Neonatal care

The care of a newborn is termed as “Navajata shishu paricharya” in Ayurveda. ‘Navajata shishu’ is a newborn baby, and ‘paricharya’ indicates the care and necessary management protocols.The atmosphere and surroundings change from intrauterine dependent life to independent external life after birth.The child has to adapt to the new changes quickly. It is essential to take care of newborns until the body systems are well adopted and developed to survive in the new world. Ayurveda classical texts include the methods and practices followed for newborn care in ancient times.The ancient practices include use of available natural resources. Hence, they can be practiced with cost effectiveness and least medical equipments.Though the principles of care are same, the contemporary practices have changed significantly with advances in medical technology.This article deals with the analysis of these practices along with their contemporary views.

Care of healthy newborn

A normal newborn is born at term with birth weight between 2,500 g and 3500 g, without any breathing difficulty, major congenital malformations, or any birth injuries. The goals of neonatal care in all medical systems are uniform: a) Ensure successful transition from fetal to neonatal life. b) Initiate and accustom the child to external stimuli of all kinds. c) Clean the oral cavity of the child to clear the airway (wiping, anointing). d) Maintain the body temperature of the newborn. e) Proper and hygienic clamping and severing of umbilical cord. f) Ensure earliest possible initiation of breastfeeding.

Immediate care of newborn

In the classical literature of Ayurveda, the immediate procedures similar to resuscitation methods are described as the measures to re-establish and maintain vital energy (prana). It is recommended for every newborn irrespective of their vital status at the time of birth. [Cha.Sa. Sharira Sthana 8/42]. In contemporary views, if the baby is born at full term with a good tone and normal respiration (or healthy cry), only routine care needs to be given. The baby is to be kept dry, warm, and with airways clear. If, the baby does not satisfy the criteria of term tone and breathing, he/she has to be in the the warmer area and subjected to a neonatal resuscitation algorithm.

Ancient resuscitation measures (prana pratyagamana vidhi)

The principle behind these procedures is the stimulation of sense organs. The activation of the brain centers through sensory stimuli to initiate motor activity, especially breathing. Rubbing stones at the base of the ears is the first step in immediate care. [Cha. Sa. Sharira Sthana 8/42] Hymns to be uttered in the right ear of the neonate are also mentioned. [A. Hr. Uttara Sthana 1/3]. These are the forms of auditory stimuli. Sprinkling or washing the face with cold or hot water in accordance with the climate; (i.e., cold water is for hot climate and hot water for cold climate) is advised. Fanning the child using a fan made of straw, grass, and bamboo is also recommended. [Cha. Sa. Sharira Sthana 8/42]. Pouring of lukewarm medicated oil ‘Bala taila’ followed by gentle massage is performed to relieve the stress caused by labor. [Su. Sa. Sharira Sthana 10/12], [A.Hr. Uttara Sthana 1/1] These can be considered measures to generate tactile stimuli and maintain proper thermo-regulation. They also resist the contact of the umbilical stump with water, hence reducing the possibility of microbial overgrowth. Rubbing stones on the base of the ears and sprinkling water on the face is expected to stimulate the vestibulocochlear nerve and facial nerve. These procedures are to be done till the child starts breathing independently.

Cleaning of channels and orifices

Once the child starts breathing properly, cleaning the external orifices and bathing of the child is to be done. Cleaning of the orifices is done by wiping with cotton wrapped around the fingers. The nails of the caretaker shall be trimmed to prevent any skin injury to the newborn. While cleaning the oral cavity, the direction shall be from palate to lips. Then the buccal cavity shall be cleaned from throat to tongue. [Cha.Sa.Sharira Sthana 8/42] In modern pediatric practice, the cleaning of the airway is done by inserting a laryngoscope. Clearing the mouth and posterior pharynx is done by using a suction catheter under direct vision in case of visible obstruction of the airway of the neonate with respiratory distress syndrome. The patency of these orifices and the presence of any congenital abnormality are also examined while cleaning.

Therapeutic emesis

Administration of ghee mixed with rock salt to induce emesis is recommended. [Cha. Sa. Sharira Sthana 8/43]. This emesis is targeted to eliminate accidentally swallowed or aspirated amniotic fluid, especially meconium-stained (ulba). Currently, this procedure is not generally practiced. In the case of meconium aspiration, it is recovered by slow suction by a suction device connected with the endotracheal tube inserted into the trachea.

Application of oil on head (shiro pichu)

Application of cotton soaked in ghee or medicated oil with Sida cordifolia (bala) over the vertex of the newborn is practiced. [Su. Sa. Sharira Sthana 10/12] The covering of anterior fontanels (where there could be open intracranial sutures at birth) using oil or ghee smeared tampons act as a protective mechanism to the open sutures. It also optimizes the heat regulation mechanism. At this point, examination of fontanels is also performed.

Cutting of umbilical cord

The time of cutting and clamping the umbilical cord is crucial for the health of the newborn. In Ayurveda, cutting of the umbilical cord is recommended only after the baby become stable in the external environment. [ A.Hr. Uttara Sthana 1/5-6] World Health Organization recommends delayed umbilical cord clamping i.e., at least one minute after birth for better health and nutritional outcomes of the mother as well as the baby. The cord is cut at a point 16 cm (eight angulas) away from the umbilicus. The cord is held gently and firmly on both sides of the point and carefully cut using scissors (ardhadhara) made up of gold, silver, iron, or similar metals. The proximal end of the cut umbilical cord is tied with a thread, and the other end of the thread should be tied loosely around the neck of the child. [Cha. Sa. Sharira Sthana 8/44] Tying a knot on the cord using a thread before cutting, and then attaching it to the neck after cutting the cord, is also desirable.[Su. Sa. Sharira Sthana 10/12], [A.Hr. Uttara Sthana 1/5-6] Now a days, umbilical cord clamp is used for this purpose. In modern obstetrical practices, early clamping and cutting of the umbilical cord was a practiced as a part of active management of third stage of labour. But recent studies suggest that it may be harmful to the baby. Delayed clamping helps in reducing incidence of anaemia, intraventricular haemorrhage, and the need for transfusion for hypovolaemia and anaemia, except in the case of growth restricted babies who are already at risk of hypoxia induced polycythaemia.

Diseases due to improper cutting of the umbilical cord

Due to improper handling of the umbilical cord, abnormal conditions of cord stump are described. • Vertically swollen (ayama uttundita) • Horizontally swollen (vyayama uttundita) • Combination of both (ayama vyayama Uttundita) • Formation of circular mass or ring around the umbilicus (pindalika) • Swollen at margins and depressed at centre (vinamika) • Undue and prolonged increase in size (vijrmbhika) [Cha.Sa. Sharira Sthana 8/61] When the umbilicus becomes inflated due to vata dosha, the condition is known as “nabhitundi”. [A.S.Uttara Sthana 2/51] There are other conditions wherein the umbilicus gets suppurated (nabhipaka), umbilical edema (nabhishotha), raised umbilicus (unnata nabhi), depressed umbilicus (anunnata nabhi), etc. Management: • Dusting (avachoornana) with powdered drugs or ash of goat manure. • Anointment (lepana) of thick paste of medicines along with jiggery. • Pouring (parisheka) of the decoction or oil processed with Glycyrrhiza glabra Linn (yasti), Symplocos racemosa (lodhra), Curcuma longa (nisha), and Panicum frumentaceum (shyamaka) or dusting using the powder made out of the same drugs is done as per the clinical condition of umbilicus. • In nabhitundi, vata alleviating measures like oleation (sneha), sudation (sweda), application of poultice(upanaha) should be done. • A combination of Symplocos racemosa (Lodhra), Glycrrhiza glabra (Madhuka), Aglaia elaeagnoidea (Priyangu), Cedrus deodara (Suradaru), and Curcuma longa (Haridra) shall be used as a powder for dusting and oil made of their pastes shall be used for pouring. General measures to alleviate vata and pitta are to be administered in cases of diseases due to improper cutting of the umbilical cord. [A.S.Uttara Sthana 2/51] In modern practices also, the umbilical cord is maintained clean and dry. Spirit is used for cleaning. No local antiseptics are used as routine care. The stump falls off in 7 to 10 days. Neonatal omphalitis, umbilical hernia, umbilical granuloma, umbilical polyp, umbilical cyst, etc. are common disorders of the umbilicus.

Examination of newborn baby

Ayurveda recommends the examination of the newborn for the signs indicative of life span. Specific features of different body parts are given. These indicate good health and life span. [Cha. Sa. Sharira Sthana 8/51] It is given in the table below. Sl No. Organ Signs of good life span 1. Hair Soft, sparse, unctuous, deep-rooted, black 2. Skin Thick and dense 3. Head As per one’s constitution, slightly bigger than normal, proportionate to other parts, umbrella-shaped. 4. Forehead Compact, even, well aligned to the temples, having three lines transversely laid, semilunar shaped 5. Ears Thick, large, lobes even on height, equal in size, elongated downwards, bent backward 6. Eyebrows Hanging a bit, optimally separated, compactly arranged, large 7. Eyes Equally sized, with stable sight, well divided into sclera, cornea, etc., radiant, with beautiful outer canthi. 8. Nose Straight, no difficulty in taking deep breath, well septate, slightly lowering at the tip 9. Mouth Large, straight, with properly arranged gums, 10. Tongue Of appropriate dimensions, smooth, soft, and of color matching one’s constitution. 11. Palate Smooth, well-formed, warm to touch, reddish. 12. Voice Loud, not weak, not dry, resonant, sounding intense and brave. 13. Lips Of optimal size and dimensions, covering the mouth well, red. 14. Jaws Large 15. Neck Round, not too large 16. Chest Compact, well formed 17. Clavicle and Vertebral column Situated deep inside (not prominent) 18. Breasts Well separated 19. Flanks Even, firm 20. Arms, thighs, fingers Round, full and extended 21. Hands and Legs Large, well formed 22. Nails Firm, round, unctuous, copper-colored, elevated, tortoise-shaped. 23. Umbilicus Whirled clockwise , deep 24. Waist One-third thinner than chest (circumference), compact with muscles 25. Buttocks Rounded, firm and plump muscles, not too elevated or depressed 26. Thighs Rounded, well formed 27. Calf region Not too broad or thin, resembles that of a deer, vessels and joints well covered 28. Ankles Not too broad or thin 29. Feet Not too broad or thin, Tortoise-shaped Other than these signs, the child with the proper evacuation of flatus, urine, feces, normal genitalia, sleep, waking, expression of tiredness, smiling, crying, sucking (breasts) in concordance with one’s constitution, is indicative of long life span.[Cha. Sa. Sharira Sthana 8/51] By the examination, the early detection of any congenital structural abnormality shall be assured. As per modern view also, examination of the newborn is performed in terms of various parameters. Normal features in newborn Anthropometry Parameter Average value Birth weight 3.35 kg (male) , 3.25 kg (female) Length 49.9 cm (male) , 49.1 cm (female) Body Mass index 13.4 kg/ m2 (male) 13.3 kg/m2 (female) Head circumference 34.5 cm (male) 33.9 cm (female) Chest circumference 2 to 3 cm less than head circumference

Vital parameters Vital parameters Range Respiratory rate 40 – 60/min, Periodic breathing Heart rate 120 – 160/min Blood pressure 40 - 60/ 25 – 40 mm Hg

Urine and Stool Passage First urine is usually passed within 48 hours after birth. Delay of urine passage without abdominal distension is probably due to inadequate feeding. Bladder distension in male child indicates posterior urethral valve. The stool is normally passed within 24 hours. If there is constipation, the probable cause behind it should be identified. The major causes are, imperforate anus, prematurity, meconium plug, megacolon (congenital), meconium ileus and hypothyroidism.

General care of the newborn

Ayurveda explains the care of new born through medical interventions combined with some spiritual practices. These measures promote spiritual health along with physical health. It includes the birth rites (jatakarma), oil massage and bathing of the newborn, breastfeeding and protecting the child from unfavorable external factors. These are initiated on the first day itself, and the procedures are continued as a daily routine for a certain period.

Birth rites (jatakarma)

Initially, the neonate shall be fed with ghee and honey and the chanting of Vedic hymns. [Cha. Sa. Sharira Shana 8/46]. Acharya Sushruta advises the addition of gold to the above mixture. [Su. Sa. Sharira Sthana 10/ 13]. Research works are being conducted on the topic of the administration of gold-containing medicines (“swarnaprashan”) to the neonates. Many clinical trials have shown its efficacy in improving the baby's immunity. A clinical trial was conducted in 102 infants to analyze the effects of gold nanoparticles (swarna bhasma) administered with ghee and honey compared to plain ghee and honey (ratio 1:4). The number of drops of medicine administered was equal to the age of the infant in months. The quantity of gold in the drops (in milligrams) was 0.2 times the age in months. The drops were administered for 4 weeks. No adverse drug reactions were observed. Even though both the groups showed considerable improvement in immunological parameters, there was significant normalization of immunoglobin G in the group administered with gold compared to the other group. An earthen pot filled with water is recommended to be placed near the head of the neonate. [Cha. Sa. Sharira Sthana 8/46] It was considered as auspicious during the ancient times.Its therapeutic effect in thermoregulation or in any means is a topic of evaluation by further research. In neonates who have undergone perinatal asphyxia, therapeutic hypothermia of the scalp via cooling caps, if induced as early as possible, prevents further damage to brain and neurons. The procedure of placing the water-filled pot near the head of the baby might be a precursor of the same.

Oil massage (abhyanga)

It is recommended to apply the oil processed with herbs like Sida cordifolia (bala taila) and gently massage the neonate. [Su. Sa. Sharira Sthana 10/13] The process of oil application followed by massage on neonate (abhyanga) has been reported to be effective in gaining weight, reducing pain, enhancing immunity and accelerating healthy growth and development. Neonatal massage is a genre of external therapy that has been widely discussed. There are internationally acclaimed methods and procedures for the procedure. Neonatal massage has been proved to improve weight gain, optimize energy and stress levels and has reduced the risk of mortality and infection. Recently, home-based infant massage protocols based on the consensus of various medical streams have also emerged.

Bathing (snana)

Bathing of the baby is advised to be performed using, the decoction of the bark of the five milky trees (Kshiri Vriksha), [namely Ficus bengalensis (Vata), Ficus glomerata (Udumbara), Ficus religiosa (Ashvattha), Thespesia populina (Parisha), and Ficus lacor (Plaksha)], and other fragrant drugs. The decoction of Limonia acidissima (Kapittha), mildly heated by dipping heated gold and silver. [ Su. Sa. Sutra Sthana 10/13], [ A. Hr. Uttara Sthana 1/6] Recent studies regarding bathing the newborns opine that delaying the bath by 48 hours (from birth) was effective in preserving the body temperature of the infant. The apt technique to bath neonates is swaddled bath, which has been found better in maintaining body temperature. The temperature of water in which the baby is to be bathed is recommended to be kept just above the body temperature, around 37 to 38 degree Celsius. The cleansing agents used in infants while bathing influence the skin mostly by altering the pH level. The pH of a term neonate ranges from 6.3 to 7.5, falling to 5 by 2 weeks and is maintained below 5 throughout adolescence and adulthood. The acidic pH of skin is crucial in its barrier mechanism, repair processes, etc. Hence it is recommended that the pH of the soaps should be around 5.5. In a study, bar soaps were found to have higher pH levels than liquids and synthetic detergents (syndets), which showed the ideal pH level (acidic and close to neutral).

pH of baby shampoos is seen to be around 6.0 to 7.0. This is because there is a need to reduce ocular irritation and excessive lacrimation in infants resulting from the acidic pH of shampoo. This is called the “no tear concept”.  Despite these observations, there are no international standards set in these respects.

Breast feeding (Stanapana)

In neonates, breastfeeding shall be initiated as early as possible because it is the most potential and suitable source of nutrients. It should be done as part of birth rites (jatakarma) on the first day itself. The right breast is recommended to be introduced first for suckling. [Cha. Sa. Sharira Sthana 8/46]. Its relevance is yet to be explored using scientific studies. In cases where breast milk production is delayed due to strenuous labor, a schedule has been recommended for alternatives of breastfeeding. • On the first day, the child is to be fed with gold or Cynodon dactylon (durva), along with honey and ghee, twice. • The second and the third day, ghee medicated with Ipomoea sepiaria (Lakshmana) is given. • On the fourth day, the child is to be breastfed with the administration of butter or honey-ghee mixture. • From the fifth day, normal routine feeding shall be initiated. [Su.Sa. Sutra Sthana 10/14-15] If insufficiency of breast milk is noted, two wet nurses shall be entrusted. Feeding the child from breast of more than two ladies is also not recommended. [A.Hr. Uttara Sthana 1/16] Cow’s milk and goat’s milk are recommended in the absence of breast milk. The milk is recommended to be processed with drugs like Solanum indicum, Solanum xanthocarpum, Desmodium gangeticum, Uraria picta, and Tribulus terrestris. [A.Hr. Uttara Sthana 1/20] As per the current view, breastfeeding must be started soon after the birth, and exclusive breastfeeding is to be continued up to 6 months. For the first few weeks, the baby shall be fed 7 to 8 times a day. A newborn normally loses weight up to 10% in the first week and regains its birth weight by the 10th day. But the loss of weight above 10% in first 4 days indicates either poor feeding or illness of the baby. With higher content of lactose, whey and lactalbumin, lower solute load, and osmolality compared to that of animal milk, human milk stands the best choice of diet for babies, at least up to 6 months. The substitution of breast milk with animal milk or formulas based on them is not recommended unless the situation demands. In such cases, goat milk or cow milk-based formula or liquid milk shall be provided. Goat milk-based infant formulae have been found to be resembling human milk than those of cow milk . All the substitutes for breast milk, their production, distribution, advertising, etc. are governed by the Infant Milk Substitutes Act 1992.

Protective measures

There are various methods that were practiced in ancient times to protect the neonate from surrounding morbidity-causing factors. 1. Placing branches of the following trees around the maternity home: - Acacia catechu (khadira), Zyzyphus nummularia (karkandhu), Salvadora persica (pilu), and Grewia asiatica (parushaka). 2. Grains of Brassica juncea (sarshapa), Linum usitatissimum (atasi), and rice are strewn around the place where the newborn baby is kept. 3. A ritual of offering rice to the fire (tandula balihoma) , is done twice daily till the day of naming ceremony (usually the 10th day). 4. A club or pestle is placed along the lower wooden beam of the door frame. 5. Medicines like Acorus calamus (vacha), Saussurea lappa (kushta), Ferula asafetida (hingu), Brassica juncea (sarshapa), Linum usitatissimum (atasi), and Allium sativum (lashuna) and other drugs that are capable of eliminating the surrounding morbidity factors (rakshoghna) are to be tied inside a cloth packet and suspended down from the upper beam of the door frame. 6. These packets are worn by the mother and child on their necks. 7. They are also kept along with cooking vessels, water pots, couches, etc. 8. Inside the maternity home, there is a constant fire that arises from burning medicinal plants like Diospyros peregrina (Tinduka). 9. Female attendants who have the experience of raising multiple children, who are friendly, compassionate, devoted, devoid of grief, capable of handling stress, and friends and relatives are to stay awake in the nights up to 10 to 12 days. 10. The house is filled with pleasant people and hymns of Atharva Veda (hymns are to be chanted twice a day in the maternity home). [Su.Sa. Sutra Sthana 10/23] Maintaining strict asepsis in the nursery is critically important. Many of the infections in neonates, especially bacterial, can be prevented by strict monitoring of asepsis. Among the aseptic measures, hand washing before entering the nursery and after touching each neonate is most important. Housekeeping practices like vacuum cleaning (for dust removal), wet mopping using 3% phenol solution, disinfection practices in adherence with the recommendations, use of sterile equipment, fumigation using 40% formalin, proper biomedical waste management, and regular surveillance of bacterial flora are pivotal in the management of nursery.

Recommendations for the neonatal care unit or child nursery

• Constructed by an expert in architecture (vastuvidya ) • Attractive • Devoid of darkness • Protected from excessive air entry • Firm • Safe from attack of animals. • Well compartmentalized into areas for water storage, grinding, lavatory, bathroom and kitchen. • Fitting all the season • Bed, seats, mats, etc. set in accordance with the respective season. The house shall be well protected, and the prerequisite rituals are conducted. Hygiene and availability of medical service also must be ensured [Cha. Sa. Sharira Sthana 8/60]

Recommendations regarding the bed and fabrics used for the child

Beds, seats, sheets, and clothes used for the child should be soft, light, clean and pleasant-smelling. Once contaminated with sweat, excreta, germs, urine and feces, these must be discarded or cleaned, dried and fumigated and then reused. The drugs usable for fumigation include Hordeum vulgare (yava), Brassica juncea (sarshapa), Linum usitatissimum (atasi), Ferula asafetida (hingu), Commiphora mukul (guggulu,), Acorus calamus (vacha), Angelica glauca (choraka), Bacopa monnieri (brahmi), Nardostachos jatamamsi (Jatamamsi), Saraca asoca (ashoka), Picrorhiza kurroa (rohini), and slough of snake mixed with ghee. [Cha. Sa. Sharira Sthana 8/61] The drugs that are mentioned for fumigation and preventing infection have antimicrobial action (especially against Staphylococcus aureus) in vitro.

Wearing of amulets

Amulets made from pearls and other jewels end of right horns of rhinoceros, deer, or bull, drugs which have the property of promoting the growth of the child (prajasthapana).eg- Bacopa monnieri (aindri) are advised to be worn. [Cha. Sa. Sharira Sthana 8/62] Any scientific explanation regarding the action of talismans and amulets is not available. Even though it has been made an object of study in various research works. It is considered to be an element indicating emotional and psychological support. The concept of evil eye and measures to fend it off are prevalent in various forms all over the globe. Even these spiritual tools shall be used with caution as they are also not completely free from adverse reactions, for instance some amulets have been identified to be potential chemical toxins (especially lead).

Recommendations for selection of toys

Toys for the baby must be diverse, sound-producing, attractive, light, devoid of sharp edges, non-swallowable, non-dangerous, non-frightening. [Cha. Sa. Sharira Sthana 8/63] In those times, if the physical attributes of the toys were the primary area of concern, today, chemical aspects also are to be taken care. Phthalates, lead, and cadmium used in soft plastic or PVC toys, button batteries, and several other chemicals have posed dangerous threats to children. Cancer, kidney and reproductive dysfunction, and intellectual disabilities are the major diseases associated with these chemicals. Most countries have safety regulations for toys. The toys also play a pivotal role in the child's development in all domains of creativity, intellect, problem-solving ability, and social behavior. Toys are to be judiciously selected, specifically according to the need of the child. According to the utility, toys are of five categories: i. Symbolic and/or pretending (cooking set, doctor set, doll, car) ii. Fine motor, adaptive, manipulative (blocks, jigsaw, shapes, puzzles) iii. Art (music instruments, clay, coloring) iv. Language, concepts (letter scrabbles, letter toys, number games, board games, cards) v. Gross motor (Tricycles, push and pull toys, large toy cars, etc.) It is also important that the toys improve the interactions between the child and his caregivers, peers, and parents. Obesity, aggression, and poor social interactions are often observed as consequences of excessive indulgence in electronic toys and games).

Approach to an unhealthy newborn

The guidelines for the management of an unhealthy neonate are as follows. . If a neonate is ill, the following is to be considered in him/her: - Genetic constitution on the basis of doshas (prakriti) - Probable etiology - Prodromal symptoms, if any - Clinical features - Aggravating and relieving factors - Geographical influences - Climatic influences - Site of origin and manifestation of the disease. [Cha. Sa. Sharira Sthana 8/64]

Evaluating a sick newborn

A history comprising the age of neonate, antenatal and intrapartum events, delivery mode, Apgar score, neonatal resuscitation, feeding history, disease history is to be taken primarily. There are various scales that are used in neonatology: i. Apgar Score : Apgar score is one of the most initial and relevant scores used in neonatology. It is primarily used to assess the basic condition of the child at birth. ii. Downe’s score : The score and Silverman and Anderson score are used to assess respiratory distress in neonates. iii. New Ballard’s score : This score calculates the gestational age of the child under two broad headings, physical and neuromuscular maturity. iv. Sarnat & Sarnat staging , Levene staging : Hypoxic-ischemic encephalopathy (HIE) is caused due to hypoxemia and/ or reduced cerebral blood flow due to a peripartum event. It is one of the significant causes of mortality and long-term morbidity in neonates. These two scales are used to stage HIE. v. CRIB score : Clinical Risk Index for Babies score is a UK based score that takes into consideration the birth weight, gestational age, congenital malformations, maximum base excess in the first 12 hours, and the minimum and maximum levels of inspired oxygen in the first 12 hours for evaluating the risk of mortality amongst low birth weight babies. It has been recently updated to CRIB II. vi. SNAP score : The score for Acute Neonatal physiology was a USA-based score for assessing mortality and morbidity risk in a neonatal ICU. It considered 26 factors, which was simplified in its further generations, now in the form SNAPPE II (SNAP with Perinatal Extension II) considering six major factors.

Diseases of the newborn

There are a few diseases of newborn and their management protocols mentioned in classical texts of Ayurveda.

Fetal aspiration syndrome (ulbaka)

Due to insufficient clearing of amniotic fluid or the mucus in the throat, the nutrient fluid derived from the consumed food gets vitiation due to interaction with them. This leads to the fainting of the child with clenched fists. The child also gets afflicted by various other diseases like heart diseases, convulsions, dyspnea, cough, vomiting and fever. It is called ulbaka or ambupurna. [A.S.Uttara Sthana 2/52] Management: After immediate neonatal resuscitation, the disease should be treated with principles of purification of channels (srotoshodhana) followed by palliative therapy (shamana chikitsa) Daily administration of goat’s urine is recommended in this condition. It is not practiced currently. Oil massage and bathing are strictly contraindicated. A medicated ghee preparation namely “Billvadi gritam” is indicated in this condition. [A.S.Uttara Sthana 2/52] Meconium aspiration syndrome The fetus passes meconium (greenish to brownish black thick secretion containing gastric contents), which may be aspirated in utero, during birth, or after birth known as “Meconium aspiration syndrome”. The meconium that has been breathed in, due to its mechanical properties, result in trapping of air inside the alveoli, and with irritant nature and toxicity, causes the inflammation of lung parenchyma, deactivation or wash-out of the surfactant and pulmonary hypertension leading to further complications. The clinical features of the condition include apnea leading to respiratory distress, suprasternal, substernal and intercostal retractions, grunting, emphysema, atelectasis, and consolidation. The management of MAS includes stomach wash, oxygen supply, thermoneutral environment, and symptomatic management. Continuous positive airway pressure, specific antibiotics, inhaled nitric oxide, and surfactant therapy constitute other therapeutic considerations.

Swelling on head ( upashirshaka)

The vata dosha gets vitiated in the skull of the fetus, leading to the formation of edema with color similar to the body, without pain. This condition is called Upashirshaka. [A. Hr. Uttara Sthana 23/21] Management: The management protocol is the same as disorders of vata(vatavyadhi).Keeping the cotton soaked with oil on the scalp(shiropichu)and application of oil preparation called “bala taila” are mentioned in the standard regimen. If the swelling is not subsiding with these measures, the line of treatment of abscess(vidradhi) may be adopted. [ A. Hr. Uttara Sthana 22/19-20] Caput succedaneum and cephalhematoma These two are the main clinical conditions that resemble upashirshaka. They shall be differentiated as follows: Feature Caput succedaneum Cephalhematoma Onset Birth After 2-3 days of birth Site Soft tissue of scalp Sub-periosteum Feature of swelling Pitting, non-fluctuant, diffuse, not separated by sutures. Non-pitting, fluctuating, separated by sutures. Associated features Ecchymosis over face in face or brow presentation Rarely associated with linear fracture of skull Time taken to resolve Few days Few days to few weeks Extent of resolution Spontaneous and complete Spontaneous, very rarely leaves elevated margins and calcifications. Intervention Not needed Incision or aspiration in case of infection or hyperbilirubinemia.

Diaper rash (gudakuttaka)

Due to increased sweating or adhesion of feces to the anal region, coppery-colored lesion associated with itching occurs. Gudakutta in Ayurveda is also popular by other names Matrkadosha, Ahiputana, Anamika (Diaper rash or diaper dermatitis). [A. Hr. Uttara Sthana 2/69-70] Management: • Purification of mother’s breast milk with drugs having the property of alleviating pitta and kapha • cold decoction of Santalum album(chandana) is administered • Lepana with collyrium, honey and Santalum album (chandana) • Pouring of decoction of Emblica officinalis (Amalaki), Terminalia bellerica (Bibhitaki), Terminalia chebula (Haritaki, Ziziphus mauritiana (badari), and Ficus lacor Ham. (plaksha) • Dusting of fine powder of Glycyrrhiza glabra Linn(yasti), conch(shankha) and collyrium (sauveeranjanam) • Leech therapy (raktamoshana using jaloka) in cases of redness and itching. [ A.Hr. Uttara Sthana 2/71-75] Diaper dermatitis is contact eczema that results from the cumulative effect of hyperhydration of the stratum corneum due to the stagnation of urine and feces within the diaper. The friction of the diaper on the skin leads to inflammation, skin barrier dysfunction and increased vulnerability to infections. Maceration of skin, fungal infection, etc. are also seen contributive to diaper rash. It is managed by educating the parents about diaper related hygiene and topical medications like Zinc Oxide, petrolatum, Aquaphor or rarely topical steroids. Some other diseases and symptoms mentioned in Ayurveda classics, prevalent in neonates and infants are: • Palatal disorders like palatine polyps (talukantaka) • Diseases associated with cranium and sutures (mastulungakshaya and symptom of talukantaka) • Born with teeth(sadantajanma) • Diabetes mellitus type I (Jataprameha) • Congenital hemorrhoids (Sahajarshas) • Malnutrition related disorders (Phakka, Kumarashosha, Parigarbhika) • Dermatological disorders (Balavisarpa, Mahapadma, Paridagdhacchavi) Repeated vomiting of breast milk Diseases arising due to consumption of vitiated breast milk (Ksheeralasaka, Kumarashosha) Affliction by evil forces named Grahas is described. These conditions are similar to the present-day infections and developmental disorders due to birth trauma and other perinatal factors.

General principles of management of diseases in newborns and children

The pathophysiological factors of diseases in the infant are the same as that in an adult., The difference is that body components in the infant are very immature..[ A.Hr. Uttara Sthana 1/30-31] Hence, there are restrictions in administering medicines and therapeutic procedures in children. The nature of medicines used in children must be decided after considering the following factors: - Lower doses - Sweet in taste - Soft - Light to digest - Pleasant smelling - Cool (not too hot or pungent) - Auspicious In the medium of milk [Cha. Sa. Chikitsa Sthana 30/285] In case of medicines to be given orally in infants, the mother's breasts shall be anointed with the paste of the medicines and given to the child for sucking.

Thesis Works done

1. M. S. Kamath (1981) , “Response of Madhu and Ghrita in New born”, I.P.G.T. &R.A., Jamnagar 2. Amruta Gaikwad, (2011) “A Comparative Pharmaco-Clinical study of the effect of Madhu-Ghrita and Swarna-Vacha-Madhu-Ghrita on Neonates”, I.P.G.T. &R.A.,Jamnagar. 3. Sital S Desai (2011), “Effect of Suvarnaamritaprashana in recurrent attacks of kasa”,RGUHS, Bangalore. 4. Aniket Patil (2012), “To Clinically Evaluate the effect of Suvarna binduprashan on immunity and intelligence quotient”,BMK Ayurveda Mahavidhyalaya,KLE,Belgaum. 5. Vinamra Sharma (2012), “Toxicity study of Suvarna Binduprashana in albino rats”,KLE, Belgaum. 6. Anupriya (2013), “Safety and efficacy study of Swarna Prashana drops prepared from Swarna Bhasma and Swarna Lavana” (Dept of RSBK), I.P.G.T.&R.A.,Jamnagar. 7.Jyothy.KB, (2013), “A Randomized Controlled Clinical Trial on Swarna Prashana in infants w.s.r. to its immunomodulatory activity”, I.P.G.T. &R.A., Jamnagar. 8.Singh Kumari Poonam(2016): A Randomized Controlled Clinical Trial On Swarna Prashana And Its Immunomodulatory Activity in neonates, Department of Kaumarabhritya,IPGT &RA, Jamnagar.

Related Chapters

Jatisutriya Sharira

Abbreviations

• Sa. = Samhita • Cha. = Charak • Su. = Sushruta • A. = Ashtanga • Hr. = Hridaya • S. = Sangraha

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