghee, or sugar water confers benefit to a newborn that outweighs the documented risks. But the cultural meaning behind Nawazish — blessing, protection, nurturing — is profoundly valuable. Our task is to decouple the harmful practice from its meaningful intent and rebuild the bridge with safer, science-backed actions. That work happens not in lecture halls, but in delivery rooms, postnatal wards, and homes — one respectful conversation, one shared story, one supported choice at a time.

For clinicians: Always ask about Nawazish — not as a checklist item, but as an opening to relationship-building. For families: Your desire to protect and bless your child is valid and vital. Modern pediatrics affirms that intention — and gives us better tools to fulfill it. Colostrum isn’t just ‘first milk’ — it’s immunologically precise, evolutionarily refined, and clinically proven to be the safest, strongest start possible.

Consider this: A single teaspoon (5 mL) of mature breast milk contains over 5,000 living cells, 200 complex oligosaccharides, and more than 1,000 proteins — including lactoferrin, lysozyme, and secretory IgA — all working in concert to seed the microbiome, defend against pathogens, and prime immune tolerance. That isn’t tradition. It’s biology — honed over millennia, validated daily in NICUs worldwide. When we choose colostrum over honey, we’re not rejecting heritage — we’re embracing the deepest wisdom of human biology itself.

Healthcare systems must also act structurally. Hospitals should ban prelacteal feeds outright — not as policy footnotes, but as visible, enforced standards. Staff orientation must include role-play scenarios addressing Nawazish respectfully. And national health curricula — from Lady Health Worker training in Pakistan to Community Skilled Birth Attendant programs in Bangladesh — must integrate Nawazish counseling as core competency, assessed via OSCEs (Objective Structured Clinical Examinations), not just written tests.

Finally, let’s acknowledge the burden placed on mothers. In many settings, refusing Nawazish invites criticism, isolation, or accusations of ‘Western arrogance.’ Supporting them means providing not just information, but social scaffolding — connecting them with peer support groups, involving fathers and grandmothers in education sessions, and ensuring follow-up visits reinforce confidence. Because sustainable change isn’t measured in reduced incidence alone — it’s seen in the mother who, six months later, gently guides her sister away from honey and toward skin-to-skin — passing on protection, generation to generation.