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EFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OF CHILDREN DURING COMPLEMENTARY FEEDING - LEKSHMI M.K, DEPT. OF KAUMARABHRITYA, GOVERNMENT AYURVEDA COLLEGE, THIRUVANANTHAPURAM, KERALA

EFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OF CHILDREN DURING COMPLEMENTARY FEEDING - LEKSHMI M.K, DEPT. OF KAUMARABHRITYA, GOVERNMENT AYURVEDA COLLEGE, THIRUVANANTHAPURAM, KERALA

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  • 1. DEPT. OF KAUMARABHRITYA GOVERNMENT AYURVEDA COLLEGE THIRUVANANTHAPURAM KERALA Certificate This is to certify that Dr. LEKSHMI M.K has worked on ‘’ A STUDY ON THEEFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OFCHILDREN DURING COMPLEMENTARY FEEDING’’ for her thesis as a partialfulfillment for the degree of Doctor of medicine (Ayurveda) - Kaumarabhritya of the universityof Kerala, under my supervision and guidance. Under nutrition and under weight is most prevalent among children under fiveyears of age, especially in the weaning and post weaning period. Improper complementaryfeeding is the root cause of the condition even though many interventions are at hand. Thepresent study seeks the evidence for an ideal and palatable complementary food formulation,Priyalamajjadi. The findings are valuable and have contributed substantially to the presentknowledge on the subject. Dr. Lekshmi.M.K is a talented,, active research worker. She is hard working,reliable and good at conduct and character. I strongly recommend this thesis to be forwarded to the adjudicators for acceptance. Dr. S.K. RAM ACHANDRAN MD ( Ay) Professor & Head
  • 2. Declaration I here by declare that this thesis work entitled ‘A STUDY ON THEEFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OFCHILDREN DURING COMPLEMENTARY FEEDING’ is a bonafide record of theresearch work done by me under the guidance of DR. S.K. RAMACHANDRAN,Professor and Head, Department of Kaumarabhritya, Government AyurvedaCollege, Thiruvananthapuram, and that no part there of has been presentedearlier for any Degree or Diploma or similar title of any other university.Thiruvananthapuram Dr. Lekshmi M.K
  • 3. Acknowledgement I with utmost courteousness and gratitude submit my relentless praises to theAlmighty for having bestowed his grace and blessings over me to accomplish this task ofcompleting the thesis. I express my sincere gratitude to Dr.S.K Ramachandran, Professor and Head, deptof Kaumarabhritya, for the immense ideas shared, which formed the entire basis of thework I express my gratitude to Dr. M.R Vasudevan Nampoodiri, Principal, GovtAyurveda College, Thiruvananthapuram, for providing necessary requirements in time. My sincere thanks to staff members of the Immunization unit, Govt. AyurvedaCollege Hospital for Women and Children, Poojappura for their cooperation and supportto conduct the study smoothly. My thanks to the Faculty and staffs of Pharmacy, Government Ayurveda College,Thiruvananthapuram, for their immense cooperation for preparing the study formulation. I remember with utmost gratefulness my colleagues, family and friends, for theirtimely help and support for completing the thesis in time. Above all, I dispense my love to those fifty-five giggling weeping cute littleparticipants who made the study a reality. Dr. Lekshmi M.K
  • 4. ContentsList of tables iList of figures iiiList of abbreviations ivAbstract vIntroduction 1a. Need and significance of study 2b. Aim and objectives of the study 3c. Hypothesis 4d. Contents of the thesis 4The literature reviewChapter 1 – Growth and Development 51.1 Infant growth and development during the first two years of life 61.2 Assessment of growth and development 10Chapter 2 – Child nutrition 212.1 Introduction and background 212.2 Nutritional requirements 21Chapter 3 – Breast feeding 303.1 Nutritional considerations in the first year of life 313.2 Human-milk intakes 313.3 Composition of human milk 323.4 Some important approaches in infant feeding 393.5 Contraindications of breast-feeding 413.6 Formula Feeding 42Chapter 4 – Complementary feeding 444.1 Relevant definitions 44
  • 5. 4.2Ideal time to start complementary feeding 454.3 Research findings on the duration of exclusive breast feeding 474.4 Complementary feeding practices 494.5 Complementary foods 514.6 Improved weaning practices 544.7 First-Year Feeding Problems 594.8 Feeding During the Second Year of Life 64Chapter 5 – Growth and development – Ayurvedic Perspective 695.1 Growth and development 705.2 Factors controlling growth and development in a child 715.3 Factors that enhance strength and immunity 765.4 Assessment of growth and development in Ayurveda 785.5 Classification of children 82Chapter 6 – Infant and young child feeding in Ayurveda 866.1 Importance of Food 866.2 Infant and young child feeding in Ayurveda 886.3 Improved weaning practices in children – Ayurvedic perspective 976.4 The main weaning disorders described in Ayurveda 1036.5 Certain dietetic aspects considered especially for children 104Chapter 7 – Evaluation of the formulation under consideration 1057.1 Ingredients of the formulation 1067.2Therapeutic action of the formulation 118Methodology of researchChapter 8 – Methodology of research 1198.1 Objectives of the study 1198.2 Research approach 1198.3 Research design 1208.4 Reasons for selecting the design 1228.5 Variables 1238.6 Selection criteria 1238.7 Randomization 1248.8 Dropouts 124
  • 6. 8.9 Duration of study 1248.10 Method of preparation of the study drug 1258.11 Data collection 1268.12 Assessment criteria 1278.13 Intervention schedule 1288.14 Follow up 1298.15 Data analysis 1298.16 Ethical considerations for the study 130Observation, analysis and interpretationsChapter 9 - Observation, analysis and interpretations 1319.1 Data relating to Socio demographic factors 1329.2 Data relating to weaning practices noticed in the sample 1369.3 Analysis and Interpretations 1379.4 Data relating to interventions and its efficacy including analysis and Interpretations 1399.5 Assessment of development in all the groups 1569.6 Assessment of morbidity 158Discussion, summary and conclusionChapter 10 - Discussion, summary and conclusion 16010.1 Discussion and summary 16010.2 Statement of the major findings 16310.3 Mode of action of the formulation 16710.4 Strength and weakness of the study 16910.5 Suggestions for future research 16910.6 Conclusion 170References 171Bibliography 175Annexure – 1 177Annexure – 2 183Annexure – 3 184
  • 7. List of tablesSerial No Title PageTable 1.1 Developmental milestones in the first two years of life 6Table 1.2 Emerging patterns of behavior during the first year of life 8Table 1.3 Formulas for approximate average height and weight of normal infants and children 12Table 1.4 Dental development 17Table 2.1 Approximate energy values of the body fuels per gram 22Table 2.2 Calorie requirements during the first year of life 23Table 2.3 Protein requirements in children 24Table 3.1 Human milk composition 32Table 3.2 Energy requirements of breast fed infants 33Table 3.3 Iron Requirements of breastfed infants 38Table 5.1 Different ceremonies and their inference 80Table 6.1 Feeding schedule of newborn in Ayurveda 94Table 6.2 Comparison of commonly used animal milks and breast milk 95Table 6.3 Comparison of Nutrient composition in various milks/100ml 95Table 6.4 Dilution of cow’s milk 96Table 6.5 Dilution of buffalo’s milk 96Table 6.6 Opinions regarding the time to start weaning 97Table 7.1 Nutritive value of honey per 100 g 113Table 7.2 Nutritional value of edible portion of rice per 100 gram 116Table 8.1 Study cluster intervention schedule 128Table 8.2 Control cluster intervention schedule 129Table 9.1 Age wise distribution of the participants 132Table 9.2 Sex wise distribution of the participants 133Table 9.3 Domicile wise distribution of the participants 133 i
  • 8. Table 9.4 Distribution of participants as per educational status of the parent 134Table 9.5 Economic status wise distribution of participants 134Table 9.6 Religion wise distribution of the participants 135Table 9.7 Dietary habits wise distribution of the participants 135Table 9.8 Initial month of complementary feeding 136Table 9.9 First complementary feed given 136Table 9.10 Food with vegetable in the first month of weaning 137Table 9.11 Data relating to length – Group A 139Table 9.12 Data relating to weight – Group A 140Table 9.13 Data relating to head circumference – Group A 141Table 9.14 Data relating to chest circumference – Group A 142Table 9.15 Data relating to mid upper arm circumference – Group A 143Table 9.16 Data relating to length – Group B 146Table 9.17 Data relating to weight – Group B 147Table 9.18 Data relating to head circumference – Group B 148Table 9.19 Data relating to chest circumference – Group B 149Table 9.20 Data relating to Mid Upper Arm Circumference – Group B 150Table 9.21 Data relating to length – Group C 152Table 9.22 Data relating to weight – Group C 153Table 9.23 Data relating to head circumference – Group C 154Table 9.24 Data relating to chest circumference 155Table 9.25 Data relating to mid upper arm circumference 156Table 9.26 Developmental assessment chart for all groups 157Table 9.27 Morbidity conditions prevailed 158 ii
  • 9. List of figuresSerial No Title PageFigure 9.1 Age wise distribution of the participants 132Figure 9.2 Distribution of participants as per educational status of the parent 134Figure 9.3 Economic status wise distribution of participants 134Figure 9.4 Initial month of complementary feeding 136Figure 9.5 First complementary feed given 136Figure 9.6 Length gain in Group A 144Figure 9.7 Weight gain in Group A 144Figure 9.8 HC gain in Group A 145Figure 9.9 MAC gain in Group A 145Figure 9.10 CC gain in Group A 145Figure 9.11 Length gain – Group B 151Figure 9.12 Weight gain – Group B 151 iii
  • 10. List of abbreviationsCG Control groupSG Study groupBT Before treatmentAT After treatmentD DifferenceL LengthW WeightHC Head circumferenceCC Chest circumferenceMAC Mid arm circumference iv
  • 11. Abstract Under nutrition and problems associated with complementary feeding are of greatconcern in the field of pediatrics. The trial was proposed to study the efficacy ofPriyalamajjadi Yoga during complementary feeding by using specific parameters forgrowth and development. The study was conducted at the Immunization unit,Government Ayurveda College Hospital for Women and Children, Poojappura,Thiruvananthapuram. Children between the age of four to 24 months and startedcomplementary feeding were included in the study. Total 55 children of the criteria wereselected and assigned to three groups as per the stage of complementary feeding and rateof growth for the age. Each group is again divided into one study and control clusters.The study cluster in each group received the food formulation Priyalamajjadi in definitedose along with a proper dietary advice suitable for the age to follow. The controlclusters received the dietary advice alone. The responses of both clusters in each groupwere obtained and analyzed statistically. Final assessment of length, weight, headcircumference, chest circumference and mid arm circumference showed that thePriyalamajjadi yoga is effective for the proper growth and development of children duringcomplementary feeding in the first year of life. It is also effective in reducingconstipation associated with complementary feeding during the period. v
  • 12. Department of Koumarabhritya Introduction The dimensions of health are always changing. In the present era, health isconsidered “not mainly an issue of doctors, social services, and hospitals. It is an issue ofsocial justice”. World Health Organisation broadly defines health as “a state of completephysical, mental, and social well being, not merely an absence of disease or infirmity”.The above concept of health envisages several spiritual, emotional, vocational, andpolitical dimensions. Presently exploring medical requirements are, most of the timeincapable to fulfill these views. Therefore, Ayurveda, popularly known as the Indiansystem of medicine, which is considering the living systems in its physical, mental, andspiritual levels, gains high acceptance in the western scientific world. The medicalsystem is giving equal importance to preventive, curative, and prophylactic aspects ofmedicine, there by maintaining the sensitive homeostasis of the body, which is thefoundation of happy and wholesome existence of every living being. Kaumarabhritya, is the branch of Ayurveda which elaborates pediatrics and evenmore. It covers all aspects from genetics to dietetics in children. It gives a completeguidance for reproductive child health care, infant and young child feeding practices andadolescent care. The science had a very precise way to make out the health and ill healthof the child and the proper growth and development. It also has immunization methodsbased on its principles. Introduction 1
  • 13. Department of Koumarabhritya a. Need and significance of the study Good health depends on an adequate food supply, which in turn depends on asound agricultural policy, a good food distribution system and proper health education. Ahealthy younger generation with duly developed body, mind and brain is the bedrock fora good future. Every child in every part of the world has the potential to grow anddevelop as long as his and her basic needs are met. Adequate supply of essential nutrientsrequired as per age is the most important factor for the proper growth and development. Infant and young child feeding is the subject of great concern in the field ofnutrition since malnutrition in early childhood has serious, long-term consequencesbecause it I impedes motor, sensory, cognitive, social and emotional development.Malnourished children are less likely to perform well in school and more likely to growinto malnourished adults, at greater risk of disease and early death. One in three of theworlds malnourished children live in India. Where, around 46 per cent of all childrenbelow the age of three are too small for their age, 47 per cent are underweight and at least16 per cent are wasted. WHO Global Strategy for Infant and Young Child Feeding, 2002 advocatesexclusive breastfeeding for the first six month with the introduction of local and highnutrient complementary foods after six months while continuing breastfeeding to twoyears and beyond. After six months of age a child needs high-energy and high nutrientfoods that are rich in vitamin A, vitamin C, iron and other important minerals, in additionto breast milk. Children are more physically active and they continue to grow rapidlyduring the second half of first year. Introduction 2
  • 14. Department of Koumarabhritya The introduction of complementary foods is a time of transition when childrengradually becomes used to eating semi solid and solid foods. The nutritional role ofmother’s milk in the second year is inversely related to the adequacy of thecomplementary diet. Improper nutrition during weaning and post weaning period is theroot cause of malnutrition in children. This is a period of great dilemma, stress andhumiliation to the child and is associated with many disorders like constipation, diarrhea,colic etc. This physical and mental turmoil along with the need for a highly nutritious dietpoints out the importance of an ideal weaning food. The present study aims to find thesolution for this grave problem. b. Aim and objectives of the study The study intend to find the efficacy of the formulation Priyalamajjadi in thegrowth and development of children during complementary feeding. The study aims notonly to the efficacy of the formulation; as a broad objective, the ideal time for itsadministration is also considered. Nationally accepted international parameters are usedfor the assessment. These standards depict normal growth under optimal environmentalconditions and can be used to assess children everywhere, regardless of ethnicity, socio-economic status and type of feeding Introduction 3
  • 15. Department of Koumarabhritya c. Hypothesis Null Hypothesis: Priyalamajjadi yoga is not effective in the proper growth anddevelopment of children during complementary feeding. Alternate Hypothesis: Priyalamajjadi yoga is effective in the proper growth anddevelopment of children during complementary feeding. d. Contents of the thesis Title of the thesis is ‘A study on the efficacy of Priyalamajjadi yoga in the growthand development of children during complementary feeding.’ The thesis consists of the following parts. I. Introduction II. Literarature review III. Methodology of research IV. Observation, analysis and interpretation V. Discussion, summary and conclusionIntroduction 4
  • 16. Department of Koumarabhritya Chapter 1 Growth and Development “Growth is the most commonly used functional outcome measure of nutrientadequacy. This outcome is particularly useful for screening purposes because the normalprogression of growth is dependent on many needs being met and many physiologicalprocesses proceeding normally. However, this strength also betrays this outcome’sprincipal weakness since abnormal growth is highly non-specific. The single or multipleetiologies of abnormal growth are usually difficult to ascertain confidently. This is mostapparent in the differential diagnosis of failure to thrive found in most standard pediatrictexts.”(1) Growth and development is a continuous process which begins at the conceptionand ends at maturity. Growth, in short, may be defined as the increase in the size of anindividual due to increase in number and size of the cells. ‘Development’ is maturation of function. It depends on maturation andmyelination of the nervous system and denotes acquisition of a variety of competenciesfor optimal functioning of the individual. (2). The term growth denotes increase in size orbody mass and development is the emerging and expanding capacities of the individual toprovide progressively greater faculties in function. They are unique characteristic of Literature review 5
  • 17. Department of Koumarabhrityachildren and any obstacle in this process at any stage can possibly result in aberration ofgrowth and / or development.1.1 Infant growth and development during the first two years of life Physical growth, maturation, acquisition of competence, and psychologicalreorganization occur rapidly during the first year. These changes do not occur smoothlyover time but rather in discontinuous bursts that qualitatively change the childs behavior.Physical growth during this period is rapid; growth parameters and normal ranges forattainable weight, length, and head circumference presents an overview of milestones inthe domains of gross motor, fine motor and cognitive development (3).Table 1.1 Developmental milestones in the first two years of life (4)Milestone Average Age of Developmental Implications Attainment(months) Gross MotorHead steady in sitting 2.0 Allows more visual interactionPull to sit, no head lag 3.0 Muscle toneHands together in 3.0 Self–discoverymidlineAsymmetric tonic neck 4.0 Child can inspect hands in midlinereflex goneSits without support 6.0 Increasing explorationRolls back to stomach 6.5 Truncal flexion, risk of fallsWalks alone Exploration, control of proximity to 12.0 parentsRuns 16.0 Supervision more difficult Fine MotorGrasps rattle 3.5 Object useReaches for objects 4.0 Visuomotor coordinationPalmar grasp gone 4.0 Voluntary releaseTransfers object hand to 5.5 Comparison of objectshandThumb–finger grasp 8.0 Able to explore small objectsTurns pages of book Increasing autonomy during book 12.0 time Literature review 6
  • 18. Department of KoumarabhrityaScribbles 13.0 Visuomotor coordinationBuilds tower of two 15.0 Uses objects in combinationcubesBuilds tower of six cubes Requires visual, gross, and fine motor 22.0 coordination Communication and LanguageSmiles in response to 1.5 Child more active social participantface, voiceMonosyllabic babble Experimentation with sound, tactile 6.0 senseInhibits to "no" 7.0 Response to tone (nonverbal)Follows one–step 7.0 Nonverbal communicationcommand with gestureFollows one–stepcommand without 10.0 Verbal receptive languagegestureSpeaks first real word 12.0 Beginning of labelingSpeaks 4-6 words Acquisition of object and personal 15.0 namesSpeaks 10–15 words Acquisition of object and personal 18.0 namesSpeaks two–word Beginning grammaticization,sentences 19.0 corresponds with 50+ word vocabulary CognitiveStares momentarily atspot where Lack of object permanence (out of 2.0object disappeared sight, out of mind)(e.g., yarn ball dropped)Stares at own hand 4.0 Self–discovery, cause and effectBangs two cubes 8.0 Active comparison of objectsUncovers toy (after 8.0 Object permanenceseeing it hidden)Egocentric pretend play(e.g., pretends to drink 12.0 Beginning symbolic thoughtfrom cup)Uses stick to reach toy 17.0 Able to link actions to solve problemsPretend play with doll 17.0 Symbolic thought(gives doll bottle) Literature review 7
  • 19. Department of KoumarabhrityaTable 1.2 Emerging patterns of behavior during the first year of life (4) Neonatal period (first 4 weeks)Prone: Lies in flexed attitude; turns head from side to side; head sags on ventral suspensionSupine: Generally flexed and a little stiffVisual: May fixate face or light in line of vision; "dolls–eye" movement of eyes on turning of the bodyReflex: Moro response active; stepping and placing reflexes; grasp reflex activeSocial: Visual preference for human face At 4 weekProne: Legs more extended; holds chin up; turns head; head lifted momentarily to plane of body on ventral suspensionSupine: Tonic neck posture predominates; supple and relaxed; head lags on pull to sitting positionVisual: Watches person; follows moving objectSocial: Body movements in cadence with voice of other in social contact; beginning to smile At 8 weekProne: Raises head slightly farther; head sustained in plane of body on ventral suspensionSupine: Tonic neck posture predominates; head lags on pull to sitting positionVisual: Follows moving object 180 degreesSocial: Smiles on social contact; listens to voice and coos At 12 weekProne: Lifts head and chest, arms extended; head above plane of body on ventral suspensionSupine: Tonic neck posture predominates; reaches toward and misses objects; waves at toySitting: Head lag partially compensated on pull to sitting position; early head control with bobbing motion; back roundedReflex: Typical Moro response has not persisted; makes defensive movements or selective withdrawal reactionsSocial: Sustained social contact; listens to music; says "aah, ngah" At 16 week Prone: Lifts head and chest, head in approximately vertical axis; legs extended Supine: Symmetric posture predominates, hands in midline; reaches and grasps objects and brings them to mouth Sitting: No head lag on pull to sitting position; head steady, tipped forward; enjoys sitting with full truncal supportStanding: When held erect, pushes with feetAdaptive: Sees pellet, but makes no move to it Social: Laughs out loud; may show displeasure if social contact is broken; excited at sight of food At 28 week Prone: Rolls over; pivots; crawls or creep–crawls Literature review 8
  • 20. Department of KoumarabhrityaSupine: Lifts head; rolls over; squirming movementsSitting: Sits briefly, with support of pelvis; leans forward on hands; back roundedStanding: May support most of weight; bounces activelyAdaptive: Reaches out for and grasps large object; transfers objects from hand to hand; grasp uses radial palm; rakes at pelletLanguage: Polysyllabic vowel sounds formed Social: Prefers mother; babbles; enjoys mirror; responds to changes in emotional content of social contact At 40 week Sitting: Sits up alone and indefinitely without support, back straight Standing: Pulls to standing position; "cruises" or walks holding on to furniture Motor: Creeps or crawls Grasps objects with thumb and forefinger; pokes at things with forefinger;Adaptive: picks up pellet with assisted pincer movement; uncovers hidden toy; attempts to retrieve dropped object; releases object grasped by other personLanguage: Repetitive consonant sounds (mama, dada) Social: Responds to sound of name; plays peek–a-boo or pat–a-cake; waves bye– bye At 52 week(one year) Motor: Walks with one hand held (48 wk); rises independently, takes several stepsAdaptive: Picks up pellet with unassisted pincer movement of forefinger and thumb; releases object to other person on request or gestureLanguage: A few words besides "mama," "dada" Social: Plays simple ball game; makes postural adjustment to dressing 15 MonthsMotor: Walks alone; crawls up stairsAdaptive: Makes tower of 3 cubes; makes a line with crayon; inserts pellet in bottle Jargon; follows simple commands; may name a familiar object (ball)Language: Social: Indicates some desires or needs by pointing; hugs parents 18 MonthsMotor: Runs stiffly; sits on small chair; walks up stairs with one hand held; explores drawers and waste basketsAdaptive: Makes a tower of 4 cubes; imitates scribbling; imitates vertical stroke; dumps pellet from bottleLanguage: 10 words (average); names pictures; identifies one or more parts of bodySocial: Feeds self; seeks help when in trouble; may complain when wet or soiled; kisses parent with pucker 24 MonthsMotor: Runs well; walks up and down stairs, one step at a time; opens doors; climbs on furniture; jumpsAdaptive: Tower of 7 cubes (6 at 21 mo); circular scribbling; imitates horizontal stroke; folds paper once imitativelyLanguage: Puts 3 words together (subject, verb, object)Social: Handles spoon well; often tells immediate experiences; helps to undress; listens to stories with pictures Literature review 9
  • 21. Department of Koumarabhritya1.2Assessment of growth and development The standards of growth and development fixed by WHO by evaluating themulticentric growth trials conducted apart. The same is published in two technical reportsin the year 2006 and 2007(5).Growth can be measured in terms of 1. Nutritional anthropometry (weight, height, circumference of head, chest abdomen and pelvis). 2. Assessment of tissue growth (skin fold thickness and measurement of muscle mass). 3. Bone age (radiological by appearance and fusion of the various epiphyseal centers). 4. Dental age. 5. Growth studies and percentilesFor day to day work, anthropometry is the simplest tool.1.2.1 Nutritional anthropometry (6) This is the technique for measuring somatic growth. Literature review 10
  • 22. Department of Koumarabhritya1.2.1.1 Length Length in recumbence is measured using an infantometer until 24 or 36 months ofage. The length is recorded in centimeters up to one decimal point. After the age of twoyears, standing height is recorded by using a stadiometer. Detecto weighing scales fixedwith anthropometric rods are in common use. For community survey, portable types ofrods are also used. For recording stature, the subject should remove his/her socks andshoes and stand perfectly straight with arms relaxed by his/her sides and ankles and kneestogether. Before measurement starts, a gentle pressure may be applied over the spinewith one hand while other hand holds the anthropometric rod. The subjects head ispositioned in Frankfort plane.1.2.1.2 Sitting height For recording sitting height, the subject is made to sit on a table or otherconvenient hard surface so that his/ her head lies in Frankfort plane. The back should bestraight, thighs horizontal and comfortably positioned. The feet should be supported onthe foot board and hands should rest comfortably on the subjects lap. To ensure that thesubjects back is fully extended, the observer may run his/her index finger up the spineapplying pressure to the lumbar and sacral regions, causing the subject to sit up by reflexaction. The head board should be lowered and made to touch the head of the subject andreading should be recorded to the nearest completed unit.1.2.1.3 Body proportions The total body length is divided in two segments. The upper segment is fromhead to pubic symphysis and the lower segment is from pubic symphysis to the toes. TheU/L segment ratio is 1.7:1 at birth. By six to seven years, it reaches 1:1. If the ratio is Literature review 11
  • 23. Department of Koumarabhrityainfantile after one year of age, it suggests short limb dwarfism due to bone disorders suchas rickets and hypothyroidism.1.2.1.4 Weight It is the commonest and important anthropometric measurement. The weighingscales best suited are those which are designed on balance arm principle. Accuracy up to0.1 kg is quite acceptable. For smaller babies, machines of more accuracy are required as0.1 kg forms a higher percentage of total body weight. More recently, many electronicweighing scales giving 0.01 kg have been made available.Table 1.3 Formulas for approximate average height and weight of normalinfants and children Weight Kilograms (Pounds) (a) At birth 3.25 (7) (b) 3–12 mo age (mo) + 9 (age [mo] + 11) 2 (c) 1–6 yr age (yr) ´2 + 8 (age [yr] ´5 + 17) (d) 7–12 yr age (yr) ´7 – 5 (age [yr] ´7 + 5) Height Centimeters (Inches) (e) At birth 50 (20) (f) At 1 yr 75 (30) (g) 2–12 yr age (yr) ´6 + 77 (age [yr] ´2½ + 30)1.2.1.4 Head circumference Head circumference (HC) is measured with a non stretchable tape passing throughthe maximum point of occipital protuberance posteriorly and at a point, just above theglabellum anteriorly. HC increases by 2cm per month for the first three months, one cm Literature review 12
  • 24. Department of Koumarabhrityaper month for the next three months and 0.5 cm per month for the next 6 months where asHC at birth on an average is 34 cm. HC increases by 2 cm in the second year and one cmin the third year.1.2.1.5 Midarm circumference The upper arm circumference can be measured both in flexed and extendedpositions and also either at the maximum circumference of biceps muscles or midpoint, asthe difference between the two is negligible. It is measure by a non stretchable tapewhich is passed around the circumference of the arm while the arms hanging by the sides.The measurement is noted at the midpoint of left arm, mid way between acromion andolecranon processes. Shakir’s tape is used for quick monitoring of MAC in communitywhich gives green color, if MAC>13.5 cm, yellow if between 12.5-13.5 cm and red if lessthan 12.5 cm.1.2.1.6 Chest circumference The chest circumference for boys, prepubertal girls and men can be recorded at thelevel of xiphisternal junction during normal breathing. It is recorded to the nearest 0.1cm. 1. At Birth - about 3 cm less than the Head Circumference 2. Equal to head circumference at 1 year 3. Thereafter it increase than head circumference1.2.1.7 Age independent anthropometry As the Midarm circumference (MAC) is relatively constant between 16.5cm to17.5cm in one to five years of age, this measurement may be considered as an age Literature review 13
  • 25. Department of Koumarabhrityaindependent variable up to five years of age. Any child whose MAC is less than 12.5 cmup to five years of age, is considered malnourished.1.2.1.8 Weight for height The degree of wasting can be measured by comparing the child’s weight withexpected weight for a healthy child of the same height. Combinations of thesemeasurements have been used to distinguish different types of malnutrition. Waterlowsuggests that weight for height can be used to distinguish between malnutrition of recentorigin, i.e. wasting and malnutrition due to considerable period of months. In chronicmalnutrition, the child is stunted with the weight for age and height for age being low. Inacute malnutrition, height for age is normal but weight for age is low (wasting). Thus, theweight and height measurements together are useful in understanding the dynamics ofmalnutrition. In nutritional short stature the weight /height is equal; the child may passoff as a normal child of lower age if the chronological age is not known.1.2.1.9 Quackstick Quacker’s Midarm circumference measuring stick is a height measuring rod,calibrated in MAC than length; values of 80 percent MAC for height are marked on thestick at corresponding height levels. If a child is found taller than his/her armcircumference, level on the stick, he/she may be considered as malnourished.1.2.1.10 Midarm/head circumference ratio It is a simple and useful criterion for detection of malnutrition. A ratio 0.280 to0.314 indicates early malnutrition, 0.250 to 0.279 moderate, and less than 0,249 denotessevere malnutrition. Literature review 14
  • 26. Department of Koumarabhritya1.2.1.11 Quetlet’s index It is based on the relationship between weight and height and is expressed asweight (kg)/height (cm) x 100. Normal value varies from 0.14 to 0.16. In grossmalnutrition, it is less than 0.14. It is a quite reliable ratio for assessing malnutrition.1.2.1.12 Mid-upper arm/height ratio It is also a very good indicator for nutritional status. A ratio of less than 0.29indicates gross malnutrition, while normal value ranges from 0.32 to 0.33.1.2.1.13 Body mass index (BMI) BMI = weight (kg) / height 2 in meter. This is similar to Quetlet’s index except that the values are in SI units. BMIvalues can be used to draw standardized percentile curves in children and adolescents. Itis especially useful for defining obesity. BMI values above 95 th percentile for age areusually used to define obesity.1.2.1.14 Ponderal index (PI) PI = height (cm) / cube root of body weight (kg)This is another index similar to BMI and is often used in defining newborn withintrauterine growth retardation (IUGR).1.2.2 Tissue growth This measurement is done for special purpose and is not used in routine clinicalpractice. It is measured with a special caliper.1.2.2.1 Triceps skin fold thickness The skin fold picked up over the posterior surface of the triceps muscle, one cmabove the mark on a vertical line passing upward between bony point identified for takingmeasurement, maintaining a pressure of 10g/ mm2 on the caliper and freeing the skin fold Literature review 15
  • 27. Department of Koumarabhrityafrom the underling muscle with left hand between thumb, index and middle finger andholding caliper with the other hand. The reading is recorded to the nearest 0.1mm.1.2.2.2 Sub scapular skin fold thickness The subject stands as for the triceps skin fold with shoulder and arm relaxed. Theinferior angle of scapula is located by running finger on medial border of scapuladownward, till inferior angle is reached. The skin is pinched up immediately below theinferior angle either in the vertical line or slightly downward and reading is recorded tothe nearest 0.1mm maintaining the pressure of caliper as before.1.2.2.3 Biceps skin fold thickness For recording biceps, the child is made to stand erect, facing observer with arm onside and palm facing forward. The skin fold is picked up over the belly of biceps and1cm above the line marked for the upper arm circumference and triceps skin fold on avertical line joining antecubital fossa to the head of humerus. The caliper is applied at themarked level and reading is recorded to 0.1mm.1.2.3 Bone age or skeletal maturity Appearance and fusion of various epiphyseal centers follow a definite sequencerelated to chronologic age from birth to maturity. Radiological examination of left wristand elbow is usually considered for bone age assessment. X-ray of the lower end offemur, and talus is used for the assessment of maturity of newborn babies.1.2.4 Dental development Eruption of teeth follows a definite sequence. Eruption of temporary or deciduousteeth begins at about six months with eruption of upper or lower central incisor, followedby lateral incisor. By one year of age 4 to 8 teeth are present. The permanent teeth beginto erupt at six years. Literature review 16
  • 28. Department of KoumarabhrityaTable 1.4 Dental development (4) Calcification Age wise eruption Begins at Complete at Maxillary MandibularPrimary TeethCentral incisors 5th fetal mo 18–24 mo 6–8 mo 5–7 moLateral incisors 5th fetal mo 18–24 mo 8–11 mo 7–10 moCuspids (canines) 6th fetal mo 30–36 mo 16–20 mo 16–20 moFirst molars 5th fetal mo 24–30 mo 10–16 mo 10–16 moSecond molars 6th fetal mo 36 mo 20–30 mo 20–30 moSecondary TeethCentral incisors 3–4 mo 9–10 yr 7–8 yr 6–7 yrLateral incisors Max, 10–12 mo 10–11 yr 8–9 yr 7–8 yr Mand, 3–4 moCuspids (canines) 4–5 mo 12–15 yr 11–12 yr 9–11 yrFirst premolars 18–21 mo 12–13 yr 10–11 yr 10–12 yr(bicuspids)Second premolars 24–30 mo 12–14 yr 10–12 yr 11–13 yr(bicuspids)First molars Birth 9–10 yr 6–7 yr 6–7 yrSecond molars 30–36 mo 14–16 yr 12–13 yr 12–13 yrThird molars Max, 7–9 yr 18–25 yr 17–22 yr 17–22 yr Mand, 8–10 yr1.2.5 Growth studies and percentiles While discussing growth, various terms which are used are explained.1.2.5.1 Cross-sectional study This is a very convenient, easy, less time consuming and economical method tostudy growth. For example, children of each age group in large number collected, theirweights are recorded and an average is found out. These groups of children are studiedjust once. Literature review 17
  • 29. Department of Koumarabhritya1.2.5.2 Linear or longitudinal study In this type of study, the same child is measured from birth to maturity at yearly orpreviously decided regular intervals. It is difficult to study very large number of childrenin this fashion and hence, the linear studies have comparatively less subjects in number.The longitudinal study helps us to determine the growth velocity.1.2.5.3 Concept of percentiles While making various calculations, the use of terms like mean or average andstandard deviation (SD) is well known. While expressing growth, the term percentile orcentile is used.1.2.5.4 Growth charts Growth chart is the most important tool in assessment of growth of an individualchild. A standard chart contains weight for age, height for age and weight for height.The head circumference is included for first three years of age.Growth Chart & their significance –  Introduction – Also called ‘Road to health chart’.  Definition – Growth chart is a visible graphical display of a child’s Growth & Development designed primarily for the longitudinal follow up (growth monitoring) of the child, so that changes over time can be interpreted & progress of Growth interpreted.  Visits to be recorded – Weighing should be done at least once every month for the first year Every 2 months during second year. Every 3 months up to age of 5 -6 years. This is done in a pattern of ‘weight for age’ on the chart. Literature review 18
  • 30. Department of KoumarabhrityaTypes of Growth Chart –  WHO Growth Chart – it has two reference curves. The upper reference curve represents the median (50th percentile) for boys (slightly higher than that for girls) & the lower reference curve represents the percentile for girls (slightly lower than that for girls). The space in between two growth curves (weight channel) is called ‘Road to Health’. This includes children with +/- 2 SD on each side of standard weight.  Growth chart recommended by Govt. of India & IAP (Indian Academy of Pediatrics). – It has 4 reference curves.  ICDS Chart- 3 reference lines in addition to standard representing 80%, 60% & 50% of the reference standards.Use of Growth charts – 1. Growth monitoring – To detect malnutrition or infections by periodic assessment in progress of weight 2. Diagnostic tool – to identify ‘High risk children’. Malnutrition can bee detected long before signs & symptoms of it become apparent. 3. Planning & Policy making – By grading malnutrition it is possible to evolve an objective basis for planning & policy making in relation to child health care at local & central levels. 4. Education tool – Mothers can be taught care of her own child & encourage her to actively participate in Growth monitoring with the help of visual character of the Growth chart.Literature review 19
  • 31. Department of Koumarabhritya 5. Tool for action – Helps the health workers to decide type of interventions that is needed, which helps making referrals an easier jobs. 6. Evaluation – growth chart provides a good method to evaluate the effectiveness of corrective measures & impact of a program or of special intervention for improving child Growth & Development.The Growth Chart has been aptly described as ‘A passport to child health care’.Velocity growth charts These charts are developed by long term longitudinal studies and are known asincremental charts. They show the rate of change due to chronic illness or growthhormone deficiency. Literature review 20
  • 32. Department of Koumarabhritya Chapter 2 Child nutrition2.1 Introduction and background Nutrition may be defined as the science of food and its relation to health. It isconcerned primarily with the part played by the nutrients in body growth developmentand maintenance. Good nutrition means maintaining a nutritional status that enables us togrow well and enjoy food (7). Disturbances of feeding and related nutritional disordersconstitute a major health problem in developing countries.2.2 Nutritional requirements (8)2.2.1 Food and Energy: The chemical energy required for the human body engine is bound in fuels presentin food. The foods which supply energy are carbohydrates, fat, proteins and alcohol.Energy is required for the activities of the child as well as synthetic reaction whichproduce the chemical components of the new cells and tissues during growth. Energy isrequired for the functioning of each and every unit of the body. Literature review 21
  • 33. Department of KoumarabhrityaTable 2.1 Approximate energy values of the body fuels per gram (9) Kcal kjCarbohydrates 4 16.7Fat 9 37.7Protein 4 16.7Alcohol 7 29.32.2.2 The nutrient requirementsThe nutrient requirement depends on 1. the rate of growth 2. physical activity 3. climate 4. body temperature 5. body weight and height 6. body surface area 7. genetic and constitutional factors 8. individual variations2.2.3 Calorie requirements A one year old child usually requires about 1000 calories per day. There is somereduction in the need for calories per kilogram as the child grows and the calorierequirement for a child of two year of age is 1100 calories; three years 1200 calories; fouryears 1300 calories; and five years 1400 calories. Literature review 22
  • 34. Department of KoumarabhrityaTable 2.2 Calorie requirements during the first year of life (10) Age kcal/kg kj/kgLess than three months 120 5003-5 months 115 4806-8 months 110 4609-11 months 112 470 As the rate of growth of children is very variable depending up on the racial,genetic and constitutional factors, the calorie need will vary in different children of thesame age.Physical activity The calorie requirement will also vary greatly with physical activity. Hencechildren who are very active may need 100 to 300 calories more than less active children.2.2.4 Proteins Protein is an essential constituent of living protoplasm and it participates in allimportant processes. There are nine essential amino acids needed for older children andten for infants. They are – leucine, isoleucine, methionine, phynylalanine, threonine,tryptophan, histidine and valine. Histidine is essential for growth of infants. The majorfunctions of proteins are 1. Growth, as amino acids provide building stones for tissue synthesis. 2. Repair of body tissues under going wear and tear. 3. Supply of raw materials essential for the formation of digestive juices, hormones, plasma proteins, immunoglobulin, Haemoglobin, enzymes etc. Literature review 23
  • 35. Department of Koumarabhritya 4. In case of necessity, proteins can be used for energy purposes as each gram of protein supplies about 4 kcal of energy. 5. Function as buffers to maintain the reaction of various body fluids such as plasma, intestinal secretion, CSF etc.Protein requirements Nutritive value of proteins depends on its amino acid constituents which arerequired for building new tissues and its digestibility. The capacity of proteins to makegood one another’s deficiencies is known as their supplementary value. The protein requirement in children depends mainly upon the rate of growth,degree of tissue repair and the presence or absence of infections or infestations. In theadult as the growth ha ceased, the requirement in terms of milk or egg protein are0.57gms/kg of body weight for a man and 0.42gms/kg body weight for woman per day.The protein requirements in children are much higher than adults because of the necessityof maintaining healthy growth rates.Table 2.3 Protein requirements in childrenAge in months protein requirement in grams (In terms of milk protein)0-3 2.403-6 1.856-9 1.609-11 1.44 Literature review 24
  • 36. Department of Koumarabhritya The protein requirements also depend upon the calorie intake in children. If thecalorie intake is adequate, proteins are spared for their usual functions of growth andrepair, if calories are not adequate, proteins are diverted to the provision of energy. Abreastfed baby growing normally has a protein intake of 1.87 gms/kg body weight whichis more than adequate compared to the calculated 1.6gm/kg. a baby who gets full creamcows milk will get almost three times the amount of protein than that supplied by thehuman milk.2.2.5 Fat Fat is not only an important constituent of the diet but also an essential one. Itprovides a higher source of energy, nine calories per gram, i.e., double the energyfurnished by protein or carbohydrates. Vegetable oils are particularly rich in essentialfatty acids which play an important role in several metabolic reactions in the body.Animal fats such as butter and ghee contain vitamin A and vitamin D. Cholesterol, aconstituent of fat, may be increased in the blood when the consumption of fat is morethan 30% of the calories in the diet. Young babies absorb fat from human milk much better than cow’s milk becausein human milk fat, 74% of the palmitic acid is esterified while it is only 39% in cow’smilk. To increase the absorption of cow’s milk, butter fat is avoided in practice and amixture of animal as well as vegetable fats is used to mimic the composition of humanmilk. Linoleic acid like unsaturated fatty acids can also be added to increase theassimilation as they are readily absorbed by babies particularly if they are of plant origin.The intake of fat in the diet of a child should be enough to supply 30-35% of the totalcalories, as with a lesser intake of fats babies are likely to get more amounts of protein Literature review 25
  • 37. Department of Koumarabhrityaand carbohydrates. Both may produce undesirable effect on the body of the child. Inolder children and adolescents the intake of fat could be as low as 15% of total calories,as they are able to tolerate carbohydrate and proteins much better than infants and youngchildren below three years.2.2.6 CarbohydratesCarbohydrates have the following important functions. 1. They provide energy 2. They are used in the synthesis of DNA, RNA and other important chemicals used in building various substances in the baby. 3. They are useful in the detoxification of ammonia. 4. They are useful in counteracting acidosis. Glucose is the main source of cellular energy particularly to brain cells.Carbohydrates are important in the maintenance and improvement of liver functions. Acommon method of detoxification is conjugation with glucoronic acid which is formedfrom glucose and predominantly galactose in the neonatal period. This indicates thespecial need of galactose in the neonatal period apart from glucose in the conjugation ofbilirubin, steroids and drugs like chloremphenicol. The high lactose content of breastmilk is an excellent source of glucose and galactose particularly in the neonatal period,where an adequate amount of lactase in the intestinal mucosa of the newborn is availablefor digestion of lactose. The carbohydrates are utilized for energy purposes and hence the fatty acids fromfat are not necessary when glucose is adequate. In the absence of adequate carbohydrates,particularly glucose, fat will break down for energy which results in ketosis. Also Literature review 26
  • 38. Department of Koumarabhrityaglucose will prevents acidosis in the neonatal period by proper glycogenesis andglycogenolysis. Essentially no carbohydrate reaches the colon in normal children, and indeedmany of the consequences of carbohydrate malabsorption are the result of carbohydrateentry to colon. Infants can absorb sucrose readily because of sucrase activity in theintestine readily from birth. They can also deal with partial hydrolysis of products ofstarch usually called dextri-maltose, and quite young babies can digest cooked starch forthey have the maltase activity necessary for breaking it down. Carbohydrate in baby’s food includes lactose or sucrose in infants fed on top milk.The carbohydrates should supply 50% or more of the calorie requirements. Though olderchildren can thrive on a diet of carbohydrate which supplies 32% or more of the totalcalories, in infancy and early childhood reduction below 32% are likely to producesymptoms of carbohydrate deficiency. High lactose milk like human milk has a slightlaxative action and hence the breast fed babies stools are semi formed, and 3-4 numberper day.Percentage distribution of calories Just as adequate calories are necessary for maintaining health, proper distribution ofthe calories from protein, fat and carbohydrate is of equal importance particularly inchildren. In an infant, distribution of calories in breast milk is 8% from protein, 42%from carbohydrates, and 50% from fat. This has proved to be highly successful inadequate growth of the baby with excellent nutrition if the quantity of the human milkwas sufficient. A marked disturbance in the distribution calories adversely affects thechild’s health and produce malnutrition in spite of excess calories. Various types of Literature review 27
  • 39. Department of Koumarabhrityapictures may be produced, depending on the amount of protein intake and adequate or nosugar. This result in various syndromes like 1. carbohydrate malnutrition a. with protein overload b. without protein overload 2. protein overload syndrome Though the human metabolism can adjust to many of the variations in diet, markeddisturbance in the percentage of calories supplied from proteins, carbohydrates and fatscan be deleterious in infancy and early childhood.2.2.6 Vitamins Vitamins are a group of organic accessory food substances which the body needsin small amounts to maintain health. The FAO/WHO expert groups have consideredhuman requirements for 8 vitamins.The vitamins for human requirements can be classified in the following three categories 1. The obligatory vitamins, which must be supplied in the diet to maintain proper health. They are (1) vitamin A (A1 and A2), (2) thiamine, (3) riboflavin, (4) pyridoxine, (5) folic acid, (6) cyanocobalamin,(7) ascorbic acid and (8) cholecalciferol. 2. Conditional vitamins are those which are mainly needed in the presence of deficit of other nutrients. They are nicotinic acid, choline and vitamin K. 3. Questionable vitamins are the substances which have not been proved essential for the normal human subject though recent studies suggest that Vitamin E deficiency can occur if there is a deficiency of the trace element selenium in the diet. Literature review 28
  • 40. Department of Koumarabhritya2.2.7 Water Water is the most essential fluid for life. Though it is not a nutrient per se it is themost essential vehicle concerned with all cellular and extra cellular metabolisms. Lack ofit will result in death in a matter of days.The requirement for water depends on various factors: 1. the climate 2. the body temperature 3. the protein and mineral content of the diet 4. the solute load presented for renal secretion 5. metabolic and respiratory rates 6. faecal loses and habit The water requirement per kilogram weight varies from 125 – 150 ml in infancy; 100– 115 in the preschool age and 40 – 100 ml in other age groups. However during the hotseason as in tropical countries, requirement increase by 25 – 50 ml per kg per daydepending on the heat. If the child is exposed to direct sunlight as may happen withworking mothers, the requirement may increase up to 60 ml per kg per day. Except in theinfants, in most children, the fluid requirement can be easily decided by the presence ofthirst. Healthy children cry mainly because of hunger or thirst. All personnel concernedwith the health of the baby must realize that all infants should give extra amounts ofboiled water varying from 25 – 50 ml per kg per day during hot weather. Failure torecognize high water requirements and relatively less food requirement in hot weathermay often cause pyrexia, vomiting, diarrhea, dehydration, and heat pyrexia in theseinfants. However, breastfed babies do not need water in the first four months if thequantity is adequate, as judged by weight gain of the body. Literature review 29
  • 41. Department of Koumarabhritya Chapter 3 Breast feeding Breast feeding, the most natural way of feeding the young infant, satisfies theinstinctive urge and assures the continuity of life and health of the progeny particularly soin a developing country like India. The breast milk is a complete food for the infant asthe lactatory apparatus of the mother is both efficient and specific for the proper growthand development of the baby. However in industrialized cultures and in modern andsophisticated families often the breast milk, the natural food of infant, is being replacedby artificial baby foods and other breast milk substitutes. Breast feeding however stillremains a necessity more so for developing countries and it is now realized more andmore that it is the best milk for babies even in developed societies. The nutrient adequacy of breast milk during the first year of life especially in thefirst six months of life is experimentally proved by multicentric trial conducted by WHO.The data is very useful in highlighting the importance of breast feeding. Although thisstudy aims to attain a natural weaning food, the importance of breast milk is never beingunder estimated. Literature review 30
  • 42. Department of Koumarabhritya 3.1 Nutritional considerations in the first year of life (11) Estimates of nutrient requirements for the first year of life are based on measuredintakes of human milk during the first 6 months. Estimated needs during the second 6months are sometimes determined by extrapolating from these intake measures. Thereasons for selecting the first 6 months appear arbitrary. One can offer physiologicalmilestones as a reason for selecting this age, e.g. changes in growth velocities, stability innutrient concentrations in human milk, disappearance of the extrusion reflex, teething,and enhanced chewing capabilities. However, the variability in the ages at which thesemilestones are reached is far greater than the specificity that the cut-off suggests. Asnoted above, growth may be used to justify selecting the first 6 months as a basis forestimating nutrient requirements, although its use this way has severe limitations.3.2 Human-milk intakes Studies conducted in presumably well-nourished populations from developedcountries and in under-privileged populations from developing countries in the 1980s–1990s were compiled and showed the following results. Mean human milk intake ofexclusively breastfed infants, reared under favorable environmental conditions, increasesgradually throughout infancy from 699 g/day at 1 month, to 854 g/day at 6 months and to910 g/day at 11 months of age. The mean coefficient of variation across all ages was 16%in exclusively breastfed infants compared to 34% in partially breastfed infants. Milkintakes among the partially breastfed hovered around 675 g/day in the first 6 months oflife and 530 g/ day in the second 6 months. Literature review 31
  • 43. Department of Koumarabhritya3.3 Composition of human milk The composition of human milk changes dramatically in the postpartum period assecretions evolve from colostrum to mature milk. The stages of lactation correspondroughly to the following times postpartum: colostrum (0–5 days), transitional milk (6–14days), and mature milk (15–30 days). . The first 3 to 4 months of lactation appear to bethe period of most rapid change in the concentrations of most nutrients. After that periodnutrient concentrations appear to be fairly stable as long as mammary gland involutionhas not begun. However, few studies assess the dietary and physiological factors thatdetermine either the rate of change in nutrient concentrations or inter individualvariability.Table 3.1 Human milk composition3.3.1 Energy content of human milk Proteins, carbohydrates and lipids are the major contributors to the energy contentof human milk. Protein and carbohydrate concentrations change with duration oflactation, but they are relatively invariable between women at any given stage oflactation. In contrast, lipid concentrations vary significantly between both individual Literature review 32
  • 44. Department of Koumarabhrityawomen and populations, which accounts for the variation observed in the energy contentof human milk. Within-day, within-feeding, and between-breast variations in milkcomposition; interference with milk “let-down”; and individual feeding patterns affect theenergy content of human milk. The mean energy content of human milk ranges from0.62 kcalth/g to 0.80 kcalth/g (33). For present purposes, a value of 0.67 kcalth/g hasbeen assumed.Table 3.2 Energy requirements of breast fed infants Literature review 33
  • 45. Department of Koumarabhritya3.3.2 Protein composition of human milk The protein content of mature human milk is approximately 8–10 g/l . Theconcentration of protein changes as lactation progresses. By the second week postpartum,when the transition from colostrum to mature milk is nearly complete, the concentrationof protein is approximately 12.7 g/l . This value drops to 9 g/l by the second month and to8 g/l by the fourth month where it appears to remain until well into the weaning processwhen milk volumes fall substantially. At this point protein concentrations increase asinvolution of the mammary gland progresses. The interindividual variation of the proteincontent of human milk, whose basis is unknown, is approximately 15%.Protein intake and growth It thus appears that human milk meets the protein needs for growth of infantsbetween 0 and 6 months. Based on factorial and balance studies, infants’ mean proteinrequirements are approximately 1.1 g/kg per day from 3 to 6 months of ageImmune function Protein under nutrition adversely affects immune function. Protein-deficientinfants present impaired immune responses that, in turn, increase their risk of infectiousepisodes.3.3.3 Total nitrogen content of human milk Human milk’s total nitrogen content, which appears to depend on the stage oflactation and dietary intakes, ranges from 1700 to 3700 mg /l. Eighteen to 30% of thetotal nitrogen in milk, is non-protein nitrogen (NPN). Approximately 30% of NPN are Literature review 34
  • 46. Department of Koumarabhrityaamino acids and thus should be fully available to the infant. As much as 50% of NPNmay be bound to urea and the remaining approximately 20% is found in a wide range ofcompounds such as nitrogen-containing carbohydrates, choline, nucleotides andcreatinine.3.3.4 Vitamin A content of human milk Vitamin A is a generic term for a group of retinoids with similar biologicalactivity. Recent recommendations by the United States Food and Nutrition Board re-evaluated conversion equivalency and recommended use of 1/12 retinol equivalents (RE)from a mixed diet. The vitamin A content of human milk depends on maternal vitamin Astatus. .The mature milk of well-nourished mothers contains approximately 1.7 moles/lvitamin A. The recommended vitamin A intake level for infants 0 to 6 months was set at1.4 μmoles/day and 1.75 μmoles/ day for infants 6 to 12 months based on the intakes ofbreastfed infants of well-nourished women. In populations that are at risk of vitamin Adeficiency, the age at which a deficiency occurs is related to the age of weaning, i.e. theshorter the duration of breastfeeding, the earlier the onset of deficiency. Associations between linear growth retardation and vitamin A deficiency havebeen found in some, but not all, studies. Age-specific paired comparisons showed alower height-for-age, weight-for-height, mid upper arm circumference and triceps skin-fold in children under 3 years of age with xerophthalmia than in controls. Vitamin A-deficient children consumed almost half the amount of vitamin A-containing foods (dark-green leafy vegetables and) than controls (11). Literature review 35
  • 47. Department of Koumarabhritya3.3.5 Vitamin D content of human milk Vitamin D is a fat-soluble vitamin that is synthesized in the skin and may beobtained from the diet. In postnatal life, the most widely recognized functions of vitaminD are related to calcium and phosphate metabolism. It is widely accepted that human milk contains very low levels of vitamin D.Vitamin D concentrations in human milk depend on maternal vitamin D status. Factorsaffecting vitamin D status include skin pigmentation, season and latitude. Increased skinmelanin concentration reduces the efficiency of vitamin D synthesis in the skin. The United States Food and Nutrition Board recommend 5 g of vitamin D forinfants 0 to 6 months of age, although it also acknowledges that breastfed infants “withhabitual small doses of sunshine” do not require supplemental vitamin D. Two hours isthe required minimum weekly amount of sunlight for infants if only the face is exposed,or 30 minutes if the upper and lower extremities are exposed. Severe vitamin Dinsufficiency results in inadequate mineralization of the skeleton. In growing infantsdeficient mineralization leads to rickets3.3.6 Vitamin B6 content of human milk Vitamin B6 functions as a coenzyme in the metabolism of protein, carbohydrateand fat. Signs and symptoms of vitamin B6 deficiency include dermatitis, microcyticanaemia, seizures, depression and confusion. In infants vitamin B6 deficiency appears toadversely influence growth. The vitamin B6 content of human milk varies with maternal B6 status and intake.The mean B6 concentration in human milk of women with B6 intakes below 2.5 mg/dayis 0.13 mg/l (778 nmol/l). Mean B6 levels in milk of women with B6 intakes between 2.5and 5 mg/day are substantially higher – approximately 0.24 mg/l. Other factors, e.g. Literature review 36
  • 48. Department of Koumarabhrityalength of gestation, stage of lactation and the use of B6 supplements, influence thevitamin B6 concentration in human milk. The adequate intake for vitamin B6 is 0.1mg/day for infants 0 to 6 months and 0.3 mg/day for infants 6 to 12 months of age.3.3.7 Calcium content of human milk Human milk contains 250–300 mg/l of calcium with no pronounced changesduring lactation . Generally, maternal diet does not appear to influence the concentrationof calcium in milk. Calcium requirements are affected substantially by genetic variabilityand other dietary factors. Pronounced calcium deficiency resulting in tetany rarely occursin the healthy, breastfed infant and therefore is not helpful in determining requirements.Assessment of calcium status is difficult since serum levels are homeostatically regulatedand therefore do not reflect body content. Inadequate calcium intake can result in lower-than-normal bone mineralization. Since bone mineralization did not differ betweenbreastfed and formula-fed infants after weaning, retention of more calcium than thatachieved by breastfed infants does not seem to benefit bone mineralization later in life.3.3.8 Iron content of human milk The concentration of iron in human milk declines from ~0.4–0.8 mg/l incolostrum to ~0.2–0.4 mg/l in mature human milk. The iron content of human milkappears to be homeostatically controlled by up and down-regulation of transferrinreceptors in the mammary gland ; consequently, it is unaffected by maternal iron status ordiet. Major factors determining iron requirements during infancy are iron endowment atbirth, requirements for growth and a need to replace losses. The newborn infant is wellendowed with iron stores and a high concentration of haemoglobin. Between 4 and 6 Literature review 37
  • 49. Department of Koumarabhrityamonths of age, there is an increased dependence on dietary iron. Dietary iron provides~30% of the requirement for haemoglobin iron turnover, compared to 5% in adultsBecause of the considerable iron requirement for growth and the marginal supply of ironin infant diets, iron deficiency is prevalent among infants between 6 and 12 months ofage.Table 3.3 Iron Requirements of breastfed infants3.3.9 Zinc content of human milk The concentration of zinc in human milk declines precipitously from 4–5 mg/l inearly milk, to 1–2 mg/l at 3 months postpartum, and to ~0.5 mg/l at 6 months. There isconsiderable inter-individual variation in milk zinc concentrations. Severe zincdeficiency results in acrodermatitis enteropathica, impaired immune function, diarrhoeaand growth retardation. Mean serum zinc was stable in breastfed infants from 2 to 9months, but the number of infants in the low range (0.55mg/l) increased from 3% at birthto 30% at between 4 to 9 months. Serum zinc correlated with zinc intake and milk zincconcentrations. Using stable isotope studies, the estimated mean net zinc absorption,which does not include urinary or integumental losses, was 0.26 mg/day at 2 months and0.29 mg/day at 4 to 5 months. Even with very efficient absorption and conservation ofendogenous losses, net zinc absorption did not meet zinc requirements at 2 months or 4 to Literature review 38
  • 50. Department of Koumarabhritya5 months. Zinc requirements are higher in boys than in girls and are highest in earlyinfancy, at the time of greatest weight gain.3.4 Some important approaches in infant feeding3.4.1 Baby-friendly Hospital Initiative The Baby-friendly Hospital Initiative (BFHI) was launched by WHO andUNICEF in 1991, following the Innocenti Declaration of 1990. The initiative is a globaleffort for improving the role of maternity services to enable mothers to breastfeed babiesfor the best start in life. It aims at improving the care of pregnant women, mothers andnewborns at health facilities that provide maternity services for protecting, promoting andsupporting breastfeeding. Different tools and materials were developed and provided forimplementation of the BFHI, including an 18-hour course, a self-appraisal tool, and anexternal assessment tool. Since its launching BFHI has grown, with more than 20,000designated facilities in 152 countries around the world over the last 15 years. Theinitiative has measurable and proven impact, increasing the likelihood of babies beingexclusively breastfed for the first six months.3.4.2 HIV and infant feeding The HIV pandemic raised concerns and queries in relation to feedingrecommendations for children of HIV-infected mothers. In 2003, as a result ofcollaboration between nine UN agencies, a framework for priority action on HIV andinfant feeding was published, promoting optimal infant and young child feeding for alland including support for BFHI. Additionally, there is new research on breastfeeding andinfant feeding and information on the critical importance of breastfeeding in emergencysituations. The main objective of the guideline is to promote breast feeding by women Literature review 39
  • 51. Department of Koumarabhrityawho are known not to be infected with HIV, and for women whose infection status isunknown, protect, promote and support exclusive breastfeeding for 6 months, followed bycontinued breastfeeding, together with appropriate complementary feeding, for up to twoyears of age or beyond. 3.4.3 Evidence for the ten steps to successful breastfeeding The “Ten Steps to Successful Breastfeeding” are the foundation of theWHO/UNICEF Baby Friendly Hospital Initiative (BFHI). They summarize the maternitypractices necessary to support breastfeeding. The BFHI addresses a major factor whichhas contributed to the erosion of breastfeeding – that is, health care practices whichinterfere with breastfeeding. Many other factors affect how women feed their infants andthe length of time for which they breastfeed. In the ‘Ten Steps’, policy development andstaff training resulting in appropriate skilled support of mothers before, during and afterdelivery, and ongoing postnatal support in the community, are all necessary to realize theimprovements aimed for by other activities.3.4.3.1 The Ten Steps to Successful Breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within a half-hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. Literature review 40
  • 52. Department of Koumarabhritya 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in - allow mothers and infants to remain together - 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast- feeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.3.5 Contraindications of breast feeding: For the average, healthy, full-term infant there are no disadvantages to breast-feeding, provided that the mothers milk supply is ample and that her diet containssufficient amounts of protein and vitamins. Infrequently, allergens to which the infant issensitized may be conveyed in the milk. In such cases, an attempt should be made to findthe specific allergen and to remove it from the mothers diet; its presence rarely is a validreason for weaning the baby. From the mothers standpoint, there are few contraindications to breast-feeding.Markedly inverted nipples may be troublesome. Fissuring or cracking of the nipples canusually be avoided if engorgement is prevented. Mastitis may be alleviated by continuedand frequent nursing on the affected breast to keep it from becoming engorged, by localheat applications, and by antibiotics. Acute infection in the mother may contraindicatebreast-feeding if the infant does not have the same infection; otherwise, there is no need Literature review 41
  • 53. Department of Koumarabhrityato stop nursing unless the condition of either necessitates it. When the infant is unaffectedand the mothers condition permits, the breast may be emptied and the milk given to theinfant. Septicemia, nephritis, eclampsia, profuse hemorrhage, active tuberculosis, typhoidfever, breast cancer, and malaria are contraindications to nursing, as are chronic poornutrition, substance abuse, debility, severe neuroses, and postpartum psychoses.3.6 Formula Feeding (12) Whole cows milk or its modified form is the basis for most formulas, althoughother milks and milk substitutes are available for infants who cannot tolerate it.Sterilization and refrigeration of the formula greatly reduce morbidity and mortality fromgastrointestinal infections. Milk processing (ranging from simple home boiling tocommercial pasteurization, homogenization, and evaporation) alters the casein so thatsmall and readily digestible curds form in the stomach, eliminating the principal cause forindigestibility of cows milk protein. Although breast-feeding is considered superior to formula feeding for normalinfants, many infants receive formula from birth. Changing social and cultural patternsmay encourage formula feeding. Because they are employed outside the home, manymothers are reluctant to nurse their infants. Others believe that nursing will limit theiractivities or they fear failure at nursing. Some regard weight gain and loss of breast toneas unattractive and some consider breast-feeding as socially unacceptable. Whatever thereasons, the present popularity of artificial feeding could not have been reached withoutprior improvements in the safety and quality of the substitute milks. Literature review 42
  • 54. Department of Koumarabhritya Objective nutritional studies of growing infants (e.g., rate of growth in weight andlength, normality of various constituents in blood, performance in metabolic studies, bodycomposition) show relatively small differences between infants fed human milk and thosefed cows milk. Although such techniques may not record small but important variations,these investigations attest to the normal infants ability to thrive by making satisfactoryphysiologic adjustments to wide ranges of ingested protein, fat, carbohydrate, andminerals. Conventional formulas of whole and evaporated cows milk provideapproximately 3–4 g of protein/kg/24 hr ("high protein" intake largely exceeding thebasic need, whereas breast milk and many commercially prepared feedings simulating thecomposition of breast milk supply 1.5–2.5 g/kg/24 hr ("low-protein" intake supplying asmaller degree of excess). Commercial formulas are modified from a cows milk base, and their protein andash levels are reduced nearer to those of human milk, thus decreasing osmolality andrenal excretory load. The saturated fat of cows milk is replaced with some unsaturatedvegetable fatty acids, and vitamins are added. The concentration of lactose is lower incows milk than in human milk. Some formulas include higher whey protein and lowercasein, such as in breast milk. Low-birth weight infants in particular may benefit from theincreased cystine of whey proteins. Until more information is available, breast-feeding forall infants appears prudent, but if this is impossible, then a formula as compositionallyclose to breast milk as possible is desirable. Literature review 43
  • 55. Department of Koumarabhritya Chapter 4 Complementary feeding 4.1 Relevant definitions(13) Complementary food means any food whether manufactured or locally prepared,suitable as a complement to breast milk or to infant formula, when either becomeinsufficient to satisfy the nutritional requirements of the infant Such food is alsocommonly called weaning food or breast-milk supplement. Breast-milk substitute means any food being marketed or otherwise presented as apartial or total replacement for breast milk, whether or not suitable for that purpose. Infant formula means a breast-milk substitute formulated industrially inaccordance with applicable Codex Alimentarius standards, to satisfy the normalnutritional requirements of infants up to between four and six months of age, and adaptedto their physiological characteristics. Literature review 44
  • 56. Department of Koumarabhritya 4.2 Ideal time to start complementary feeding (the optimal duration of exclusive breastfeeding) (14) The debate over the optimal duration of exclusive breastfeeding has had a longhistory. Growth faltering is a commonly observed phenomenon in developing countriesafter about 3 months of age. This growth faltering has traditionally been attributed tothree factors: 1. The inadequacy of energy intake from breast milk alone after 3 or 4 months. 2. The poor nutritional quality (i.e., low energy and micronutrient content) of the complementary foods commonly introduced in many developing countries. 3. The adverse effects of infection on energy intake and expenditure. The inadequacy of breast milk for energy requirements beyond 3 or 4 months wasinitially based on calculations made by the Food and Agricultural Organization (FAO)and World Health Organization (WHO) in 1973. The belief that breast milk alone isnutritionally insufficient after 3 or 4 months, combined with the fact that complementaryfoods given in many developing countries are both nutritionally inadequate andcontaminated, led to concern about the so-called “weanling’s dilemma.” Breastfeeding isa life-and death issue in developing countries. A recent metaanalysis reported markedlyreduced mortality (especially due to infectious disease) with breastfeeding even into thesecond year of life. A recent study from India reported an increased risk of post neonatalmortality associated with exclusive breastfeeding >3 months, but reverse causality (illness Literature review 45
  • 57. Department of Koumarabhrityaprior to death preventing the infant’s acceptance of complementary foods), selection bias(exclusion of infants who died prior to each cross-sectional period), or uncontrolledconfounding might explain this result. The weanling’s dilemma and the risk of mortality associated with earlyintroduction of complementary foods are concerns primarily in developing countries. Inmost developed countries, uncontaminated, nutritionally adequate complementary foodsare readily available, and growth faltering is relatively uncommon. With the resurgence ofbreastfeeding in developed countries, however, recent attention has turned to theimportance of promoting its duration and exclusivity. The epidemiologic evidence is nowoverwhelming that, even in developed countries, breastfeeding protects againstgastrointestinal and (to a lesser extent) respiratory infection, and that the protective effectis enhanced with greater duration and exclusivity of breastfeeding.13–17 (“Greaterduration and exclusivity” is used in a general sense here; the references cited do notpertain specifically to the subject of this review, i.e., the optimal duration of exclusivebreastfeeding.) Prolonged and exclusive breastfeeding has also been associated with areduced risk of the sudden infant death syndrome (SIDS) and of atopic disease, and somestudies even suggest acceleration of neurocognitive development and protection againstlong-term chronic conditions and diseases like obesity, type I diabetes mellitus, Crohn’sdisease, and lymphoma. Maternal health benefits have also received considerableattention in developed countries, including possible protection against breast canceramong pre menopausal women, ovarian cancer and osteoporosis. Literature review 46
  • 58. Department of Koumarabhritya In the last years, recommendations for the optimal duration of exclusivebreastfeeding promoted by WHO and UNICEF started to differ. WHO had continued torecommend exclusive breastfeeding for 4 to 6 months, with the introduction ofcomplementary foods thereafter, whereas UNICEF preferred the wording “for about 6months”. This led to concerns in the larger infant nutrition and public healthcommunities. The American Academy of Pediatrics’ position is unclear; in two differentsections of their Pediatric Nutrition Handbook, they alternatively recommend human milk“as the exclusive nutrient source during the first 6 months” and “to delay introduction ofsolid foods until 4 to 6 months”.4.3 Research findings on the duration of exclusive breast feeding (ideal time to start complementary feeding) A review paper was published by Department of nutrition for health anddevelopment and Department of child and adolescent health and development, Worldhealth organization, regarding The Optimal Duration of Exclusive Breastfeeding, in theyear 2002. The primary objective of this review was to assess the effects on child health,growth, and development, and on maternal health, of exclusive breastfeeding for 6months versus exclusive breastfeeding for 3–4 months with mixed breastfeeding(introduction of complementary liquid or solid foods with continued breastfeeding)thereafter through 6 months. The main results obtained in the study were as follows. Sixteen independentstudies meeting the selection criteria were identified by the literature search: 7 fromdeveloping countries (2 of which were controlled trials in Honduras) and 9 from Literature review 47
  • 59. Department of Koumarabhrityadeveloped countries (all observational studies). Neither the trials nor the observationalstudies suggest that infants who continue to be exclusively breastfed for 6 months showdeficits in weight or length gain. The data are scarce with respect to iron status, but atleast in developing country settings where newborn iron stores may be suboptimal,suggest that exclusive breastfeeding without iron supplementation through 6 months maycompromise hematological status. Based primarily on an observational analysis of a largerandomized trial in Belarus, infants who continue exclusive breastfeeding for 6 months ormore appear to have a significantly reduced risk of one or more episodes ofgastrointestinal infection. No significant reduction in risk of atopic eczema, asthma, orother atopic outcomes has been demonstrated in studies from Finland, Australia, andBelarus. Data from the two Honduran trials suggest that exclusive breastfeeding through6 months is associated with delayed resumption of menses and more rapid postpartumweight loss in the mother.. The reviewers of the study further conclude that they found infants who areexclusively breastfed for 6 months experience less morbidity from gastrointestinalinfection than those who are mixed breastfed as of 3 or 4 months, and no deficits havebeen demonstrated in growth among infants from either developing or developedcountries who are exclusively breastfed for 6 months. Moreover, the mothers of suchinfants have more prolonged lactational amenorrhea. Although infants should still bemanaged individually so that insufficient growth or other adverse outcomes are notignored and appropriate interventions are provided, the available evidence demonstratesno apparent risks in recommending, as public health policy, exclusive breastfeeding forthe first 6 months of life in both developing and developed country settings. Literature review 48
  • 60. Department of Koumarabhritya4.4 Complementary feeding practices (15) Literally weaning/complementary feeding means to detach child from itsbiological food, and introduce substitute foods. However, breast milk remains animportant part of the diet. Weaning is a period of physical psychological and nutritionalstress to the child and is of vital importance in developing countries where it is oftenassociated with protein calorie malnutrition and other nutritional disorders. A proper weaning is extremely important to maintain the health of thebody. It has to be done slowly around 4-6 months of age when breast milk usuallyinadequate particularly in malnourished women which forms the bulk in the underprivileged communities. Their babies do very well in first 3 to 4 months of life, but from4 to six months onwards, their growth curve becomes flat and baby developsmalnutrition. However often in well nourished mothers in orthodox cultures, the humanmilk alone may be adequate for a period of 9 months or more. Slow weaning is also preferable to prevent breast addiction syndrome which islikely to occur if baby is not used to introduction of artificial milk feeds, semi solids orsolids by about 4 to 6 months of age. The situation today is that mother’s milk yield isnot as much in the past, particularly in malnourished mothers of underprivilegedcommunities and even in well nourished mothers in urban societies. Under thesecircumstances, the energy needs of the child can not be satisfied by the mother’s milkalone after 4 to 6 months. Hence early introduction of weaning foods is necessary byperforming ‘Annaprasm ceremony’ in 6 months of age. Literature review 49
  • 61. Department of Koumarabhritya The process of weaning should consist of gradually replacing breast feeding byliquids and milk initially and later semisolids and solid foods, administered with a spoonor from a cup. In the second six months, mother’s milk is important food but other foodsare also important for necessary calories. Hence in second month of life child is likely toget 30-40 percent of calorie requirements from mother’s milk, about 30 percent fromsemisolid and solid foods. Mother’s milk is an important food even in second year of lifeas a supplement to main food of cereals, pulses and legumes which are available in theusual diet of the family. Complete weaning may be achieved by the age of 18 – 24 months in low socioeconomic groups where the necessity of even small amount of breast milk is very great,compared to upper and middle socio economic groups who could afford the foods andmay wean the babies between 14 and 18 months. Early weaning should not be induced ifthe baby is doing well with mother’s milk, as early introduction before 4-6 months willreduce the milk yield of the mother. Moreover, introduction of other foods may producegastrointestinal upsets if the weaning is done at an early age. There may be allergicmanifestation due to other foods in some children and obesity in the upper socioeconomic groups. On the other hand, weaning should not be delayed if the child is notgaining weight or shows signs of hunger and under feeding. In such case other foodsshould be introduced between 4 and 6 months of age. Weaning should not be abrupt to or acute as this leads to great emotional trauma,particularly in the baby. If the family can afford other foods baby’s nutrition may notsuffer. However in the vast majority of underprivileged population in developingcountries lack of financial resources to buy top milk feeds and solids. Absence of goodweaning foods and lack of hygienic facilities n the family the abrupt weaning may lead to Literature review 50
  • 62. Department of Koumarabhrityaacute malnutrition, emotional deprivation and infection and a picture of marasmus andkwashiorkor in 6-8 weeks weaning. The abrupt weaning in an older infant is moretraumatic as the older infant has developed stronger attachment to his mother.4.5 Complementary foods (16) In the developing countries, weaning foods should consist of usual family foods.There is no difference between the adult and baby food except that baby foods are cookedlittle more to make them digestible. The usual family foods have an advantage becausethey are easily available, forms a part of family life and are better accepted, are verycheap and could be easily prepared by the mother. A large number of tinned baby foodsavailable in the market is a danger in the developing countries as these discourage breastfeeding. The objective of giving weaning food is to strengthen the calorie content of baby’sdiet or to meet with the energy requirement of the baby, supply complete protein andminerals from the vegetables. The idea is to give double cooked rice or wheat gruelmixed with double cooked pulses like green grams and red grams. These are usuallyfound digestible and cheap. A small amount of mashed vegetables should be added so asto supply the minerals and vitamin A and make the food a triple mix. In well to docommunities by the age of 6-7 months chicken soups, eggs, boiled fish, by 8 monthmutton soup could be introduced. The best weaning food is a mixture of cereals andpulses, two parts of cereals and one part of pulses, cooked at home with addition of somegreen vegetables. Ten to fifteen grams of mixed food should be given to start with and itshould be increased to about 30 grams a day and given between the breast feeds. At nightbreast milk alone should be continued because of ease and convenience. Literature review 51
  • 63. Department of Koumarabhritya4.5.1 Some recent observations regarding supplementary feeding (16) The weaning foods mentioned earlier though are most convenient, cheap, andacceptable and hence practical at any level have only one difficulty and that is they arebulky and have low calorie density. For example in infants of 4-6 months to provide aextra calorie of 300-400 per day, the infant will have to consume about 100-150 gms ofuncooked cereal pulse mixture or 300-500 gms of cooked quantity, usually rice and greengram, Tuvar (red gram) in two to one proportion. This means that the infants will have toconsume about 2 cupfuls of cooked food. This is a large bulk and produces abdominaldistension or the baby may look potbellied. This may not be significant in the populationat large but if the same food can be given in smaller bulk with a higher calorie density andwith out increasing cost and labor significantly, it will be desirable. Under the circumstances in poor communities when the baby is doing fairly wellonly on mother’s milk, introduction of supplementary feeding may be delayed till 6months of age as the incidence of diarrheal diseases in these infants will be very lowwhen they are breast feed only. There is another important consideration. The supply ofhuman milk depends on the demands by the baby. The greater the frequency and durationof breast feeding, greater will be the yield of human milk. Hence to maintain adequatemilk yield, in poor communities, breast feeding alone should be continued till 6 months ofage and then supplementary feeding should be added. However , it should be emphasizedthat mother must continue feeding the baby till 18 to 24 months of age as the human milkthough at this age of the baby is not meant to provide only nutrients, but to provide antiinfective substance. Literature review 52
  • 64. Department of Koumarabhritya4.5.2 Types of supplementation In poor communities living in unhygienic conditions with no access to to safewater supply the use of freshly cooked foods containing cereals, pulses and vegetableswhich can be cooked pose less risk of alimentary infection compared to commercial foodsstored and prepared under unhygienic conditions. In upper socio economic groups, with better living conditions, the supplementaryfeeding can be started at 3-4 months, while in lower socioeconomic groups with mother’sbetter lactation performance, it should be started at 6 months. It is desirable to give malted food which reduces the bulk and provides highcalorie density. Standard method of balanced food formulation which has low pasteviscosity and could therefore be used for increasing the calorie intake of the babies ascomplementary to breast feeding after 4-6 months of age. Various cereals and pulses canbe malted eg; the grains like ragi and green gram, wheat or rice. Ragi is relativelyinexpensive food grain with high content of calcium while green gram is free from toxicanti growth and flatus producing factors. The combination of cereals and pulses will alsobalance the aminoacid profile of the formula.The steps of malting 1. The grains are germinated for 1-2 days and then dried. 2. They should be toasted and dehusked so that unwanted enzymes are destroyed, while amylase is preserved. 3. The dehusked grain flour are mixed in the proportion of 2:1 Literature review 53
  • 65. Department of Koumarabhritya4.6 Improved weaning practices Any new food should be initially offered once a day in small amounts (1–2teaspoonfuls). Any small spoon that easily fits the babys mouth may be used. New foodsare generally best accepted if fairly thin or dilute. Food is frequently pushed out by thetongue rather than back because the baby cannot yet swallow efficiently. This should bementioned to the mother, who might otherwise interpret the "spitting out" of new foods asdislike. It is usually wise to offer the same food daily until the baby becomes accustomedto it and not to introduce new foods more often than every 1–2 wk. The feeding at which these foods are offered is not particularly important. Theyshould be given when the babys hunger is no longer satisfied by milk alone and whenthey fit into the daily schedule. There is no reason for persisting with or forcing aparticular food that is definitely disliked. The familys dislikes and prejudices forparticular foods are contagious and should not be displayed before the infant. Thephysician should avoid prescribing a definite amount of a given food lest the motherinterpret the suggestion too literally. Many infants are overfed by overzealous parentswho mistake acceptance of food for appetite. The infants appetite is the best index of theproper amount, and respect for the infants wishes will avoid many problems. Weaning is a hazardous period for many infants. This is because the child may notreceive food of adequate nutritional value and the food and drinks provided may becontaminated with pathogenic microbes, including those that cause diarrhea. The dangeris that the child will become undernourished due to an inadequate diet and repeatedepisodes of diarrhea, or will succumb to dehydration caused by an acute episode of Literature review 54
  • 66. Department of Koumarabhrityadiarrhea. Unfortunately, these processes are inter-related. Undernutrition increases thechilds susceptibility to infection so that the child experiences more frequent and moresevere episodes of diarrhea, and diarrhea accelerates the development of undernutrition. Some specific problems associated with weaning that can lead to undernutrition ordiarrhea are: 1. Delaying the start of weaning beyond 4-6 months of age 2. Weaning too abruptly. 3. Giving too few meals per day. 4. Giving supplementary foods with a low content of protein and particularly energy. 5. Preparing and storing weaning foods in a way that permits bacterial contamination and growth. 6. Giving milk or other drinks prepared with contaminated water or in a contaminated feeding bottle. 4.6.1 Implications for mothers Weaning should begin when the child is 4-6 months old. While continuing tobreast-feed, the mother should give a little well-cooked soft or mashed food, such ascereals and vegetables, twice each day. When the child is 6 months of age, the variety offoods should be increased and meals should be given at least four times per day, inaddition to breast-feeding. After 1 year of age, the child should eat all types of food;vegetables, cereals, and meat should continue to be well-cooked, and mashed or ground.Food should be given 4-6 times per day. If possible, breast-feeding should be continued. Literature review 55
  • 67. Department of Koumarabhritya Cereals and starchy roots are the most widely used weaning foods, but these arerelatively low in energy. They should be given as a thick pap or porridge, using a spoon,and not as a dilute drink. The energy content should be increased by mixing one or twoteaspoonfuls of vegetable oil into each serving. The objective is to achieve an energyintake of about 110 kcal/kg/day. Between the age of 6 months and one year, pulses, fruit,green vegetables, eggs, meat, fish, and milk products should be added to the diet. In areaswhere vitamin A deficiency is a problem, the diet should include orange, yellow, or dark-green vegetables, yellow fruit, red palm oil, and, if possible, liver, full-cream dairyproducts, or fish.4.6.2 Common complementary foodsa. Cereals- The various precooked cereals on the market provide in a convenient form avariety of grains excellent for infants. Most contain iron and factors of the vitamin Bcomplex.b. Fruits- Strained or crushed cooked fruits furnish minerals and some water-solublevitamins and usually have a mildly laxative effect. Raw ripe mashed banana is readilydigested and enjoyed by most infants. Many infants who are slow in accepting new foodsseem to prefer fruits.c. Vegetables-Vegetables are moderately good sources of iron and other minerals and ofthe B-complex vitamins. They should be freshly cooked and strained or commerciallyprepared. Vegetables are usually added to the infants diet by about 7 mo of age.d. Eggs- Eggs are usually introduced during the second 6 mo of life, although somephysicians offer egg yolk at an earlier age. The yolk of the egg is used initially and ispreferably hard-cooked. As with all new foods, a small amount is offered at first, with Literature review 56
  • 68. Department of Koumarabhrityagradual increases up to a whole yolk 1–3 times a week. Egg white should be introducedwith equal caution to minimize any possible allergic manifestations.e. Starchy Foods - Potatoes, rice, bread, and similar starchy foods have principally acaloric value. As a rule, they are not included in the infants diet until the more essentialfoods mentioned earlier are being taken regularly. Toast or biscuits may be offered to theinfant when he or she shows an interest in "gumming" on coarser foods (usually 6–8 moof age). It is with such foods that infants learn to chew and to feed themselves.f. Meats- Meat is an excellent source of protein as well as of iron and vitamins. Groundfresh beef or liver or the strained canned meats may be used initially by about 6 mo ofage. Meats may be more readily accepted when mixed with another food. The commercial soups and meat and vegetable mixtures are relatively high incarbohydrate and are not considered optimal sources of iron or protein. Many home-prepared soups are bulky out of proportion to their food value, and much of the vitamincontent is lost by overcooking.g. Sweets - Desserts, Puddings, junkets, and custard are good foods for older infants,particularly if they temporarily prefer milk in that form. If, however, such foods are givenas a bribe or reward or only after other foods have been finished, poor eating habits arelikely to be established. Sweet foods should be offered as casually as the rest of the mealand at any place in the meal that the child desires.h. Salt - To increase their palatability, particularly for the parent, excessive salt used to beadded to baby foods. This practice has been discontinued. The significance of largeintakes of sodium, which are in the ranges seen in populations with a high incidence ofhypertension, is not clear, but the possibility that they might contribute to thedevelopment of hypertension later in life cannot be ignored. Literature review 57
  • 69. Department of Koumarabhrityai. Food additives - Naturally occurring chemicals and food additives, particularly theartificial flavors and colors, have been implicated in health problems. It has beenestimated that more than 3,000 flavors are currently being used, and few children arespared exposure to them in their daily diet. Artificial flavors and colors have beenassociated with respiratory allergic disorders, with urticaria and angioedema, with lesionsof the tongue and buccal mucosa, with digestive disturbances, with arthralgia andhydrarthroses, and with headache and behavioral disturbances, including hyperkinesis inchildhood.4.6.3 Preparation and feeding of complementary foodsMothers should be taught ways of preparing, giving, and storing weaning foods thatreduce the risk of bacterial contamination. These include: 1. Washing her hands before preparing weaning foods and before feeding the baby. 2. Preparing the food in a clean place. 3. Cooking or boiling the food well when preparing it. 4. If possible, preparing the food immediately before it will be eaten. 5. Covering food that is being kept. Keeping food in a cool place; refrigerating it if possible. 6. If cooked food was prepared more than two hours before it is used, reheating it until it is thoroughly hot before giving it to the baby. 7. Feeding the baby with a clean spoon, from a cup, or with a special feeding spoon. Feeding bottles should never be used. Literature review 58
  • 70. Department of Koumarabhritya 8. Washing uncooked food in clean water before feeding it to the baby; an exception is fruit that is peeled before it is eaten, such as a banana.4.6.4 Implications for doctors 1. Make the assessment of weaning diets and weaning education a routine element of well-baby programmes. This should be coordinated with the use of growth charts to identify children with growth faltering, for whom improved feeding is especially important. 2. Evaluate the nutritional status of children with diarrhea, by measuring mid-upper arm circumference, weight for age, or weight for height: 3. Refer all children with severe undernutrition to a treatment centre where nutritional rehabilitation is possible; 4. For moderately undernourished children, ask about the childs weaning diet and feeding practices. Advise the mother on ways of increasing the childs intake of safely prepared, energy-rich foods. If possible, follow up the child after diarrhea stops until the weight or rate of growth has become normal; 5. Otherwise, provide advice on correct feeding during diarrhea and afterwards (giving one extra meal each day for at least two weeks after diarrhea stops).4.7 First-Year Feeding Problems (17)4.7.1 Underfeeding Underfeeding is suggested by restlessness and crying and by failure to gain weightadequately, despite complete emptying of the breast or bottle. Underfeeding may alsoresult from the infants failure to take a sufficient quantity of food even when offered. In Literature review 59
  • 71. Department of Koumarabhrityathese cases, the frequency of feedings, the mechanics of feeding, the size of the holes inthe nipple, the adequacy of eructation of air, the possibility of abnormal mother-infant"bonding," and possible systemic disease in the baby should be investigated. The extentand duration of underfeeding determine the clinical manifestations. Constipation, failureto sleep, irritability, and excessive crying are to be expected. There may be poor gain inweight or an actual loss. In the latter case, the skin becomes dry and wrinkled,subcutaneous tissue disappears, and the infant assumes the appearance of an "old man."Deficiencies of vitamins A, B, C, and D and of iron and protein may be responsible forcharacteristic clinical manifestations. Treatment consists of increasing the fluid and caloric intake, correctingdeficiencies in vitamin and mineral intake, and instructing the mother in the art of infantfeeding. If some underlying systemic disease or psychological problem is responsible,specific management of these disorders is necessary.4.7.2 Overfeeding Overfeeding may be quantitative or qualitative. Regurgitation and vomiting arefrequent symptoms of overfeeding. As a rule, infants can be depended on not to takeexcessive quantities, but occasionally an infant who has postprandial discomfort fromeating too much may nonetheless gain weight excessively. Diets too high in fat delaygastric emptying, cause distention and abdominal discomfort, and may cause excessivegain in weight. Diets too high in carbohydrate are likely to cause undue fermentation inthe intestine, resulting in distention and flatulence and in too rapid gain in weight. Suchdiets may be deficient in essential protein, vitamins, and minerals. Formulas too high incaloric content in the first 1–2 wk of life are likely to result in loose or diarrheal stools. Literature review 60
  • 72. Department of KoumarabhrityaObesity is undesirable at any time in life; often the excessively fed infant becomes theobese child and adult.4.7.3 Regurgitation and vomiting The return of small amounts of swallowed food during or shortly after eating iscalled "regurgitation" or "spitting up." More complete emptying of the stomach,especially occurring some time after feeding, is called "vomiting." Within limits,regurgitation is a natural occurrence, especially during the first 6 mo or so of life. It canbe reduced to a negligible amount, however, by adequate eructation of swallowed airduring and after eating, by gentle handling, by avoiding emotional conflicts, and byplacing the infant on the right side for a nap immediately after eating. The head shouldnot be lower than the rest of the body during the rest period because gastroesophagealreflux is common during the first 4–6 months. Vomiting, one of the most commonsymptoms in infancy, may be associated with a variety of disturbances, both trivial andserious. It should be distinguished from rumination; its cause should always beinvestigated.4.7.4 Loose or diarrheal stools The stool of the breast-fed infant is naturally softer than that of the infant fedcows milk. From about the 4th to the 6th day of life, the stools go through a transitionalstage in which they are rather loose and greenish yellow and contain mucus; within a fewdays, the typical "milk stool" appears. Subsequently, the use of laxatives or the ingestionof certain foods by the mother may be temporarily responsible for an infants loose stools.Excessive intake of breast milk may also increase the frequency and the water content ofthe stool. Actual diarrhea in a breast-fed infant is unusual and should be consideredinfectious until proved otherwise. Literature review 61
  • 73. Department of Koumarabhritya Although the stools of artificially fed infants tend to be firmer than those ofbreast-fed infants, loose stools may result from artificial feeding. In the first 2 wk or so oflife, overfeeding is likely to cause loose, frequent stools. Later, formulas too concentratedor too high in sugar content, especially in lactose, may produce loose, frequent stools.Many temporary diarrhea disturbances in artificially fed infants result from foodcontaminations that would not disturb an older child and are not serious enough to causeprolonged difficulty for the infant. The ease with which artificially fed infants acquirediarrheal disturbances and their potential seriousness are strong arguments for extremecare in providing food free of pathogenic bacteria.Mild diarrheal disturbances due to overfeeding respond quickly to temporary decrease orcessation of feeding. Withholding all solid food and one or several milk feedings,substituting boiled water or a balanced electrolyte solution, are usually all that is required.4.7.5 Constipation Constipation is practically unknown in breast-fed infants receiving an adequateamount of milk and is rare in artificially fed infants receiving an adequate diet. The natureof the stool, not its frequency, is the mark of constipation. Although most infants haveone or more stools daily, an infant will occasionally have a stool of normal consistencyonly at intervals of 36–48 hr. Whenever constipation is present from birth or shortlythereafter, a rectal examination should be performed. Tight or spastic anal sphincters maybe responsible occasionally for constipation, and correction usually follows fingerdilatation. Anal fissures or cracks may also cause constipation. If irritation is alleviated,healing usually occurs quickly. Aganglionic megacolon may be manifested byconstipation in early infancy; the absence of stool in the rectum on digital examinationsuggests this possibility. Literature review 62
  • 74. Department of KoumarabhrityaConstipation in the artificially fed infant may be caused by an insufficient amount of foodor fluid. In other cases, it may result from diets too high in fat or protein or deficient inbulk. Simply increasing the amount of fluid or sugar in the formula may be corrective inthe first few months of life. After this age, better results are obtained by adding orincreasing the amounts of cereal, vegetables, and fruits. Prune juice (1/2–1 oz) may begiven as a temporary measure, but it is better to add foods with some bulk. Enemas andsuppositories should never be more than temporary measures. Milk of magnesia may begiven in doses of 1–2 teaspoonfuls but should be reserved for unresponsive or severeconstipation.4.7.6 Colic The term "colic" describes a frequent symptom complex of paroxysmal abdominalpain, presumably of intestinal origin, and of severe crying. It occurs usually in infantsyounger than 3 mo of age.The clinical pattern is characteristic. The attack usually beginssuddenly; the cry is loud and more or less continuous; so-called paroxysms may persistfor several hours; the face may be flushed, or there may be pallor; the abdomen isdistended and tense; the legs are drawn up on the abdomen, though they may bemomentarily extended; the feet are often cold; the hands are clenched. The attack mayterminate only when the infant is completely exhausted, but often there is apparent reliefwith the passage of feces or flatus. The cause of recurrent attacks is usually not apparent, although they may beassociated with hunger and with swallowed air that has passed into the intestine.Overfeeding may also cause discomfort and distention. Certain foods, especially those ofhigh carbohydrate content, may be responsible for excessive fermentation in theintestines, but a change in diet only occasionally prevents further colic attacks. Recurrent Literature review 63
  • 75. Department of Koumarabhrityaattacks commonly occur late in the afternoon or evening, suggesting that events in thehousehold routine may possibly cause them. Worry, fear, anger, or excitement may causevomiting in an older child and may cause colic in an infant. Holding the baby upright or permitting the baby to lie prone across the lap or on ahot water bottle or heating pad helps occasionally. Passage of flatus or fecal materialspontaneously or with expulsion of a suppository or enema sometimes affords relief.Prevention of attacks should be sought by improving feeding techniques, includingburping, providing a stable emotional environment, identifying possibly allergenic foodsin the infants or nursing mothers diet, and avoiding underfeeding or overfeeding. Colicrarely persists after 3 mo of age. A supportive, sympathetic physician is important insuccessfully resolving the problem.4.8 Feeding During the Second Year of Life (18) Most infants naturally adapt themselves to a schedule of three meals a day byabout the end of the 1st yr of life. Although considerable latitude in the diet of each infantshould be permitted to allow for personal idiosyncrasies and family habits, the mothershould be given an outline of the daily basic dietary needs. When malnutrition, either asdietary deficiency or excess, or failure to thrive exists despite an apparently satisfactoryfood intake, the infant or childs family relationships must be evaluated, not only fororganic causes but especially for psychosocial ones.4.8.1 Reduced caloric intake Towards the end of the 1st yr of life and during the 2nd yr, because of theconstantly decelerating rate of growth, there is a gradual reduction in the infants caloricintake per unit of body weight. In addition, it is not unusual to have temporary periods oflack of interest in certain foods or even in food in general. Failure to recognize these Literature review 64
  • 76. Department of Koumarabhrityafeatures, especially the decreasing caloric needs, results in attempts to force feed. Thechild naturally rebels and feeding problems ensue. Because preventing problems is moreeffective than correcting them, the changing pattern of the infants food habits during the2nd yr of life should be explained to the mother before it appears.4.8.2 Self-selection of diet Childrens strong likes or dislikes of particular foods should be respectedwhenever possible and practicable. Spinach is an example of a nonessential food whosevirtues have been overemphasized. When consistently rejected foods include basic staplessuch as milk and cereal, food allergy should be considered. Children, including infants, tend to select diets that, over several days, assume abalanced nature. Thus, the child may be permitted a wide choice of foods, as long as he orshe eats adequately over the longer period. Normally, the child determines the quantity tobe eaten of a given food and of the entire meal. At this age, eating habits may be stronglyinfluenced by older children in the family, particularly in respect to food likes anddislikes. Eating patterns and habits developed in the first 2 yr of life usually persist forseveral years.4.8.3 Self-feeding by infants Before 1 yr of age, the infant should be permitted to participate in the act offeeding. By approximately 6 mo, the infant can hold a bottle; within another 2–3 mo, acup. Biscuits, Rusk or other hand-held foods can be introduced by the age of 7–8 mo. Aspoon may be used as soon as it can be held and directed to the mouth, possibly by 10–12mo of age. Mothers often inhibit this learning process because they object to itsmessiness. Literature review 65
  • 77. Department of Koumarabhritya Acquiring the ability to feed oneself is an important step in developing self-reliance and responsibility. By the end of the 2nd yr of life, infants should be largelyresponsible for feeding themselves. Permitting infants and children to go to sleep while sucking intermittently from abottle of formula, whole milk, sweet fruit juice, or water should be discouraged.Pedodontists emphasize the correlation between this habit and enamel erosion indeciduous teeth, calling it the "baby bottle syndrome."Although nutritional requirementsper unit of body weight constantly decrease with increasing age (110 kcal/kg in infancy;50 kcal/kg at 15 yr), the need for calories as well as for protein, vitamins, and minerals isrelatively greater in children than it is in adults.4.8.4 Daily basic diet Parents should be given a daily basic diet for the child from which the familymenu can be prepared. Daily selection from each of the food groups provides a balanceddiet with sufficient macronutrients and micronutrients. The quantity of intake after thebasic requirements have been met can be determined usually by the healthy growingchild. The childs history of dietary habits is essential for evaluating the nutritive intake,but such histories are often unreliable unless an accurate dietary diary is kept for severaldays. From such information, correcting the diet may be more effective.The older child should learn the content of a basic diet and its importance to propergrowth and good health, but this information should never be presented as a threat toenforce rigid feeding practices.4.8.5 Eating habits Eating habits formed in the 1st yr or 2 of life distinctly affect those of thesubsequent years. Feeding difficulties between the ages of 2–5 yr frequently result from Literature review 66
  • 78. Department of Koumarabhrityaexcessive parental insistence on eating and subsequent anxiety when the child does notconform to some arbitrary standard. The childs negative reactions naturally result fromundue mealtime stress, and correction requires improvement in parent-child relations.Other factors that disturb eating are too much confusion at mealtime, insufficient time foreating, either on the part of the adult or of the child, food dislikes of other members of thefamily, and poorly prepared and unattractively served food. A comfortable chair of properheight with a foot-rest is important for a childs ease at the table. Mealtimes should behappy, and the conversation should be on subjects of interest to the entire family. Thechilds appetite should be respected; if his or her desire for food at times is below average,there should be no persuasion to eat more. Adults should realize that eating habits aretaught better by example than by formal explanation.4.8.6 Snacks between meals During the 2nd yr and even for several years thereafter, orange juice or other fruitjuice or fruit, together with a cracker, may be given in either or both of the between-mealperiods. Snacks served in nursery schools and kindergartens should be nutritious. Olderchildren should avoid between-meal snacking if it reduces their appetite for the next meal.After-school snacks, especially of fruit, should be encouraged if they produce greaterenthusiasm and energy for play and do not reduce the appetite for the evening meal.4.8.9 Vegetarian diet All-vegetable diets supply all necessary nutrients when vegetables are selectedfrom different classes. Vegetables are high in fiber content, vitamins, and minerals.Vegetarians usually have faster gastrointestinal transit time, bulkier stools, and low serumcholesterol levels and are said to have less diverticulitis and appendicitis than meat eaters.Those who consume eggs are ovovegetarians. Those who consume milk are Literature review 67
  • 79. Department of Koumarabhrityalactovegetarians. Those who consume neither are vegans. Vegans may develop vitaminB12 deficiency and, because of high-fiber intake, may develop trace mineral deficiency.Nursing vegan mothers must be given added vitamin B12 to prevent methylmalonicacidemia in their infants. Vegetarian infants may not grow as rapidly as omnivores in thefirst two years. Literature review 68
  • 80. Department of Koumarabhritya Chapter 5 Growth and development - Ayurvedic perspective There is no such branch which is exactly equivalent to pediatrics, in the non-conventional Indian medical system – Ayurveda. The branch, which includes the diseaseof the children and their remedies in Ayurveda, is termed as ‘Koumarabhrithya’ (19). It isa branch which deals with human life far beyond conception until maturity where as inpediatrics, the life is considered from the point of conception to adolescence. Thepediatric practices came in to existence in India right from Vedic period, from where theroots of the system can be traced. But it turned out to be in an organized form andexplained in detail in the Brihathrayi period. Balachikitsa or Koumarabhrithya isincluded in the eight divisions of Ayurveda (19). The elaborated branch deals withgynecology, obstetrics and pediatrics mainly. The textual references for the treatment of children can be obtained fromBrihathrayi and Laghuthrayi. But the branch has an organized form in Kasyapasamhita, unfortunately the major part of which is lost. Arogya kalpadrumam publishedby Kaikulangara Ramawarrier is a fantastic textbook in the field, widely and effectively Literature review 69
  • 81. Department of Koumarabhrityapracticed in Kerala. Plenty of formulations are available from these text books as well asfrom the traditional medical knowledge of the state of Kerala. Growth and development is a continuous process in children which is handledwith utmost importance in the science. Many ancient scholars explain development of thefetus in vitro in detail and the explanations seems to be perfect. In this study, growth anddevelopment after birth to two years is considered mainly.5.1 Growth and development Growth is the increase in dhatus (body tissues), ojas and increase in the pramana(measures) of the body with in normal limits. Development is the gradual maturation ofindriyas (sense organs), manas (mind) and budhi (intelligence). Growth is a processhappening each moment in a child’s body where as development is time bound and thecumulative representation of growth over a period. The union of sukra (sperm), sonata (ovum) and jeeva (eternal spirit) inside theuterus results in the formation of garbha (fetus) which is constituted by matrja(maternal), pitruja (paternal), rasaja (nutritive), satvaja (psychic), satmyaja (congenial)and atmaja (spiritual) factors (20,21). The garbha gets nourishment from the nutrientsreceived from the mother (upasneha) and the proper environment inside the womb(upasweda) initially and later on with the rasadhatu of mother from apara throughnabhinadi as per kedarakulyanyaya. Vata helps in the further development. Variousangas, indriyas, manas and budhi gradually develop in the fetus during its intrauterinelife. By seventh month, it will have a miniature of all dhatus, tridoshas, sarvangas, Literature review 70
  • 82. Department of Koumarabhrityaindriyas and manas (22). In the last trimester, it will mainly increase in size and developinto a healthy baby. Many of the physiological activities not present in the fetus develop later in thelife after birth. For example due to the very little amount of feaces, the decreased actionof apanavayu and also the reduced size of pakvasaya the excretion of faeces, urine andflatus will not be there in the foetus (23). Since the face of fetus is covered by jarayu(membranes), the throat is filled with kapha and there is blockage of vata the foetus willnot cry (24). It will have the same respiration, movements and sleep as that of mother(25). After delivery the development of the body, the organ systems starts to mature andthe above functions appears (26).5.2 Factors controlling growth and development in a child Susrutha in the Sareerasthana explained six basic reasons for the formation,development and maintenance of the universe and its each component. Dalhana, thecommentator of Susruthasamhitha has beautifully converged this concept in thedevelopment of human life. The six jagat karanas can be incorporated in the concept ofgrowth and development of children as follows (27)5.2.1 Swabhavam This indicates the genetic factors of growth and development- the specific patternof growth that makes a particular species/organism unique is because of this factor. It notonly gives inter species differentiations but also the reasons for intra species diversities.The major determinant of prakruthi is swabhavam and other factors play only a Literature review 71
  • 83. Department of Koumarabhrityaregulating role. The concept of apoptosis, which determines the growth and developmentby controlling the ‘programmed cell death’- PCD exactly, explains swabhavam. Afterdelivery the development of the body, formation and falling of teeth etc is by PCD thesame explained by Dalhana as Swabhava .5.2.2 Iswaram The metabolic factors that drive the growth and development- Dalhana hasexplained that the agni situated in the body and even in each cell of an individual can beconsidered as iswaram. Paka-transformation- is the function of agni. When consideredin the macro level, the development of dhathus and the development of cells or even intracellular components, when considered in the micro level, are due to this factor.5.2.3 Kalam Environmental factors- this is represented by seetha and ushna mainly andrepresents the six seasons widely. Growth and development is regulated byenvironmental factors greatly. All the exogenous factors such as availability and natureof food, sanitation, infections etc is greatly influenced by the factor. The internal climateof the body is influenced b these factors and need to be regularized by proper methods asexplained in seasonal regimens. The growth & development is time bound. Once a particular time or age is goneany impairment that had happened can not be corrected nor does it wait for fulfillingnecessary requirements. E.g. the brain grows very rapidly during first six months of lifeand the head circumference becomes 44 cm from 34 cm. During the late six months the Literature review 72
  • 84. Department of Koumarabhrityabrain growth is only 3 cm and HC becomes 47 cm. if there is failure in such growth, itcan not be made good later. Thus, Kala may also be taken as time bound growth &development In a child as developing drastically in the first year by using madhura,snigdha aharas and being kapha predominant proper regulations are needed.5.2.4 Yadrucha Accidental factors- this generally adversely affects the growth and developmentof a child. Unexpected factors interfering with the growth of the child may end up withdangerous out puts. They mainly include  Nutrition – One of the most important factors. Growth retardation occurs in PEM, anemia & vitamin deficiency.  Chemical Agents – Androgenic hormones can accelerate growth but epiphyseal fusion occurs earlier.  Trauma – fracture of epiphyses can retard the bone growth.  Infection & Infestations – Reduces the velocity of Growth.  Emotional factors – Anxiety, lack of security, lack of emotional support & love can adversely affect the neurochemical regulation of Growth.  Cultural Factors – Child rearing & feeding are determined by cultural taboos which can sometimes adversely affect the mental constitution or the nutrition of the child. Literature review 73
  • 85. Department of Koumarabhritya5.2.5 Niyathi Socio-economic factors- proper positive social interaction of the child with thecommunity is responsible for the physical more over the psychological development ofthe child. Economic factors and availability of resources are very important.5.2.6 Parinamam Transformation- all the above said factors ultimately leading to the finaltransformation process of the growth and development in the body. Parinamam in achild’s body is very drastic. Dhathuparinama from rasa by assimilating ahararasa bythe influence of the above factors lead to the development of the child. Kala andparinama are two major factors, as both should match each other. There is specific time(Kala) for completion of each transformation (parinama). This means the age wisemilestones explained attaining timely is the indication of proper parinama. Completionof dhathuparinama is attained at sixteen years of age, Parinama from kapha predominantgrowth period to pitta predominant maturation period attains at this age. The views of Susrutha and Dalhana can be converged in to four main factors asexplained by Charaka and Chakrapani. Though these are explained for fertilization, byfine evaluation we can see that it can be applied in this context also. Proper quality of Ritu(ovulatory phase), kshetram (uterus), ambu (nutrition), and beejam (the gamates) arenecessary for the fertilsation and the same four is needed for growth and development(28). Literature review 74
  • 86. Department of Koumarabhritya In this context, Ritu means the environmental factors that create the ideal period for thedevelopment of the child and the proper time bound growth. Kshetram is the socio economic and familial factors that determine the propersupply of nutrients. Ambu is all those nutrients necessary for the physical, psychological, social andspiritual growth and development of the child. Beejam not only means the hereditary factors but also indicates the specific genepool of a race or a community determines the swabhava and there by the prakruthi of anindividual. These are again described by Charaka in terms of Shareera Vriddhikara bhavas(growth promoting factors) and Bala Vriddhikara bhavas (strength promoting factors)(29). Play vital role in the development of a child after birth until the attainment ofadulthood.The Shareera Vriddhikara bhavas explained are:a) Kalayoga (proper time)b) Swabhava samsiddhi (innate potentiality)c) Ahara soustava(food)d) Avighata (absence of any trauma) Literature review 75
  • 87. Department of Koumarabhritya Among these, the first two are the same as described by kala and swabhavaamong the causes of formation of the universe. Avighata is described in it as Yadrucha,which include the entire physical and mental trauma, which affect the proper growth anddevelopment of the child. Of all the above, Ahara soustava (food) is the most important one. The termimplies that the nutritious and balanced diet with all the required proteins, fats,carbohydrates and vitamins help for the optimal growth and development of the child.After birth, food alone is considered the most important factor for the development, and itis considered as Bahya Prana.5.3 Factors that enhance strength and immunity(30) Balavriddhikara bhavas means not only the factors which increase bodily strengthbut it also includes the factors which influence or increase the immune system i.e.vyadhikshamatva in an individual. Because proper growth and development includesphysical, mental and spiritual well being and this is possible when adequate and properbalavriddhikara bhavas are present or functions in an individual.5.3.1 Bala Vriddhikara bhavas include: 1. Balvat desha:- This means taking birth in a place where healthy individuals have born. The economical and cultural aspects of a country definitely influence the growth and development of a child. Malnutrition and childhood mortality are high in developing countries than developed countries. Literature review 76
  • 88. Department of Koumarabhritya 2. Sukha Kalayoga: Moderate climate when there is neither excess heat nor cold, and which is pleasant, helps in promoting proper growth and development of a child. This will have a direct influence on the agriculture and thereby the economy of a country, which will later affect the health of the society. 3. Balvat Kala: -ideal time of birth-This bhava indicates that when a child takes birth in a Balavan family and in good season like Visarga kala, which is known to be Balavan naturally, it shows its impact over his Samvardhana 4. Beeja kshetra sampath: - ideal genetic and intrauterine conditions 5. Ahara Sampath: Food is the most important factor for the growth & development of the body. The food should be very much balanced with all nutritional rasas containing adequate quantities of carbohydrates, fat, protein, vitamins, minerals etc. 6. Shareera Sampath: This results from the chromosomes of parents or due to virtuous actions of past life. Genetically some races have better physique. 7. Satmya Sampath: Sathmya is anything, which an individual assimilates or accommodates without causing any injury to both mind and physique. After birth of a child when fed with Ahara, which is Shadrasayuktha, and Satmya with proper Vihara (like sadvritta, etc.) this helps for proper growth. 8. Satva Sampath: A good proportionate combination of aggression and libido (Raja and Satva) helps in building up proper Samvardhana (growth) 9. Swabhava Samsiddhi: Favorable disposition of the nature or innate potentiality of an individual. 10. Yauvana: The prepubertic spurt of growth helps in bringing better strength to the body. This is kalayogaja bala.Literature review 77
  • 89. Department of Koumarabhritya 11. Karma: Karma includes normal activities, which keeps body organs strong & steady. E.g. Vyayama. 12. Samharsha: The psychic development of a child depends upon interaction between endowment and environment. The child with contentment never suffers from psychological disorders. 5.4 Assessment of growth and development in Ayurveda A healthy infant is described as one who does not have the features likehypopigmentation, hyperpigmentation, tallstature, shortstature, emaciation, obesity,hypertrichosis. alopecia, hypotonia and hypertonia (31). Also he should cry, feel happy,get angry, sleep, awake, take food, excrete and digest food at regular intervals and bestable, active and alert. The first one excludes all the structural anomalies and second oneincludes the metabolic derangement in the newborn. Such a healthy infant will have along healthy life and will have proper growth and development (32). For such childrenfurther samskaras (ceremonies) are explained.5.4.1 Samskaras (ceremonies) Ayurveda describes the attainment of growth and development through variousceremonies that are the determinants of specific stages of growth.Periodical healthchecking of the child should be done to assess his physical and emotional growth and forintroducing newer ceremony. Each ceremony makes the growing child to acquire a newmile stone. Thus, various ceremonies, which form different milestones in a growinginfant, have been described in Ayurvedic texts. Literature review 78
  • 90. Department of Koumarabhritya Jatakarma - this samskara is to rule out any pathology present in the newborn.The immunodeficiency of the newborn is very clear from the fact that Vranitopasaneeyavidhi (do’s and don’ts of an injured person) is prescribed for the newborn and mother andvarious rakshoghna (preventive) karmas are explained in the context. At birth, theVrdhapana or Nadikartana or cutting of the umbilical cord is done. Nadikartanasamskara ensuring the proper breathing by the child and established functioning of heartand circulation in the neonates body(33). The namakarana samskara is done for a healthychild and indicates the initial steps of the growth and development is perfect. Dolasayanasamskara particularly indicates the child is well enough to be separated from the mother. Samskaras are prescribed not only as preventive measures and to judge the growthand development for the introduction of newer challenges but also to achievepurushaarthas (the ultimate aim of life). A proper growth and development is judged bythe factors explained earlier and from the strength, complexion and longevity withlightness in body and soothed or delighted sense organs with pleasing mind and a pleasantsleep with a happy awakening (34). The concept of well baby clinic is similar to thefestive ceremonies explained, the opportunity of which can be used to assess the wellbeing of the child. Literature review 79
  • 91. Department of KoumarabhrityaTable 5.1 Different ceremonies and their inferenceSl Age of the child Ceremonies Particulars InterpretationNo a. feeding of a. initial immunization1 At birth Jatakarma ghritha and madhu b. rooting and sucking reflexes b. breast feeding A celestial and 11th day or 100th Has its impact on the person2 Namakarana colloquial name day or one year through out the life given Done when the child has th Child transferred recovered from the fatigue of3 12/13 day Dolasayana to a cradle birth injury has no jaundice and the nabhi has healed well. Now the child is able to look Child is made up up at objects with control in During first Soorya candra to see and worship4 eye movements – macular month darsana the rising sun and fixation moon5 Birth day festival Dugdhapana Cows or goats Development of the GIT to at the end of first milk is fed to child receive liquids other than breast month (first with a conch shell milk. Vardhapan)6 2 nd month Jalapooja Mother worships Allowing water to be to water administered to child7 4 th month Nishkramana The child is taken Development is complete enough out of the house for an environmental exposure for the first time different from that of a home. usually to a temple8 5 th month Upavesana The child is made Developmental ability to sit to sit daily for some time9 6 th month Phalaprasan Fruit juices are Vitamin C in fruits are introduced to the antioxidants,promote immunity child and helps development of connective tissue.10 6/7/8 month Karna Piercing the ear For protection and to initiates the vedhana lobule wound healing mechanisms th11 10 month Annaprasana Introduction of The next stage of development of semi solids foods git- the git is prepared to admit to the child when solid foods and be able to digest teeth erupts it due developed enzyme systems. Literature review 80
  • 92. Department of KoumarabhrityaOther important concepts in Ayurveda regarding the assessment of the growth anddevelopment of the body include,5.4.2 Pramana (body measures) The measurement of whole body and each body part have been described by allscholars in terms of Anguli, a unit of length based on the width of finger of eachindividual. According to Charaka, length of the whole body of an adult is 84 angulas andthe same by Susruta is 120 angulas(35). These are the measures of an adult body. The agewise description of such measures for children is not available in classics and it is verydifficult to interpret the values from the available data. The values vary from child tochild according to the width of the finger. It can only be mentioned that the measures willbe less in case of children.5.4.3 Samhananam (proper built of the body) This indicates a proportionate body with all the joints, bones, muscles, blood andall other tissues in proper position. This means a body without any deformity.Sara( the essence of each dhatus)- The qualities of a man with properly nourished anddeveloped dhatu is described, each one separately. It is a good criterion for assessing theproper growth and development. However, in children the sara is not complete, so thefeatures described are not completely applicable for children. Literature review 81
  • 93. Department of Koumarabhritya5.4.4 Balam (Strength) It is said that the strength of the body can be assessed by the capacity to doexercise. In children, it will be definitely less due to the immaturity of tissues and allorgan systems.(36)5.5 Classification of children5.5.1 Age wise There are many age wise classifications in different classics; most useful is addedhere. The age wise classification helps to get an idea about the state of tissues of thechild, which are important measures of growth and development in children. Theseclassifications are based on specific attainment of milestones and definitely representparticular stage of development. That’s why age has a definite role in determining thematra (dose) of food or medicine in a child as well as in an adult. Different age groupsin children differ considerably by the dosage forms along with the dose. Not all kalpanasor food may be well appreciated in all age groups of children especially in neonates andinfants (37). Therefore age is the most important variable to be considered in a pediatricpractice. The nature of the disease is always same whether it is an adult or a child. But thenature of the patient is different and that determines the therapeutical factors such as drug,adjuvant etc. A child is not always considered as mini adult in many respects. As farAyurveda is considered, a child is different from an adult due to Literature review 82
  • 94. Department of Koumarabhritya Soukumaryata –having soft and tender body structure Alpakayata – under developed body Vividha anna Anupasevanata – GIT not fit to eat all types of food Apari pakwa dhathu – transformation and development under progression Ajata vyanjanam – incomplete secondary sexual characters Aklesa saham – cannot tolerate stress of any kind Asampoorna balam – bala is the measure of strength and the essence of all tissues based on immunity. This means children have poor immunity. Slesma dhathu prayam – dosha predominant is sleshma, indicating the drastic growth and development undergoing As we see, the body of a child is very different from the adult in many respects.The developing tissues and under developed organ systems make them not fit for almostall purification therapies and rejuvenation therapies.(38) . The third point is considered most important – “vividha anna anupasevanata”.The development of the gastro intestinal tract(GIT) depends on exposure to different foodcomponents slowly. The growth factors present in the breast milk contribute to earlydevelopment of GIT. That is why Ayurveda has given a functional classification, whichcompletely depends on the development of the GIT judged by the intake of different typeof foods, rather than an age wise classification for the administration of medicine. Literature review 83
  • 95. Department of Koumarabhritya 1. Jathamatran -just born 2. Pakshatheethan -after fifteen days 3. Athipakshan -after one month 4. Thriamasikan -three months of age 5. Shanmasikan -six months of age 6. Ekabdan -one year old 7. Thraibdan -three years old 8. Panchahayanan -five years old 9. Ashtabdan -eight years old 10. Dasabdan -ten years old 11. Dwadashabdan -twelve years old The classifications above are typically based on some important developmentalmilestones of the GIT(39). In this classification, jathamatran, pakshatheethan andathipakshan are particularly important as they belong to neonate. In pakshatheethan, the development of GIT is acquiring, not all dosage formsmay be suitable. Therefore, medicine administration should be very careful and avoidedas far as possible. Literature review 84
  • 96. Department of Koumarabhritya5.5.2 Classification of children based on diet patterns As far as the administration of different food and medicines and for thedetermination of dose is considered, rather than the age wise classification, theclassification based on diet and growth and development should be considered. This isbecause of the fact that, the classification is based on the functional development of GIT.Ksheerapa Infant who depends only on breast milk (or any other similar milk or feeds ifbreast milk is not available or conditions of intolerance). It was considered up to one yearof age classically, but presently up to four to six months (WHO).Ksheera annada Infant who has started feeds other than milk. It was considered up to one to twoyears of age classically, presently four to six months is the lower limit; upper limit twoyears (WHO).Annada Withdrawn from breast milk and depends only on other feeds, above two years ofage to 16 years classically, presently lower limit is 2 years of age.(40) Literature review 85
  • 97. Department of Koumarabhritya Chapter 6 Infant and young child feeding in Ayurveda6.1 Importance of Food Food is said to be the basis of life. It is the most important one among the threepillars of life. Food that we take is described in Ayurveda in four forms- Ashitam(swallowed food), khaditam (chewables), peetam (drinks) and leedham (lickables). Thisfood lodge themselves finally and vitally in a tenfold place –as ushma (heat) of the body,sweat, stools, urine and the tridoshas which are the basic constituents of the body, breastmilk in women, semen in men and blood. Life gets established and steady in such tenfoldaspect (41). Thus, properly ingested food provides man strength, complexion, vital power,growth and development, clarity of sense organs, luster, pleasure, increase of tissueelements, intellect, health etc. Entire life of individual depends upon food. All theactivities of this world, as well as efforts made for eternal emancipation depend uponfood. Literature review 86
  • 98. Department of Koumarabhritya The reason for health and ill health is directly related to the equanimity and non-equanimity of the constituents of food. It is by equanimity among the foods taken indeedthat a nectar like disposition flourishes forth in the body with all the three doshas beingbalanced thereby. It is their non-equanimity, which is the root cause of all the diseases(42). Any other medicament just like food is not available. One is able to make mandisease-free only with a congenial diet. Man is not able to sustain life without food evenif he is endowed with medicine. So diet is said to be the Mahabhaishajyam (the mostpotential medicine) (43). This is very relevant in the case of children who are immature inall respects, as medicine is veerya predominant, while food is rasa predominant. Thusfood plays a major role in a child’s life by facilitating proper growth and developmentand also as a source of administration of medicine. The quantity of food to be ingested is different according to different scholars.The quantity is described dividing the stomach into different parts. As per the generalrule, 1/3rd part food, 1/3rd part liquid, and 1/3rd part vacant (44). Vagbhata has stateddifferently as ½ part food, 1/4 part liquid, and 1/4 part vacant (45). After ingestion, pranavayu takes the food to the stomach. There it is moistened bythe kledaka kapha and then digestive fire is excited by vayu. This fire staying in the lowerpart of the stomach digests and separates the food into essence and waste product. Theentire food is first changed into sweet taste in the stomach, which increases kapha. It thenbecomes acidic and increases pitta. The food is then propelled by vayu into large Literature review 87
  • 99. Department of Koumarabhrityaintestine, there due to absorption of its liquid; it becomes solid and pungent and increasesvata. This is further acted upon by the fire of different dhatus metabolizing the foodmaterial according to fires of five principal elements, thereby promoting the growth anddevelopment.6.2 Infant and young child feeding in Ayurveda The importance of Kaumarabhritya lies in the fact that the child has immaturity intissues and systems of the body. So the child is delicate, cannot withstand stress, has lessimmune response and has predominance of kapha. The tissues, sense organs and vitalpower continue to grow and develop during this period. The dhatus, indriya and ojas gradually develop during childhood (47). So moreimportance should be given in improving the quality of the developing dhatus, indriyasand ojas. This can be attained only with the help of proper food as both food and body arecomposed of five elements called panchamahabhoothas. Also prabha (complexion),medha (intelligence), twak (skin), sukra, all indriyas (sense organs) and manas graduallydevelop during childhood. The word Kaumarabhritya itself defines it as a science of nurturing, managementand treatment of children. The diet consumed by the pregnant women becomes wholesome to the child after birth, therefore such food articles should be offered to the child,taking into consideration, place, time and digestive capacity. This means the food for thechild should be madhura (sweet), snigdha (soft), laghu (easy to digest), seeta (cold) and Literature review 88
  • 100. Department of Koumarabhrityahita (congenial) as these properties helps in nurturing the developing dhatus and alsoincreases ojas. Infant and young child feeding practices described in Ayurveda are as follows a. Breast feeding by mother b. Breast feeding by dhatri (wet nurse) c. Breast milk substitutes d. Weaning food 6.2.1 Breast-feeding by mother In Ayurveda , breast milk is considered as the best milk for the baby. It is said thatas a lady becomes pregnant the blood which has to be transformed into the menstrualblood becomes diverted in two ways- one part enriches the placenta and the rest will helpin breast development and formation of breast milk. The ahararasa that is a by-productof the food taken by the mother is mixed along with water and pitta. Later the digestiveenzymes in the GIT do the digestion of this combination and then disintegration takesplace. Then it is called ksheeratoya. This enters the channels pertained to carry breastmilk and is transformed into breast milk which is predominantly of somaguna (48). Regarding the secretion of breast milk, Vagbhata mentions that the milk carryingducts remain closed in the breast of a nullipara thus barring the possibility of the descentof doshas through them and thus the attack of any disease on that part. On the contrary,such ducts in the breast of a primipara open and expand of their own accord, thus makingthe advent of diseases possible that are peculiar to the mother. Literature review 89
  • 101. Department of Koumarabhritya6.2.1.1 Physiology of lactation Just like semen, breast milk lies hidden and invisible in the mother though it ispresent in a subtle form. At the sight, touch or thought of a child it gets secreted and flowsout just like semen (49). The milk which is secreted immediately after delivery is termedas Peeyusha. It is heavy and increases sleshma (50). The quality and quantity of breast milk depends on the diet and regimen of themother. An unwholesome diet and lifestyle causes the vitiation of breast milk that willresult in various pathologies in the breast-fed infants. The prevalence of breast milkvitiation was as high as 98% as shown by studies. The vitiation was pronounced in theinitial months of breast feeding and subsided gradually (51). Pure and healthy milk is thin, cold and clear, tinged like the hue of conch shell, iseasily miscible in water, does not give rise to froths or shreds, neither floats or sinks inwater (52). The milk which instantly mixes with water, tastes sweet and retains its naturalgrayish tint is pure. Pure breast milk is light, appetizer, improves vision, is pathya(congenial), easily digestible and is palatable (53). Breast milk is considered as amrita(nectar) and it is the nature’s best and cheapest gift for the proper growth anddevelopment of the newborn.6.2.1.2 Various abnormalities of breast milk and breasts Stanya nasha (suppression of breast milk)- Due to anger, grief, absence of naturalaffection towards the child, taking less food, excessive physical exercise, taking fooddevoid of oily substances and excessive sexual indulgence loss or suppression of breast Literature review 90
  • 102. Department of Koumarabhrityamilk occurs (54). In such conditions, diet and regimen that helps to increase breast milkshould be followed. The baby will not get sufficient food, so either a wet nurse isappointed or breast milk substitutes should be used. Stanya dushti (breast milk vitiation) - The three doshas (humors) of the mother areaggravated by ingestion of inappropriate and incompatible food or those things whichtend to derange the doshas of the body and hence her milk may be vitiated. The vitiatedbreast milk has eight features, they are.Distasteful, frothy and dry - due to vata vitiated milkDiscolored and bad smelling - due to pitta vitiated milkUnctuous, heavy and slimy - due to kapha vitiated milkCharacteristics of all doshas - due to milk vitiated by all three doshas A child fed on the vitiated milk of a woman falls an easy prey to many diseases.6.2.1.3 Disorders produced by vitiated breast milkKsheeralasaka This is a condition inferred to the infant who is fed on breast milk vitiated by thethree doshas. Due to this the agni of the child becomes feeble and this results in improperdigestion. Intestinal toxins are produced which then gets absorbed into generalcirculation as Aamavisha causing various toxic manifestations including convulsions. Theclinical features of the condition are fetid, watery stools with indigested food, stool ofvaried colour, frothy, part solid, part liquid, abdominal pain, urine is yellow or white andthick, fever, thirst, loss of taste, retching, yawning, pain in the body, tossing of limbs, Literature review 91
  • 103. Department of Koumarabhrityarestlessness, tremors, giddiness, conjunctivitis, stomatitis and similar other diseasesappear. It is very difficult to cure (56).Ksheeraja phakka roga Phakka is a state of growth retardation and developmental delay. Milk vitiated bykapha is called phakka dugdha (milk which causes phakka). It blocks the srotas(channels) of the child and causes impaired nutrition leading to emaciation. In the laterperiod he becomes apathetic and adopts slow movements because of weak and wastedbody. The dehydration from loose stools adds to the disaster. Thus the child will not beable to walk even after one year of age, which is the cardinal feature of the disease.Treatment should be given to the mother for purifying the breast milk and also for thechild to cure the ailments (57).Daurbalya (Weakness) This is a disease among the twenty-two ailments of children caused by non-unctuous milk. This vitiated milk causes the child loose his energy leading to weakness.Kapha vitiated milk can also cause weakness along with cough and dyspnoea (58).Paschaadrujam The vitiated milk in turn vitiates the pitta of the child that moves towards the anusand produces a wound resembling the body of a leech. High fever, burning sensation andloose motions of either green or yellow colour are the other clinical features (59). Literature review 92
  • 104. Department of KoumarabhrityaShosha (emaciation) The child who sucks kapha-vitiated milk or drinks cool water repeatedly and whosleeps for a long time gets the nutritional channels blocked with kapha and suffers fromanorexia, running of nose, cough and fever. Gradually there will be wasting of the bodygiving a marasmic appearance with white puffy and slimy face. Certain ancient scholarsdescribe this condition as Ahindika or Ahitundika (60). The diseases Kukunaka and Charmadala though are said to arise from vitiatedmilk, their etiology is disputed. Kukunaka is also said to arise from the metabolicdisturbances of the dentition period. Charmadala is said to arise by hereditarytransmission and by contact as an allergic manifestation (61). In all these conditions though breastfeeding is said to continue along withtreatment for mother and the child, but situations will arise when we have to provide thebaby with breast milk substitutes particularly in the case of suppression of breast milk,emaciation and weakness6.2.2 Breast feeding by wet nurse (62) The first and foremost substitute of mother’s breast milk explained in Ayurveda isbreast milk itself. The concept of Dhatri (wet nurse) appears in this context. The qualitiesof Dhatri is explained in detail which shows the importance of physical, mental andcultural attitude of the breast feeding woman, indirectly indicating the quality of breastmilk and the perfect bondage between the wet nurse and the baby. For satisfying this, theconcept of two Dhatri is taken into consideration. As the vatsalya (bondage) is an Literature review 93
  • 105. Department of Koumarabhrityaimportant factor in generating breast milk, one dhatri could not do it by her all the time,as she has to feed her child also.6.2.3 Breast milk substitutes The concept of breast milk substitute in Ayurveda is very elaborate and scientifictoo. The possibility of a physiological absence or shortage of breast milk and inability ofthe mother to feed the newborn due to various causes is tackled in a scientific way. It issaid that breast milk will be formed completely only after three or four days afterdelivery. So for the first three days, specific supplementation is explained in almost allclassics. But breast feeding is not restricted on the first three days. It is said to beginimmediately after birth (63).Table 6.1 Feeding schedule of newborn in AyurvedaFirst day Mixture of honey and ghee or Three times Honey and ghee in an emulsion form either with daily goldSecond and third Ghee prepared with Lekshmana Three timesday dailyFourth day Handful of butter with breast milk or Two times daily Handful of ghee and honey mixture with breast milk Continued absence of breast milk needs supplementation which is equivalent tothe nature of breast milk. Continuous administration of either of the above two is nottolerated by the premature GIT of the newborn and is not recommended also. In the absence of human milk, milk of other choices are considered. Goat’smilk is preferred as it is laghu (easily digestible and assimilable). The qualities of milk ofother animals are considered in this context. Literature review 94
  • 106. Department of KoumarabhrityaTable 6.2 Comparison of commonly used animal milks and breast milk (64).Origin Rasa(taste) Guna(Quality) Action in diseasesof milkBreast Madhura(sweet) Laghu(easily Alleviates vata and pitta, good for eyesmilk Kashaya digestible) and cures diseases due to vitiation of anurasa blood, trauma, emaciation etc. (astringent)Cow’s Madhura Guru (heavy) Can be used in emaciation,prolongedmilk (sweet) fever,cough,thirst,dysuria etc.Goat’s Madhura Comparatively Can be used in diarrhea, bleedingmilk (sweet) laghu disorders, fever, emaciationBuffalo Madhura Comparatively Good for insomnia and increasedmilk (sweet) guru appetiteTable 6.3 Comparison of Nutrient composition in various milks/100ml Milk Energy(kcal) Protein(g) Fat(g) Carbohydrate(g) Calcium(mg) Human 65 1.1 3.4 7.4 28 Cow’s 67 3.2 4.1 4.4 120 Goat’s 72 3.3 4.5 4.6 170 Buffalo’s 117 4.3 6.5 5 210 Even though the technique of dried milk and skimmed milk were not available atthose times, they modified milk from other animals like goat, cow etc to satisfy thechild’s needs and digestive capacity, as given below. Cow’s milk diluted by boiling with specific drugs like laghu panchamoola orsthira and sugar to suit the proportion as that of goat’s milk or animal milk diluted withhalf the quantity of water (65, 66). Literature review 95
  • 107. Department of Koumarabhritya6.2.3.1 Conventional method of dilution of animal milk (67)Table 6.4 Dilution of cow’s milk Age of the child Ratio of dilution of milk and water First few weeks 1:2 Two to three months 3:1 After Six months without dilutionTable 6.5 Dilution of buffalo’s milk Age of the child Ratio of dilution of milk and water Two to three months 3:1 After two to three months without dilution Boil the milk and remove the thick cream formed on the top, then diluted asabove.6.2.4 Weaning food In classics, weaning is described as a gradual process starting with the eruption ofteeth in a baby. Steadily he is taken off from breast along with introduction of other typesof milk and easily digestible and nutritious food materials. The nature of the weaning dietis changed progressively from liquid to semi solid to solid food. Teeth eruption is taken as the time to start weaning in children. Teeth is said toerupt from fourth month onwards, but the teeth formed in the eighth month is having allthe qualities of good and ideal teeth. Natal teeth and qualities of teeth formed from first Literature review 96
  • 108. Department of Koumarabhrityamonth onwards are also described. The metabolic disturbances during the period ofdentition give rise to various constitutional disorders. This along with weaning makes thisperiod a time of great stress and humiliation to the baby. Opinions regarding the time tostart weaning are given below.Table 6.6 Opinions regarding the time to start weaning Vagbhata Teeth eruption Charaka Six months Susrutha Six months Kasyapa Six months-fruit supplementation Ten months-solid food The child who does not get other foods, but continued to be fed on milk for a longtime is likely to become ill with nutritional disorders. The digestive fire of a child whohas started weaning is labile due to the change in the dietary pattern. Hence the childbecomes lean during second year. Therefore, the diet given should adapt to the nature ofthe child and should have all the qualities of weaning food described below.6.3 Improved weaning practices in children – Ayurvedic perspective The quality of food and ideal method of its administration is explained byKasyapa and Charaka (68). It can be practiced generally with special implications inchildren as follows. Literature review 97
  • 109. Department of Koumarabhritya6.3.1 Kalam (the time of feeding) 1. Desire of food, 2. Easy digestion of ingested food, 3. Proper excretion of faeces urine and flatus, 4. Lightness of body 5. Comfortable sleep and awakens, 7. Happiness, strength and complexionAll these conditions indicate timely administration and digestion of food. Not all the above features are particularly useful in children, as they are explainedfor adults also. Demand feeding is mostly explained for children. Annaabhilashatha(desire for food) in children is expressed by crying usually. Proper bowel and bladderfunction, sleep habits, and alertness and activity are good indicators for regular feeding.This is also included as the feature of a healthy child. Indigestion is pathological and the signs and symptoms of indigestion, related andprogressive pathologies should be identified by using the features explained inVedanadhyayam of Kasyapa Samhitha.6.3.2 Satmyata (congeniality) The food that is more appropriate for a person will become naturally favorabledue to its continuous use, which is termed as satmya. So primarily supplementationshould be start with milk supplements as milk and milk products will be more congenialto the body of a child. Due to the continuous growth and development process of thechild, the rasas suitable for promoting tissue development particularly madhura andguna, snigdha is mostly preferred. Weaning may be started with traditionally used food Literature review 98
  • 110. Department of Koumarabhrityapreparations as they are congenial to the desa (region) itself. This indirectly implies thatno food should be introduced in a child which is not known or does not have records oflong use. This is not applicable in the case of classically explained formulations.6.3.3 Matra (Dose/quantity ) This is directly related to the quality of food particularly its digestibility. Foodswhich are difficult to digest should be administered half the quantity than preferred.Generally light food are only preferred and heavy foods treated prior to administration tomake it easily digestible. Treatment of cow’s milk with laghu panchamoola beforeadministration as a breast milk supplement is the best example (65). Kashyapa hasdescribed that as the quantity of doshas and dhatus are less in children the quantity offood, drinks and drugs given to them should also be less (69).6.3.4 Ushna (warm) The child appreciates warm touch of food in the buccal cavity, as it feels tasty.This also implies that the food should be freshly prepared, and should not keep very longtime. Re warming of food materials are not good. Extremely hot and cold foods shouldbe avoided.6.3.5 Snigdha (unctuous) The guna increases the strength and quality of developing dhathus. As it ispreenana, helps positively in the development of mind (70). Small amount of butterfat,oil or ghee should be administered in a child diet while food should be seasoned lightlypreferably only with salt all other spices should be avoided. Excess amount of fibrous Literature review 99
  • 111. Department of Koumarabhrityafood irritates the tender digestive tract; it is therefore advisable to give fruits andvegetables after ‘stewing’- removing of the fibers to reduce the dryness (rookshatwa).Athi snigdha and athi rooksha (extremely dry and unctuous) food should be avoided.6.3.6 Avirudham (non-contrary) There are 18 types combinations explained by Charaka which negatively affectsthe body in constant use. This may be fatal to the developing tissues and organ systems ina child’s body. Therefore, non-judicial food combinations, cooking and dietetic practicesshould be avoided for a child. So homely foods, which are in, practice in sufficientquantity is preferred in a child.6.3.7 Soucam (cleanliness) This is of utmost importance in the feeding practices of a child. Clealiness inutensils used for preparing and feeding, kitchen, feeding place and the child itself and theperson who feed the child must be observed. This is elaborated in improved weaningpractices (71).6.3.8 Aswadayathi (enjoyable) “What people eat is not calories, but food, and consideration of fads, flavors andvariations of appetite can make nonsense of the dieticians theories (72).” The likes anddislikes of the child should be taken in to consideration before preparing the food. If ababy does not like a particular item, change it or give it in a different form and wait bygiving smaller doses of a new food until the child likes it rather than giving it in full andfor the last time. Literature review 100
  • 112. Department of Koumarabhritya6.3.9 Thanmana (concentration) Ensure the mealtime for the child should be relaxing. Meals that look colorfuland attractive to catch the attention of the child from any other diversions, and motivatethem to eat is preferable. The motivation can be achieved by giving the child, the food theway they like it as mentioned below 1. They enjoy to feed themselves. 2. They like food in small pieces 3. They like food that can be eaten with fingers6.3.10 Nathidrutham and naathivilambitham (optimum duration for eating) Feeding fast adversely affect the digestion of food and is against the above twofacts explained. Small and frequent meals need to be given with appropriate duration to achild. Too slow feeding not only kills the time but is boring to the child also.6.3.11 Nathidravam and naathi sushkam (nor too diluted and dry) Reduced bulk of the meal with increased nutrients is preferred in a child. It isdesirable to give malted foods (amylase rich food-ARF) which reduce the bulk andprovides high calorie density. Standard method of balanced food formulation, which haslow paste viscosity and could therefore, be used for increasing the calorie intake of thebabies as complementary to breast feeding after 4-6 months of age. Literature review 101
  • 113. Department of Koumarabhritya Discourage the child from eating sticky foods, fried foods and dried foods as theyare difficult to eat, digest and may cause bowel irregularities. However, once teething hasstarted some amount of crunchy foods which aid in teething and provide exercise to thegums may administered in a controlled manner.6.3.12 Na akamkshitha (no forceful feeding) Give as much as the baby wants at a time refrain from forcing the infant to eat. Ifthe infant or child refuses to eat, before searching for any pathologies, make sure that theabove all criteria’s are satisfied.6.3.13 Na aekarasam (balanced diet) Primarily the quality of the food in Ayurveda is measured in terms of rasa.Optimally a balanced diet in Ayurvedic perspective indicates the presence of all rasas init. A multi mix made of cereal porridge added with pulses, milk, sugar, animal foodsor green leafy vegetables or other vegetables is one of the best complementary foodwhich definitely contain all the six rasas. There is no need to write particularly the property of such a dietetic practice as itis evident that it will definitely increase arogyam (health), ayus (prolonged life) andbalam (strength- physical and mental). Literature review 102
  • 114. Department of Koumarabhritya Two important points additionally explained by Charaka is swabhavam andsamskaram, both are having very much significance (73). Swabhavam is the naturalqualities inherent to a material and samskaram is the alteration of the qualities byappropriate processing. Several methods are explained for samskara. Samskara isparticularly needed for child feeding; as non-processed foods are never recommended to,a child as far as Ayurveda is concerned. The above criteria should definitely be followed in preparing weaning food, asthis is a critical period in which there is gradual shift of the functioning of the gastrointestinal tract from the digestion of milk to the digestion of more complex vegetable andanimal substances. This is a time of various disorders as the solids introduced fail tosupply the required protein in a digestible form resulting in symptoms of proteindeficiency. The main weaning disorders described are given below.6.4 The main weaning disorders described in Ayurveda6.4.1 Paarigarbhika This is a disease caused by premature weaning due to successive early pregnancy.The child though breastfed may not get adequate milk or sometimes the breast simply actsas a comforter. The child suffers from fever, lassitude, irritable, respiratory and gastrointestinal infections.6.4.2 Garbhaja phakka The early weaning of a child from breast milk when the mother becomes pregnant.A child not getting proper food at that period first shows signs of arrest in the growthpattern and later loose weight and become emaciated and crippled with slow movements. Literature review 103
  • 115. Department of Koumarabhritya6.5 Certain dietetic aspects considered especially for children  Milk is advocated very freely as it is best suited to children and it extends energy, strength and growth.  Soft, sweet, easily digestible, cold potency and congenial diet is advised to promote ojas.  Supplementary feeds like lehanas (lickables) and vatakas are advised. Lehanas are prepared with drugs along with food materials that enhance body growth, intellect, immunity and fulfill the nutritional requirements (75).  Prakara yogas are also described, which serves both therapeutic and nutritive purpose, promoting growth and immunity (76).  Garlic either separately or specially cooked with oil or ghee is said energetic and cures all diseases in children (77).  Alcohol in reasonable quantity is indicated in children during the phase of dentition and to combat thirst.  Soup prepared from meat is very good for child growth.  Phanta (infusions) are widely indicated since it is very light.  Manda (the liquid part obtained when rice is boiled with water) is contra indicated in children.  Only boiled water is advised to be used in children. Literature review 104
  • 116. Department of Koumarabhritya Chapter 7 Evaluation of the formulation under consideration The formulation, Priyalamajjadi yoga is explained in Ashtanga Hridaya in thecontext of pediatric care and is given as a complementary feed. The exact name of theformulation is Priyala majjadi Modaka. The word modaka means ‘muda harshe’-thatwhich gives pleasure, since modakas always contains sweetening agents like sugar orjaggery and is generally used for dietetic purposes. It will be having circular shape andhaving big size usually it is prepared with medicine possessing weight around20gms,50gms,100gms of around big lemon fruit size medicine if rolled into circular massform then it is called modaka. The term modaka is omitted here, as it was not given in theusual form, but in powder form. This is because of the following reasons. 1. It is very difficult to keep uniform size and weight incase of modakas due to their bulk. 2. Modakas/vadakas/gudikas/cakrikas etc though in definite form are not used as such even in adults. They are administered after powdering and mixing with appropriate adjuvant for easy absorption and assimilation. The main purpose of Literature review 105
  • 117. Department of Koumarabhritya the shape is to minimize exposed surface for increased shelf life and to make them user friendly as they can be supplied as unit dosage forms. Therefore, the formulation is prepared without doing the rolling and making largesized pills out of that. The method of preparation except for the rolling remains the same.There is not much pharmacological variation but pharmaceutical variation has to beexpected as powdered form is having very low shelf life when compared to modakas.7.1 Ingredients of the formulation 1. Priyala-seeds 2. Madhuka-root 3. Madhu(honey) 4. Laja(puffed rice) 5. Sitopala(sugar)7.1.1 Priyala(seeds) (78)Botanical name - Buchanania lanzan Spreng. Syn.B.latifolia Roxb.Family - AnacardiaceaePriyala is an evergreen tree growing upto 15m high, found throughout the country in drydeciduous forests. Literature review 106
  • 118. Department of KoumarabhrityaSynonymsSanskrit - Priyalaka,Bahulavalkala, Priyala, Kharaskandha, Tapasesta,Sannakadru,Dhanuspata , Char.Bengali - Chirangi,Chowl,SatdhanGujarati - Charal,ShalichokhaHindi - Piyal,Piyar,ChiraungiKannada - NurlaalMalayalam - Mural,Priyalam,Mural maramMarathi - CharoliTamil - Muolaima,Korka,SaraparuppuTelugu - Sara,SarapappuUrdu - ChironjiConstituentsSeeds kernel contain, fixed oil - 51.8%Protein - 21.6%Starch - 12%Sugar - 5%Bark (of source tree) contains tannin about 13.4% Trunk exudes gum resin by incision. Amino acids, Carbohydrates, Maleic acid,protein, Vitamins (fruits), Lenoleic acid, Myristic, Oleic, Plamitic, Stearic & Archidicacid from kernel oil; gallotannins, Triter penopids, saponins & reducing sugar (also frombark); Kaempeferol-7-O-glucoside; and anacardic acid, cardol and phenols from shell oil, Literature review 107
  • 119. Department of KoumarabhrityaQuercetin-7-O-rhamnoside and Quercetin-7-O-rhamnoglycoside from leaves are thecompounds reported from the plant.Flowering & fruiting time- Plant flowers & fruits during the period may to JuneParts used - Seeds, Kernel, Bark.Dose - Seed kernel 10 – 20 gm. in adults. 1 -2 gm/day for infants 6 – 12 month age.Bark 50 – 100 mg.Gana - Udardaprasamana, Sramahara (Charaka Samhita), Nyagrodhadi (Sushruta Samhita).Properties and actionRasa - MadhuraGuna - Guru,Snigdha,SaraVirya - AnushnaVipaka - MadhuraTherapeutic actions Priyala fruit mitigate kapha and rakta, its fruit is sweet, heavy for digestion,unctuous, laxative, reduces problems due to burning sensation, trauma, and emaciation,purify pitta and rakta, increases kapha and sukla and may produce problems due toindigestion. Seeds of Priyala are sweet, aphrodisiac and mitigate vata and pitta. Literature review 108
  • 120. Department of KoumarabhrityaResearches on Priyala (79) Products of certain plants given to mothers after childbirth or to invalids werestudied for immunostimulant activity using the macrophage migration index (MMI) as aparameter of macrophage activation and cell-mediated immunity and haemagglutinatingantibody (HA) titres and plaque-forming cell (PFC) counts as parameters of humoralimmunity. Feeding of Prunus amygdalus (Almond(1)) and Buchanania lanzan(Chirronji(1)) significantly stimulated both CMI and humoral immunity in BALB/c miceas evidenced by the enhancement of MMI, HA titres, and PFC counts. Traditional healersof Chhattisgarh reported that water kept in a bowl prepared of Priyala for over night isnutritious for person with sexual illness.Researches on Lenoleic Acid  Weise et al. (1958) reported that for the normal nutrition of infants, 4 percent of the calories has to be supplied by the Linoleic acid when fat provides about 30 – 40 percent of the calories in the diet.  Hensen et al (1963) observed the development of a clinical syndrome of a skin rash (similar to eczema) in infants who received no essential fatty acids for several months.  Same group have also investigated the effect of essential fatty acids on the Growth infants. They found that the Growth & general health of the infants were satisfactory when lenoleic acid supplied 1.3 to 7.3 percent of the calorie intake. Lenoleic acid comprises 4.5% of the calories in the Human milk & 1.5 to 2% in the cow’s, buffalo’s and goat’s milk. It may therefore be desirable to add Literature review 109
  • 121. Department of Koumarabhritya vegetable fats rich in Lenoleic acid to infant foods based on animal milk in order to raise thee Lenoleic acid content to same level as in human milk fat.Important formulations that contains Priyala Pugakhanda,Priyala taila7.1.2 Madhuka-root (80)Botanical name - Glycyrrhiza glabraFamily - FabaceaeSynonymsSanskrit - Madhuyasti, Yastimadhu, Madhuka, Klitaka.Hindi - Mulethi, JethimadhuGujarati - JethimadhMarathi - JestimadhBengali - YastimadhuTamil - AtimadhuramTelugu - YastimadhukamEnglish - LiquoriceKannada - Yasti madhuka, Atimadhura Literature review 110
  • 122. Department of KoumarabhrityaDistributionPlants occur in Southern Europe, Egypt, Arab, Central Asia, Afghanistan, Peshawar &from Chenab to East in the Himalayas, Burma & Andaman Islands. Cultivation is beingundertaken in various regions of India on tribal basis.Chemical composition Roots – Chiefly contain an active principle Glycyrrhizin; it is present in the formof Glycyrrhizic acid which is sweet anrethan 50% in compare to sugar. The yellow color in roots is due to presence of glycoside isoliquritin (2.2%) whichis partially converted into liquiritin. A steroid eastrogen is also present in the roots. They contain glucose 3.8, sucrose2.4 – 6.5, menite, starch 30%, asparagines, bitter substance, resinous matter 2.4 & avolatile oil 0.03-0.35 % and a coloring matter. Ash (water soluble) is less than 20% inroot & 10% in root with bark, but less than 6% in barkless root.Parts used - RootsDose - 2-4g of the drug in powder formGana - Jivaniya,Shonitsthapan, Varnya ( Charaka Samhita)Kakolyadi, sarivadi, Anjanadi (Sushruta Samhita)Properties and actionRasa - MadhuraGuna - Guru, SingdhaVirya - ShitaVipaka - Madhura Literature review 111
  • 123. Department of KoumarabhrityaTherapeutic actions It mitigates vata and pitta, increases strength and bulk of body, cures diseases ofthroat,rakta, anemia, itching, burning sensation, cough, good for skin and increasescomplexion,aphrodisiac,relieves pain,promotes intelligence and reduces kapha. It is also a smooth muscle depressant, anti-microbial, hypolipidaemic, anti-atherosclerotic, anti-viral, hypotensive, hepato-protective, anti- exudative, spasmolytic,antidiuretic, antiulcer, antimutagenic, antipyretic, antioxidant, anti-inflammatory andexpectorant.7.1.3 Madhu(honey) Honey is defined as the natural sweet substance produced by honeybees from thenectar of flowers or from secretions coming from living organisms feeding on plants, thatbees gather, transform and combine with specific ingredients, store and leave to ripen inthe combs of the hive.Types of Honey Eight types of honey are described in Ayurveda depending on the type of beewhich collects it. They are Pouttika, Bhramara, Kshoudra, Makshika, Chatra, Arghya,Oudalaka and Dala. Literature review 112
  • 124. Department of KoumarabhrityaChemical constituents 1. Sugars like fructose, glucose, sucrose, maltose, lactose and other disaccharides and trisaccharides. 2. Proteins, fats, vitamins, minerals, enzymes and amino acids, 3. Volatile aromatic substances. 4. Ashes and water etc.Table 7.1 Nutritive value of honey per 100 g Constituents Quantity Sugars 82.12g Dietary fibre 0.2 g Protein 0.3 g Water 17.1 g Riboflavin 0.038 mg Niacin 0.121 mg Pantothenic acid 0.068 mg Vitamin B6 0.024 mg Folate 2 micro g Vitamin C 0.5 mg Calcium 6 mg Iron 0.42 mg Magnesium 2 mg Phosphorus 4 mg Potassium 52 mg Sodium 4 mg Zinc 0.22 mgProperties and action (81)Rasa - Madhura,kashayamGuna - Guru,rukshaVeerya - SheetaVipaka - Katu Literature review 113
  • 125. Department of KoumarabhrityaTherapeutic actions  As it contains sugars which are quickly absorbed by our digestive system and converted into energy, this can be used as instant energizer.  As it is hygroscopic it speeds up healing, growth of healing tissue and dries it up.  Honey acts as a sedative and is very useful in bed wetting disorders.  Honey is very good anti-oxidant which restores the damaged skin and gives soft, young looks.  Honey has antibacterial properties due to its acidic nature and enzymically produced hydrogen peroxide.  Constant use of honey strengthens the white blood corpuscles to fight bacteria and viral diseases.  Honey is very good for eyes and eye sight.  It quenches thirst.  Dissolves kapha.  Reduces effects of poison.  Stops hiccups.  It is very useful in urinary tract disorders, worm infestations, bronchial asthma, cough, diarrhea and nausea -vomiting.  Cleanse the wounds.  It heals wounds.  Helps in quick healing of deep wounds.  Initiates growth of healthy granulation tissue.Literature review 114
  • 126. Department of Koumarabhritya  Honey which is newly collected from bee hive increases body weight and is a mild laxative.  Honey which is stored and is old helps in metabolism of fat and scrapes Kapha.  Honey is called as “Yogavahi” . The substance which has a quality of penetrating the deepest tissue is called as Yogavahi. When honey is used with other herbal preparations it enhances the medicinal qualities of those preparations and also helps them to reach the deeper tissues.7.1.4 Laja (Puffed rice) Puffed rice is usually made by heating rice kernels under high pressure in thepresence of steam, though the method of manufacture varies from location to location.Paddy fried and allowed to form flower like, this is called Laja. It has all the qualities ofrice.Botanical name: Oryza sativa.LinnFamily: GraminaceaeSynonymsSanskrit - Laja, Lava, KhilEnglish - Puffed riceHindi - KurmuraTamil - NelporiMalayalam - Malar,PoriTulu - Kurlu, churmuri Literature review 115
  • 127. Department of KoumarabhrityaTable 7.2 Nutritional value of edible portion of rice per 100 gram Type of Energy Protein Fat Ca Fe Thiamin Riboflavin Niacin Rice (cal.) (g) (g) (mg) (mg) (mg) (mg) (mg) Raw 345 6.8 0.5 10 3.1 0.06 0.06 1.9 (milled) Parboiled 346 6.4 0.4 9 4.0 0.21 0.05 3.8 (milled) Flakes 346 6.6 1.2 20 20.0 0.21 0.05 4.0 Puffed 325 7.5 0.1 20 6.6 0.21 0.01 4.1 Rice is a complex carbohydrate, which contains starch, and fibre, which isdigested slowly allowing the body to utilize the energy released over a longer periodwhich is nutritionally efficient. It contains only a trace amount of fat. Rice is gluten free,so suitable for coeliacs and it is easily digested and therefore a wonderful food for thevery young and elderly.Properties and actionRasa - Madhura,KashayaGuna - Laghu, RookshaVirya - SheetaVipaka - MadhuraTherapeutic actionsLaja is sweet, cold in potency, light for digestion, where as increase digestive fire,produce less quantity of urine and feaces, cause dryness, increase strength, mitigates pitta Literature review 116
  • 128. Department of Koumarabhrityaand kapha, relieve vomiting, diarrhea, burning sensation, bleeding disease, diabetes,obesity and thirst. Lajapeya(gruel prepared with laja) is beneficial in those who are exhausted afterdoing stressful work and with feeble voice. Laja-Manda(the liquid part obtained after boiling laja with water) cures thirst,diarrhea, help keeping Rasadi dhatus in equilibrium increase digestive fire. It is beneficialfor persons with improper digestive fire, for children, old people, women and the delicate7.1.5 Sitopala(sugar)Sugar is obtained from the stem of sugar cane.Botanical name: Saccharum officinarum.LinnFamily: GramineaeSynonymsSanskrit - Ikshu, Deerghachada, bhuriras, Gudhamula, asipatra, madhutrinaHindi - Mishri,EekhMalayalam - KarimbuTamil - KarumbuEnglish - Sugar caneTelugu - CheraguBengali - AakGujarati - Gandari Literature review 117
  • 129. Department of KoumarabhrityaChemical composition Sugar, calcium oxalate, starch, cellulose, pentosans, lignin, succinic acid,aconitic acid, citric acid, citosin, chlorophyll, anthocyanin, nitrogenic acid etc are somecompounds derived from the plant. Sugar contains the carbohydrate sucrose. Its relativesweetness is 100 and the products of digestion are glucose and fructose.It is practically100% sucrose and contains no other nutrients.Properties and action Rasa - Madhura Guna - Snigdha, Laghu Veerya - Seeta Vipaka - MadhuraTherapeutic actions Sugar is a cheap and easily digested form of energy. Sitopala is laxative, light,cold and alleviates vata and pitta.Ikshu in general cures diseases like bleeding disorders,jaundice, flatulance, anemia, ascites etc, increases strength and valor, increases kapha, isgood for throat and also helps in urine formation.7.2 Therapeutic action of the formulation The formulation is highly palatable and greatly appreciated by children. As it is afood formulation, no disease indications are there. The formulation is Preenana. Theword means that is positive to mind. Therefore, the formulation can nurture the mind andimprove the cognition. Brumhana property inherent to most of the ingredients willdefinitely enhance growth and development in a child. Literature review 118
  • 130. Department of KoumarabhrityaLiterature review 119
  • 131. Department of Koumarabhritya Chapter 8 Methodology of research8.1 Objectives of the study Research is the result of a creative instinct, giving a new perspective to solvecertain problems. The role of the food formulation Priyalamajjadi in complementaryfeeding has to be evaluated in the present changing equations of infant feeding. Eventhough the specific period of administration is mentioned, it is vague due to difference ofopinion existing between the classics regarding weaning. The present study aims toestablish the efficacy of the time tested formulation by using present conventionalparameters with a broad objective to find out an appropriate period to initialize itsadministration. The study extends to the efficacy of the formulation in tackling theadverse conditions existing during the complementary feeding.8.2 Research approach The clinical study was to test the efficacy of the Priyalamajjadi yoga incomplementary feeding, by using presently available parameters and to assess specificperiod of its administration. Children were divided in to three groups by using explicitparameters and each group again into one study and control clusters. Study cluster in all Methodology of research 119
  • 132. Department of Koumarabhrityathe three groups received Priyalamajjadi yoga in a definite dose and followed a set ofdietary advices as per the age and control groups received the dietary advices only. Asper the directions from WHO, an established proceedings can be a control (84). The datawas collected before and after the trial and analyzed for findings. The morbidityassessment was monitored during the study and evaluated.8.3 Research design Research was conducted as per the protocol. The study was designed as arandomized controlled clinical trial, in which simple randomization is used. There was anelaboration in the study by keeping the requirements in the protocol. Instead of taking asingle group, for accurate evaluation, three groups were taken and each of them divided into study and control clusters. The design was same for all the three groups and the groupswere no way related each other.8.3.1 The groups Group A – Just started weaning group - children who had just startedcomplementary feed was taken for this group. (As the formulation is not traditionallypracticed in the study population it can not be considered as congenial. Therefore, for thestudy purpose only, instead of taking the formulation as the first feed, children wereassigned after starting the complementary feed with at least a single traditional food.)Children from four months onwards were admitted in to the study and were advised forthe promotion of breast-feeding. The study proper starts in children who had completedfive months and not started seven months (i.e children of six months of age) and startedweaning. Total 20 children were taken in to this group and assigned to study and control Methodology of research 120
  • 133. Department of Koumarabhrityaclusters, 10 each. Study group received 15 grams of the formulation once daily alongwith the advised diet. Control group received same dietary advises only. Group B – Established weaning group- children who had completed at least twomonths of weaning. The study proper starts in children who had completed eight monthsand not started 10th month (children of nine months of age) and continuing breast milk.Total 20 children were taken in to this group and assigned to study and control clusters,10 each. The study cluster received the same drug but 15g twice daily and a dietaryadvice. Control cluster received the dietary advice alone. Children who had participatedin Group A study is not admitted in Group B. Group C – Established dietary group- children who had completed at least fourmonths of complementary feeding and continue to get breast milk is included in thegroup. The study proper started in children who had completed 11 months and not started17th month (children of 12 to 16 months of age). The growth velocity during the period isalmost same from 12 to 18 months, making evaluation easy. The group is having twoclusters, one study and one control. The study group received 25 grams twice daily alongwith dietary advice and the control group, dietary advice alone. Above 17 month childrenwere avoided from the study as most were not receiving breast milk. The group had total15 patients and assigned eight and seven to control and study clusters respectively.Children who had participated in Group A or group B study is not admitted in Group C. Methodology of research 121
  • 134. Department of Koumarabhritya The groups were classified by considering the rate of growth in different periodsof age. In an infant, six to nine months growth is different from that of nines to 12months. Therefore, the study in the first two groups started in the respective months ofchange of growth that is six months and nine months. Statistical evaluation will bedifficult if groups are selected with out considering the above factor. A single group ofparticipants from six to 12 months or more is therefore not possible because of thedifference in growth velocity at different points. Values and equations are available forreference only in the above manner (85). Similarly, in the second year, 12 to 18 and 18 to24 are the accepted groups, due to the same considerations as explained above. 18 to 24groups is not included in the study as breast feeding has been stopped in majority and alsoit was difficult to administer the formulation as the children developed self selection offood materials during the period.8.4 Reasons for selecting the design Under nutrition and related problems are major causes of morbidity in children.Natural and palatable formulations are explained in Ayurvedic classics which will bebeneficial in this aspect. Priyalamajjadi is one among them, the efficacy of which has tobe established for its acceptance. The above design not only establishes the efficacy ofthe formulation but also reveal the most appropriate period during complementaryfeeding for its administration. Methodology of research 122
  • 135. Department of Koumarabhritya8.5 Variables The experimental variable was the food formulation Priyalamajjadi. Growth anddevelopment along with morbidity in children were the dependent variable. A number ofintervening variables were also present such as diet and activities, medications in themother and illnesses in the infant due to infections, environmental variations, poorhygiene etc. These factors affecting the variables under consideration was controlled bykeeping a control group. The control group was exposed to the same environmentalconditions and situations as that of the study group.8.6 Selection criteria The population is young children up to 24 months of age and who had startedweaning (and continue breast feeding) selected from the Immunization departmentGovernment Ayurveda College for Women and children, Poojappura,Thiruvananthapuram by using the selection criteria and assigned to groups and then toclusters. The source population is collected from the immunization department due to theavailability of children according to the groups. The selection was made as per the inclusion and exclusion criteria, which includednormal growing children with in specific age range. The samples were taken at randomand drawn independently from the same population and assigned to each group and thento clusters.8.6.1 Inclusion criteria 1. Children who had started weaning 2. Maximum age limit will be up to 24* months (should continue to get breast milk) Methodology of research 123
  • 136. Department of Koumarabhritya8.6.2 Exclusion criteria 1. Children of age below 4 months and 24 months 2. Nutritional deficiencies associated with pathological conditions 3. Children with over nutrition 4. Children with congenital anomalies (* last paragraph under 6.3.1)8.7 Randomization Simple randomization technique was used for each group. The study and controlclusters for each group were drawn independently from the required population andassigned. In Group A, total 20 children were selected 10 each to study and control clusters.The study and control clusters were drawn independently from the same population ofspecified age group. In Group B also the same method was followed. In Group C theplan was to assign 20 patients, but due to lack of participants total 15 were included –eight to control and seven to study. Totally, 55 patients were included in the studycumulative of all groups of which eight were dropped-out.8.8 Dropouts No dropouts were in Group A. One dropout from the control cluster of Group B,the reason for which was not known. Four drop-outs from the control cluster and twofrom the study cluster of Group C were there, again the reason for the dropout not known.8.9 Duration of study The duration of the entire study including the literary evaluation was 18 months. Methodology of research 124
  • 137. Department of Koumarabhritya8.10 Method of preparation of the study drug  Purchasing of raw materials and preparation of the formulation was done in the Pharmacy, government Ayurveda College, Thiruvananthapuram. Standard raw drugs were obtained through the department.  Priyalamajja (fruit pulp) standard sample collected from Punchab, as the plant is not widely seen in Kerala and fruits are very much seasonal.  Priyalamajja and Laja were searched for any impurities and cleaned thoroughly. Standard honey obtained from the market. Best variety of sitopala also obtained and cleaned. Yashtimadhu was washed properly and dried completely.  Equal quantity of laja and priyalamajja was powdered in a pulvariser. Laja in the formulation were found to adsorb the oil from priyala and minimized the difficulty of in powdering.  Powdered yashtimadhu, only one fourth parts to priyala is added and mixed well. As yashti madhu is a promoter of emesis, equal part may produce emesis in children.  Sitopala is powdered finely and dissolved in required quantity of water by slow heating in a wide mouthed vessel.  When paka lakshanas are obtained, (Thread like extensions should appear when a small portion of the preparation is lifted out of the vessel) the powdered drugs are added slowly added and stirred well. After sometime honey is added and mixed well. Instead of rolling in to pills the mass is dried completely and powdered to thefinished product which is packed in air tight plastic bags for supply.Dose and mode of administration Methodology of research 125
  • 138. Department of Koumarabhritya No specific dose is mentioned in the classic. As it is a food formulation the dosehas to be standardized according to the digestive capacity of the children and of course itis age dependent. An arbitrary dose was taken and given in children of different agegroups as a trial and the dose of each groups were fixed. Dose is explained in detail in thecoming topics. The parents were advised to give the powdered food formulation in the prescribeddose along with milk to make it in the form of porridge. This is because of thecongeniality of the milk in children.8.11 Data collection The data was collected by using a prepared clinical Performa the efficiency ofwhich was tested. The Performa was sufficient to collect the targeted data and it wasaccepted.The following data were collected as per protocol 1. Demographic data of the participants 2. Data related to the intervention The data were collected and summarized in appropriate tables for easy statisticalevaluation. Methodology of research 126
  • 139. Department of Koumarabhritya8.12 Assessment criteria Assessments of both the clusters in each group were done before, during and afterthe study using the following parameters. 1. Measures of morbidity – illnesses which occurred in the child were recorded using the following parameters of morbidity indices (annexure -1) a. Incidence rate b. Period prevalence rate 2. Assessment of growth and nutritional status by the following measures a. Weight b. Length c. Head circumference d. Mid upper arm circumference e. Chest circumference World Health Organization, anthropometric software was used for calculations. 3. Assessment of development by muscle tone, Trivandrum Development Screening Chart etc (annexure – 2) The parameters selected were nationally accepted international parameters.Muscle tone evaluation was omitted from the study as it was found to be difficult to elicitin young children. Body mass index was not used, as it will be a reliable indicator onlyafter 24 months of age. Methodology of research 127
  • 140. Department of Koumarabhritya8.13 Intervention schedule There were three groups for the study each divided in to one control and studyclusters. The groups were according to the weaning period and clusters in each groupwere identical in all respects except for the intervention.8.13.1 Study cluster intervention schedule Study cluster in Group A, Group B and Group C received Priyalamajjadi yoga inthe following dose along with specific dietary advice for each Group by considering theage (annexure - 3).Table 8.1 Study cluster intervention schedule Group Age group Dose of the formulation Diet chart A Completed 5 months 15 grams daily yes Not started 7th month B Completed 8 months 15 grams twice daily yes Not started 10th month C Completed 11 months 25 grams twice daily yes not started 17 th month8.13.2 Control cluster intervention schedule Control clusters in Group A, Group B, Group C received specific dietary advicefor the age only, and the schedule is shown below. Methodology of research 128
  • 141. Department of KoumarabhrityaTable 8.2 Control cluster intervention schedule Group Age group Drug Dose Diet chart A Completed 5 months No yes Not started 7th month B Completed 8 months No yes Not started 10th month C Completed 11 months No yes not started 17th month8.14 Follow up Interventional schedules were advised for clusters in each groups and advised toattend the op in regular intervals to measure the morbidity if any including weaningdifficulties. It was advised to report any changes in the normal habits of the childrenimmediately. A specific data sheet of these reports for each participant was kept for theassessment of morbidity. Detailed evaluation was done before and after the intervention,that is after two months in each participant in all the groups. No follow up with out theintervention was planned.8.15 Data analysis Data were consolidated by using statistical methods. Evaluations of the efficacyof the interventions were compared and conclusions were drawn by using appropriatestatistical techniques. Methodology of research 129
  • 142. Department of Koumarabhritya8.16 Ethical considerations for the study The drugs in the combination had no known toxicity. An informed consent wasobtained from the parents before the trial. The conditions of informed consent were fullycarried out and the autonomy of the participants was given utmost respect. There was literally not any risk, as the formulation is classically explained andpurely herbal. The previous experience with the food formulation showed good results.Therefore, the most important question of risk benefit ratio in ethics was satisfied. Equal opportunities were given to all participants to be selected in the study orcontrol interventions by using random selection. The existing accepted procedure ofproper dietary advice was given to participants of all the groups for ensuring accurategrowth and development. Methodology of research 130
  • 143. Department of Koumarabhritya Chapter 9 Observation, analysis and interpretation The study was carried out in the Immunization department, Govt AyurvedaCollege Hospital for Women and Children, Poojappura, Thiruvananthapuram. Theparticipants were selected in to the study as per the protocol. Children having normalpatterns of growth and development were included in the study. Fifty five children wereselected as per the Groups, and assigned randomly to the study and control clusters ofeach group. Detailed socio demographic data regarding the sample were collected tomake an evaluation of the factors that affect the growth and development of therepresentative population, to which the participants belongs. The complementary feedingpatterns were evaluated thoroughly to understand the weaning practices existing in therepresentative population. The experimental or independent variable in the study wasPriyalamajjadi yoga in specific dose to each group and the dependent or measuredvariable were the growth and development of the children along with morbidityassociated with complementary feeding. Observation, analysis and interpretations 131
  • 144. Department of Koumarabhritya9.1 Data relating to Socio demographic factors In a nutritional study involving children or adult, the demographic and socioeconomic data play a major role, as it decides the resources and its uninterrupted supply.Proper growth is the gift of adequate nutrients. The patterns of growth vary considerablybetween male and female children and definitely in between different age groups.9.1.1 Percentage distribution of the participants according to age The percentage distribution of participants according to age are shown in thetable.Table 9.1 Age wise distribution of the participants Age Number Percentage 4 to 6 20 36.4 7 to 8 20 36.4 10 to 12 2 3.5 13 to 15 10 18.2 16 to 18 3 5.5Figure 9.1 Age wise distribution of the participants 20 18 N 16 C U H 14 M I 12 B L E 10 D R 8 R E 6 O N F 4 2 0 4 to 6 7 to 8 10 to 12 13 to 15 16 to 18 AGE IN M ONTHS Observation, analysis and interpretations 132
  • 145. Department of Koumarabhritya9.1.2 Percentage distribution of sex of the participating children Fifty three percent of the total participants were female children and rest wasmale.Table 9.2 Sex wise distribution of the participants Count Percentage Male 26 47 female 29 53 Total 55 1009.1.3 Percentage distribution of the participants as per domicile Domicile is very important as per nutritional evaluations are concerned. Poorsocio economic status and urban dwelling affects the nutritional condition even morebadly.Table9.3 Domicile wise distribution of the participants Count Percentage Rural 14 25 Urban 41 75 Total 55 1009.1.4 Percentage distribution of educational status of the parents Educational status of the parents reflects highly in the complementary feeding andhygienic aspects related to feeding. The distribution below was made by taking thehigher qualification of the parents as the criteria. Observation, analysis and interpretations 133
  • 146. Department of KoumarabhrityaTable 9.4 figure 9.2 Distribution of participants as per educational status of the parent 0% Count Percentage Illiterate 0 0 42% School 32 58 College 23 42 58% Total 55 100 Illiterate School College9.1.5 Percentage distribution of the participants as per economic status of theparents Nutritional adequacy is directly proportional to economic status, poor economicstatus means, compromised nutrition and chance of related adverse conditions.Table 9.5 figure 9.3 Economic status wise distribution of participants 15% Count Percentage Poor 27 49 49% Middle 20 36 High 8 15 36% Total 55 100 Poor Middle High Observation, analysis and interpretations 134
  • 147. Department of Koumarabhritya9.1.6 Percentage distribution of participants as per religious status of the family Religious traits have definitely a role in the dietary habits of the family.Table 9.6 Religion wise distribution of the participants Count Percentage Hindu 28 51 Muslim 14 25 Christian 13 24 Total 55 100 Fifty one percent of the samples were belong to Hindus and 25% Muslims and restwere Christians9.1.7 Percentage distribution of the participants as per general dietary habit of the family Dietary habit of the family influences the morbidity associated with infant andchild feeding. A pure vegetarian or non-vegetarian diet habit in a child need specificregulation to maintain the nutritional adequacy.Table 9.7 Dietary habits wise distribution of the participants Count Percentage Vegetarian 12 22 Mixed 43 78 Total 55 100 Seventy-eight percent belong to mixed diet families and the rest belong tovegetarian families. Observation, analysis and interpretations 135
  • 148. Department of Koumarabhritya9.2 Data relating to weaning practices noticed in the sample9.2.1 Month in which complementary feeding started in the sampleTable 9.8 figure 9.4 Initial month of complementary feedingAge Count Percentage 25 224 22 40 N 20 20 C5 20 36 U M H I 156 11 20 B E L 11 DAfter 6 2 4 R R 10 ETotal 55 100 O F N 5 2 0 4 5 6 Af ter 6 AGE IN MONTHS An enquiry in to the month in which complementary feeding started for theparticipating children revealed 40% started their first feed at fourth month, 36% at fifth,20% at sixth and the rest at after sixth month of age.9.2.2 First complementary feed given to the participants of the studyTable 9.9 figure 9.5 First complementary feed given 13%Feed Count Percentage 16%Ragi 39 71Tined food 9 16Others 7 13tTotal 55 100 71% Ragi Tined food Others Observation, analysis and interpretations 136
  • 149. Department of Koumarabhritya Seventy-one percentage of the participants had Ragi as their first feed. Sixteenpercentage had tined food as their initial feed and the rest received other feeds in practice.9.2.3 Distribution of children in which vegetables were introduced during the first month of complementary feedingTable 9.10 Food with vegetable in the first month of weaning Food with Count Percentage Vegetables 16 29 No vegetables 39 71 Total 55 100 Only 29 % of the participants were supplied with food containing vegetablesduring the first month of complementary feeding. The bulk were devoid of the same forthe mentioned period.9.3 Analysis and Interpretations The data reveals 32 out of the total participants that is 55 (58%) had attended onlyschool and falls in poorly educated group. the rest that is 23 (42%) attended college and isconsiderably educated. The economic status of the sample showed 49% (27 out of 55)were in the poor economy group and 36% (20 out of 55) in the middle-income group.Only five were there in the high-income group. Seventy five percent of the participantswere urban dwelling the rest falling in rural area. More than 40% of the participants werepoorly educated, urban dwellers with poor economic status. Therefore, a comparativelylow cost complementary feed with multidimensional action is of high significance. Observation, analysis and interpretations 137
  • 150. Department of Koumarabhritya An enquiry to the weaning practices of the participants revealed 22 out of 55(40%) participants started weaning at the age of fourth month. Thirty-six percentage (20out of 55) started at fifth month and only 20% (11 out of 55) started at sixth month. Only4% (two out of 55) even waited for above six months. 71% (39 out of 55) taken Ragi astheir first feed for complementary feeding which is traditionally practiced. Aconsiderable number of children had taken tined food as their first feed (16% - nine out of55). Even though others not take it as the first feed, most of the families included tinedfood in the feed list during later stages of complementary feeding. An investigation in tothe first month of complementary feeding exposed the fact that only 29% (16 out of 55)had started vegetables in any form as a complementary feed. The rest 71% (39 out of 55)had not started vegetables during the first month of weaning and even after that. Therefore in the present study setting proper dietary education were given to theparents as per the age of the participants in all the groups, both in study and controlclusters. Charts were prepared according to the directions of food and nutrition board andsupplied to ensure the practice. Observation, analysis and interpretations 138
  • 151. Department of Koumarabhritya9.4 Data relating to interventions and its efficacy including analysis and interpretations Efficacy of the intervention done to the three Groups were evaluated by using thestatistical methods as follows.9.4.1Evaluation of growth in Group A (Just started weaning group)9.4.1.1 LengthTable 9.11 Data relating to length – Group A L CG BT L CG AT D L CG L SG AT L SG AT D L SG 64.0000 66.9000 2.9000 64.3000 67.8000 3.5000 65.8000 68.9000 3.1000 65.0000 68.5000 3.5000 66.0000 69.0000 3.0000 68.0000 71.7000 3.7000 69.2000 72.3000 3.1000 69.5000 72.9000 3.4000 61.3000 64.9000 3.6000 68.8000 71.8000 3.0000 62.4000 65.6000 3.2000 64.8000 68.1000 3.3000 62.8000 66.2000 3.4000 63.1000 66.7000 3.6000 65.9000 69.2000 3.3000 63.0000 66.2000 3.2000 61.9000 65.0000 3.1000 62.7000 66.3000 3.6000 68.9000 71.9000 3.0000 61.8000 65.2000 3.4000 t-testGroup Name N Missing Mean Std Dev SEMD L CG 10 0 3.170 0.211 0.0667D L SG 10 0 3.420 0.210 0.0663Difference -0.250; t = -2.657 with 18 degrees of freedom. (P = 0.016)95 percent confidence interval for difference of means: -0.448 to -0.0523 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.016). Observation, analysis and interpretations 139
  • 152. Department of Koumarabhritya There is a statistically significant difference in gain of length between the studyand control clusters in Group A. The study cluster in Group A gained significant lengththan the control cluster.9.4.1.2 WeightTable 9.12 Data relating to weight – Group A W CG BT W CG AT D W CG W SG BT W SG AT D W SG 6400 7400 1000 7100 8000 900 7 200 7900 700 6600 7800 1200 7 600 8500 900 7900 8900 1000 8 000 8900 900 8000 9200 1200 6 300 7200 900 7400 8300 900 6 800 7600 800 7000 8000 1000 6 400 7400 1000 6800 8000 1200 6 700 7500 800 6500 7600 1100 7 300 8200 900 6700 7700 1000 8 200 9000 800 6100 7200 1100 t-testGroup Name N Missing Mean Std Dev SEMD W CG 10 0 870.00 0.0949 0.0300D W SG 10 0 1060.00 0.117 0.0371Difference 190; t = -3.981 with 18 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: -0.290 to -0.0897 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = <0.001). The difference in weight gain noticed in the study cluster when compared withthat in the control cluster, is statistically highly significant. The participants in the studycluster gained more weight than those in the control cluster. Observation, analysis and interpretations 140
  • 153. Department of Koumarabhritya9.4.1.3 Head CircumferenceTable 9.13 Data relating to head circumference – Group A HC CG BT HC CG AT D HC CG HC SG BT HC SG AT D HC SG 42.9000 44.0000 1.1000 43.6000 44.8000 1.2000 44.1000 45.1000 1.0000 43.2000 44.5000 1.3000 44.0000 45.2000 1.2000 43.6000 44.9000 1.3000 45.0000 45.8000 0.8000 44.1000 45.0000 0.9000 41.0000 42.1000 1.1000 43.0000 44.3000 1.3000 42.6000 43.6000 1.0000 43.1000 44.3000 1.2000 42.7000 43.6000 0.9000 42.9000 44.2000 1.2000 43.0000 43.9000 0.9000 43.6000 44.7000 1.1000 41.9000 43.0000 1.1000 42.8000 43.8000 1.0000 43.9000 45.1000 1.2000 40.8000 42.1000 1.3000 t-testGroup Name N Missing Mean Std Dev SEMD HC CG 10 0 1.030 0.134 0.0423D HC SG 10 0 1.180 0.140 0.0442Difference -0.150; t = -2.451 with 18 degrees of freedom. (P = 0.025)95 percent confidence interval for difference of means: -0.279 to -0.0214 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.025). The gain in Head circumference in the study cluster is greater than that in thecontrol cluster and is statistically significant as shown above. Observation, analysis and interpretations 141
  • 154. Department of Koumarabhritya9.4.1.4 Chest circumferenceTable 9.14 Data relating to chest circumference – Group A CC CG BT CC CG AT D CC CG CC SG BT CC SG AT D CC SG 42.1000 43.7000 1.6000 42.9000 44.5000 1.6000 43.4000 44.6000 1.2000 42.7000 44.0000 1.3000 43.3000 44.8000 1.5000 42.8000 44.6000 1.8000 44.1000 45.5000 1.4000 43.3000 44.7000 1.4000 40.2000 41.6000 1.4000 42.3000 44.0000 1.7000 42.0000 43.2000 1.2000 42.3000 44.0000 1.7000 41.9000 43.1000 1.2000 42.1000 43.9000 1.8000 42.4000 43.6000 1.2000 43.0000 44.3000 1.3000 41.3000 42.5000 1.2000 42.0000 43.5000 1.5000 43.0000 44.7000 1.7000 40.2000 41.7000 1.5000 t-testGroup Name N Missing Mean Std Dev SEMD CC CG 10 0 1.360 0.190 0.0600D CC SG 10 0 1.560 0.190 0.0600Difference -0.200; t = -2.357 with 18 degrees of freedom. (P = 0.030)95 percent confidence interval for difference of means: -0.378 to -0.0217 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.030). The mean gain in chest circumference of participants in the study cluster is greaterthan the that of the participants in the control cluster. The difference is statisticallysignificant as shown above. Observation, analysis and interpretations 142
  • 155. Department of Koumarabhritya9.4.1.5 Mid Upper Arm Circumference (MUAC)Table 9.15 Data relating to mid upper arm circumference – Group A MAC CG BT MAC CG AT D MAC CG MAC SG BT MAC SG AT D MAC SG 12.8000 13.2000 0.4000 14.4000 14.8000 0.4000 13.5000 14.0000 0.5000 12.4000 13.0000 0.6000 14.2000 14.5000 0.3000 15.2000 15.7000 0.5000 15.4000 15.9000 0.5000 14.0000 14.5000 0.5000 16.0000 16.3000 0.3000 14.9000 15.5000 0.6000 14.7000 15.3000 0.6000 15.5000 15.9000 0.4000 13.8000 14.1000 0.3000 13.2000 13.7000 0.5000 13.5000 13.9000 0.4000 12.9000 13.5000 0.6000 14.2000 14.6000 0.4000 14.6000 15.3000 0.7000 13.9000 14.4000 0.5000 15.0000 16.1000 0.6000 t-testGroup Name N Missing Mean Std Dev SEMD MAC CG 10 0 0.420 0.103 0.0327D MAC SG 10 0 0.540 0.0966 0.0306Difference -0.120; t = -2.683 with 18 degrees of freedom. (P = 0.015)95 percent confidence interval for difference of means: -0.214 to -0.0260 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.015). The increase in MUAC in study cluster is statistically significant when comparedto the control cluster Observation, analysis and interpretations 143
  • 156. Department of Koumarabhritya. Figure 9.6 LENGTH GAIN GROUP A 69 68 67 66 MEA N 65 64 63 62 BT AT CG 64.82 67.99 SG 65.1 68.52 Figure 9.7 WEIGHT GAIN GROUP A 8200 8000 7800 7600 MEAN 7400 7200 7000 6800 6600 6400 BT AT CG 7090 7960 SG 7010 8070 Observation, analysis and interpretations 144
  • 157. Department of Koumarabhritya Figure 9.8 HC GAIN GROUP A 44.4 44.2 44 43.8 43.6 MEAN 43.4 43.2 43 42.8 42.6 42.4 BT AT CG 43.11 44.14 SG 43.07 44.26 Figure 9.9 M AC GAIN GROUP A 14.9 14.8 14.7 14.6 14.5 MEAN 14.4 14.3 14.2 14.1 14 13.9 BT AT CG 14.2 14.62 SG 14.21 14.8 Figure 9.10 CC GAIN GROUP A 44.5 44 43.5 EAN 43 M 42.5 42 41.5 BT AT CG 42.37 43.74 SG 42.36 43.92Observation, analysis and interpretations 145
  • 158. Department of Koumarabhritya9.4.2 Evaluation of growth in Group B (Established weaning group)9.4.2.1 LengthTable 9.16 Data relating to length – Group B L CG BT L CG AT D L CG L SG BT L SG AT D L SG 68.5000 71.3000 2.8000 69.4000 72.1000 2.7000 69.0000 71.4000 2.4000 68.5000 71.0000 2.5000 69.2000 71.8000 2.6000 69.5000 72.3000 2.8000 70.5000 72.8000 2.3000 72.1000 75.0000 2.9000 71.0000 73.8000 2.8000 72.5000 75.1000 2.6000 67.4000 69.9000 2.5000 71.0000 73.8000 2.8000 68.5000 71.1000 2.6000 69.0000 71.7000 2.7000 73.2000 75.6000 2.4000 71.3000 74.1000 2.8000 65.8000 67.0000 69.9000 2.9000 68.2000 70.7000 2.5000 66.4000 69.0000 2.6000 t-testGroup Name N Missing Mean Std Dev SEMDLCG 10 1 2.544 0.174 0.0580DLSG 10 0 2.730 0.134 0.0423Difference -0.186; t = -2.622 with 17 degrees of freedom. (P = 0.018)95 percent confidence interval for difference of means: -0.335 to -0.0363 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.018). The gain in weight of the participants in the study cluster of Group B is greaterthan that of the participants in the control cluster. And the observed difference in thegroups is statistically significant as shown above. Observation, analysis and interpretations 146
  • 159. Department of Koumarabhritya9.4.2.2 WeightTable 9.17 Data relating to weight – Group B W CG BT W CG AT D W CG W SG BT W SG AT D W SG 7700.0000 8400.0000 700.0000 7500.0000 8100.0000 600.0000 7900.0000 8600.0000 700.0000 8000.0000 8800.0000 800.0000 7300.0000 7900.0000 600.0000 7100.0000 7800.0000 700.0000 8800.0000 9400.0000 600.0000 9500.0000 10300.0000 800.0000 9000.0000 9800.0000 800.0000 9000.0000 9900.0000 900.0000 8100.0000 8700.0000 600.0000 8300.0000 9000.0000 700.0000 8000.0000 8700.0000 700.0000 7900.0000 8700.0000 800.0000 8600.0000 9300.0000 700.0000 8600.0000 9300.0000 700.0000 8100.0000 7000.0000 7900.0000 900.0000 6900.0000 7600.0000 700.0000 6700.0000 7400.0000 700.0000 t-testGroup Name N Missing Mean Std Dev SEMDWCG 10 1 677.778 66.667 22.222DWSG 10 0 760.000 96.609 30.551Difference -82.222; t = -2.134 with 17 degrees of freedom. (P = 0.048)95 percent confidence interval for difference of means: -163.517 to -0.928 The difference in the mean values of the two groups is greater than would beexpected by chance; there is a statistically significant difference between the input groups(P = 0.048). Higher weight gain is attained by the participants of the study cluster in Group B,than the participants in control cluster. The difference in weight gain is having statisticalsignificance as shown above. Observation, analysis and interpretations 147
  • 160. Department of Koumarabhritya9.4.2.3 Head CircumferenceTable 9.18 Data relating to head circumference – Group B HC CG BT HC CG AT D HC CG HC SG BT HC SG AT D HC SG 43.5000 44.3000 0.8000 44.2000 44.9000 0.7000 44.0000 44.7000 0.7000 43.5000 44.3000 0.8000 43.7000 44.2000 0.5000 45.0000 45.6000 0.6000 42.8000 43.4000 0.6000 44.9000 45.7000 0.8000 44.7000 45.2000 0.5000 45.0000 45.6000 0.6000 46.2000 46.6000 0.4000 44.7000 45.2000 0.5000 45.5000 46.1000 0.6000 44.0000 44.5000 0.5000 45.3000 46.0000 0.7000 44.2000 44.9000 0.7000 43.2000 43.0000 43.6000 0.6000 43.5000 44.2000 0.7000 42.1000 42.7000 0.6000 t-testGroup Name N Missing Mean Std Dev SEMD HC CG 10 1 0.611 0.127 0.0423D HC SG 10 0 0.640 0.107 0.0340Difference -0.0289; t = -0.537 with 17 degrees of freedom. (P = 0.598)95 percent confidence interval for difference of means: -0.142 to 0.0846 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.598). The observed difference between the study cluster and control cluster in gain inHC is not statistically significant as shown above. Observation, analysis and interpretations 148
  • 161. Department of Koumarabhritya9.4.2.4 Chest CircumferenceTable 9.19 Data relating to chest circumference – Group B CC CG BT CC CG AT D CC CG CC SG BT CC SG AT D CC SG 43.2000 44.2000 1.1000 44.5000 44.8000 1.0000 44.1000 44.9000 1.2000 43.7000 44.5000 1.2000 43.9000 44.1000 0.9000 44.8000 45.4000 1.3000 42.6000 43.6000 1.2000 44.7000 45.8000 1.1000 44.4000 45.4000 1.3000 45.3000 45.5000 0.9000 46.5000 46.5000 0.9000 44.5000 45.3000 1.0000 45.3000 46.2000 1.1000 44.2000 44.4000 1.2000 45.5000 45.8000 1.0000 44.5000 45.0000 1.3000 42. 6000 42.8000 43.5000 1.1000 43.3000 44.3000 1.0000 42.4000 42.8000 1.0000 t-testGroup Name N Missing Mean Std Dev SEMD CC CG 10 1 1.078 0.139 0.0465D CC SG 10 0 1.110 0.137 0.0433Difference -0.0322; t = -0.508 with 17 degrees of freedom. (P = 0.618)95 percent confidence interval for difference of means: -0.166 to 0.102 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.618). The gain chest circumference in the participants of the study cluster and that of thecontrol cluster is not significant as per the statistical results are concerned. Observation, analysis and interpretations 149
  • 162. Department of Koumarabhritya9.4.2.5 Mid Upper Arm CircumferenceTable 9.20 Data relating to Mid Upper Arm Circumference – Group B MAC CG BT MAC CG AT D MAC CG MAC SG BT MAC SG AT D MAC SG 14.3 14.6 12.9 13.2 0.3000 0.3000 13.5 13.7 14.3 14.7 0.2000 0.4000 11.8 12.2 14.7 14.9 0.4000 0.2000 15.1 15.4 15.5 15.8 0.3000 0.3000 14.1 14.4 14.5 15 0.3000 0.5000 12.8 13 14 14.3 0.2000 0.3000 13.9 14.3 13.7 14.1 0.4000 0.4000 14.8 15.1 12.9 13.1 0.3000 0.2000 12.5 12.8 0.3000 13.2 13.6 13.5 13.8 0.4000 0.3000 t-testGroup Name N Missing Mean Std Dev SEMD MAC CG 10 1 0.311 0.0782 0.0261D MAC SG 10 0 0.320 0.0919 0.0291Difference -0.00889; t = -0.226 with 17 degrees of freedom. (P = 0.824)95 percent confidence interval for difference of means: -0.0920 to 0.0742 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.824). The gain in MUAC is not having any statistical significance on comparison. Observation, analysis and interpretations 150
  • 163. Department of Koumarabhritya Figure 9.11 Length gain – Group B 2.75 2.7 2.65 M E 2.6 A N 2.55 2.5 2.45 CG SG LENGTH GAIN (cm) Figure 9.12 Weight gain – Group B 760 740 720 M 700 E A 680 N 660 640 620 CG SG WEIGHT GAIN (g)Observation, analysis and interpretations 151
  • 164. Department of Koumarabhritya9.4.3 Evaluation of growth in Group C (Established dietary group)9.4.3.1. LengthTable 9.21 Data relating to length – Group C L CG BT L CG AT D L CG L SG BT L SG AT D L SG 71.9000 73.8000 1.9000 76.5000 78.6000 2.1000 75.8000 77.8000 2.0000 74.7000 76.7000 2.0000 77.0000 75.3000 78.4000 79.8000 81.7000 1.9000 79.0000 80.9000 1.9000 80.0000 69.8000 74.2000 76.1000 1.9000 76.4000 81.0000 83.0000 2.0000 68.9000 71.0000 2.1000 t-testGroup Name N Missing Mean Std Dev SEMD L CG 8 4 1.975 0.0957 0.0479D L SG 7 2 1.980 0.0837 0.0374Difference -0.00500; t = -0.0837 with 7 degrees of freedom. (P = 0.936)95 percent confidence interval for difference of means: -0.146 to 0.136 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.936). There is not a statistically significance difference in gain in length between thestudy and control clusters in Group C as shown above. Observation, analysis and interpretations 152
  • 165. Department of Koumarabhritya9.4.3.2 WeightTable 9.22 Data relating to weight – Group C W CG BT W CG AT D W CG W SG BT W SG AT D W SG 9000.0000 9500.0000 500.0000 9500.0000 10000.0000 500.0000 10100.0000 10500.0000 400.0000 7900.0000 8300.0000 400.0000 8200.0000 9100.0000 7600.0000 8000.0000 8600.0000 600.0000 9300.0000 9800.0000 500.0000 8500.0000 8600.0000 8700.0000 9100.0000 400.0000 8400.0000 10200.0000 10700.0000 500.0000 7900.0000 8400.0000 500.0000 t-testGroup Name N Missing Mean Std Dev SEMD W CG 8 3 500.000 70.711 31.623D W SG 7 2 480.000 83.666 37.417Difference 20.000; t = 0.408 with 8 degrees of freedom. (P = 0.694)95 percent confidence interval for difference of means: -92.971 to 132.971 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.694). There is no statistically significant difference between the weight gain of the studycluster when compared to the control cluster. Observation, analysis and interpretations 153
  • 166. Department of Koumarabhritya9.4.3.3 Head CircumferenceTable 9.23 data relating to head circumference – Group C HC CG BT HC CG AT D HC CG HC SG BT HC SG AT D HC SG 44.9000 45.3000 0.4000 43.4000 43.7000 0.4000 45.2000 45.5000 0.3000 46.0000 46.4000 0.3000 43.9000 44.5000 44.0000 45.0000 45.4000 0.5000 46.1000 46.3000 0.2000 43.9000 45.9000 45.7000 46.1000 0.2000 43.7000 46.0000 46.4000 0.4000 46.2000 46.7000 0.5000 t-testGroup Name N Missing Mean Std Dev SEMDHCCG 8 4 0.350 0.129 0.0645DHCSG 7 2 0.360 0.114 0.0510Difference -0.01000; t = -0.123 with 7 degrees of freedom. (P = 0.905)95 percent confidence interval for difference of means: -0.201 to 0.181 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.905). No statistically significant difference in gain in Head circumference is notedbetween the clusters by the evaluation. Observation, analysis and interpretations 154
  • 167. Department of Koumarabhritya9.4.3.4 Chest CircumferenceTable 9.24 Data relating to chest circumference CC CG BT CC CG AT D CC CG CC SG BT CC SG AT D CC SG 45.4000 46.0000 0.6000 45.4000 45.9000 0.5000 44.1000 44.6000 0.5000 45.8000 46.4000 0.6000 45.9000 45.6000 44.8000 44.3000 45.0000 0.7000 46.7000 47.4000 0.7000 44.2000 43.5000 46.3000 46.9000 0.6000 45.6000 47.1000 47.7000 0.6000 47.0000 47.6000 0.6000 t-testGroup Name N Missing Mean Std Dev SEMDCCCG 8 4 0.600 0.0816 0.0408DCCSG 7 2 0.600 0.0707 0.0316Difference 0.000; t = 0.000 with 7 degrees of freedom. (P = 1.000)95 percent confidence interval for difference of means: -0.120 to 0.120 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 1.000). No statistically significant difference between the clusters in difference in CC oncomparison. Observation, analysis and interpretations 155
  • 168. Department of Koumarabhritya9.4.3.5 Mid Upper Arm CircumferenceTable 9.25 Data relating to mid upper arm circumference MA CG BT MAC CG AT D MAC CG MAC SG BT MAC SG AT D MAC SG 14.5000 14.6000 0.1000 13.7000 13.9000 0.2000 12.3000 12.6000 0.3000 15.3000 15.6000 0.3000 15.2000 12.3000 13.7000 . 13.2000 13.3000 0.1000 14.8000 15.0000 0.2000 14.9000 12.9000 15.0000 15.2000 0.2000 14.8000 14.5000 14.6000 0.1000 15.1000 15.3000 0.2000 t-testGroup Name N Missing Mean Std Dev SEMD MAC CG 8 4 0.200 0.0816 0.0408D MAC SG 7 2 0.180 0.0837 0.0374Difference 0.0200; t = 0.360 with 7 degrees of freedom. (P = 0.729)95 percent confidence interval for difference of means: -0.111 to 0.151 The difference in the mean values of the two groups is not great enough to rejectthe possibility that the difference is due to random sampling variability. There is not astatistically significant difference between the input groups (P = 0.729). There is no statistically significance difference in MUAC between the clusters inGroup C.9.5 Assessment of development in all the groups Observation, analysis and interpretations 156
  • 169. Department of KoumarabhrityaTable 9.26 Developmental assessment chart for all groupsMile Number of children attained the mile stonestone Group A Group B Group C CGBT SGBT CGAT SGAT CGBT SGBT CGAT SGAT CGBT SGBT CGAT SGATSocial smile 10 10 10 10 10 10 9 10 8 7 4 5Eyes follow 10 10 10 10 10 10 9 10 8 7 4 5penHolds head 10 10 10 10 10 10 9 10 8 7 4 5steadyTurns head 10 10 10 10 10 10 9 10 8 7 4 5to sound ofbellTransfer 5 6 10 10 10 10 9 10 8 7 4 5objectshand tohandRolls from 4 3 7 7 7 8 9 10 8 7 4 5back tostomachRaises self - - 4 3 7 7 9 10 8 7 4 5to sittingpositionStanding up - - 3 3 7 6 9 10 8 7 4 5by furnitureFine - - 2 3 6 5 9 10 8 7 4 5prehensionpelletPat a cake - - 2 2 4 4 7 8 7 6 4 5Walk with - - 1 2 2 2 5 6 7 7 4 5helpThrows ball - - - - - - 1 2 4 3 2 3Walks alone - - - - - - - 1 7 6 3 5Says 2 - - - - - - - - 5 6 4 5wordsWalk - - - - - - - - 4 4 3 4backwardsWalk - - - - - - - - 5 4 4 5upstairswith helpPoint to - - - - - - - - 2 1 2 3parts of doll Observation, analysis and interpretations 157
  • 170. Department of Koumarabhritya Developmental milestones in all the groups were evaluated before and after thestudy using TDS chart. Children who attained the mandatory milestones for the age wereincluded in the study. After the intervention, evaluation was made in all the groups andfound that every children in two clusters were attained the mandatory milestones for theage in time.9.6 Assessment of morbidity Assessment of morbidity was done during the study. Those conditions onlyprevailed are consolidated below. Reduction of appetite, regurgitation, constipation,colic, and loose stools are particularly related to complementary feeding.Table 9.27 Morbidity conditions prevailed Group A B C Diseases SG CG SG CG SG CG Reduction of appetite 1 3 0 1 1 1 Regurgitation 2 1 1 0 1 0 Constipation 0 5 0 6 0 2 Colic - - - - - - Loose stools 3 0 1 0 1 0 Recurrent respiratory tract infection 0 2 1 1 0 1 Skin diseases 0 0 1 0 0 0 Assessment of weaning associated conditions such as loose stools; regurgitation,constipation, colic etc were evaluated along with other morbidity conditions. Weaningassociated conditions such as loose stools and constipation showed a considerablyobserved difference. During the intervention period in Group A, three participants in thestudy group showed loose stools, while none in the control group developed thecondition. On statistical evaluation, the difference shown was not statistically significant.A large sample may be necessary for a definite conclusion in this aspect. Single patients Observation, analysis and interpretations 158
  • 171. Department of Koumarabhrityafrom Group B and Group C in the study cluster also developed loose stools none in thecontrol groups developed the conditions. However, considerable difference is noted inconstipation in all the groups in the control and study settings. Five in the control clusterof Group A, six in the control cluster of Group B and two in the control cluster of GroupC had developed constipation but none developed the condition in the study cluster of anyof the three groups. In group A and Group B, the observed difference had a statisticalsignificance too (with P values 0.039 and 0.017 respectively on Z test). One of the majorproblems associated with weaning is constipation that is not there in the study groupreceived the Priyalamajjadi yoga along with the same diet that of the control group. The statistical data is not presented, as other results obtained were insignificant.Morbidity was assessed for many other diseases too, but the sample size in any groupswas not enough to draw any conclusions. Observation, analysis and interpretations 159
  • 172. Department of Koumarabhritya Chapter 10 Discussion, summary and conclusion10.1 Discussion and summary Koumarabhrithya is the branch of Ayurvedic therapeutic system, which deals withthe pediatric care along with gynecology and obstetrics. The branch not only considersdiseases in children and its management but also gives a comprehensible design on infantand young child care. The preventive pediatrics is highly developed and comprises ofelaborated nutritional considerations in the pediatric group. Concept of breast milk supplementation and complementary feeding practices arewell explained without trailing the importance of breast-feeding. The prime choice ofbreast milk supplementation explained in the science is breast milk through a wet nurse.Instead of other solid or semi solid foods, milk of other animals such as cow or goat isexplained for supplementation, as it is more congenial than any other food. Discussion, summary and conclusion 160
  • 173. Department of Koumarabhritya Different scholars indicate complementary feeding in Ayurveda from four to sixmonths and it is said in relation with teething for physiological reasons such as maturityof the gastro intestinal tract to receive solids. Complementary feeding in the science,especially by Vagbhata is advised by using special type of food preparations called‘modaka’, a particular type of food formulation, which is rolled in to a ball for betterstorage and prepared by using sugar as major ingredient for palatability. The studyintends to assess the efficacy of the classical formulation by using present parameters ofgrowth and development in children. Moreover, the ideal time in complementary feedingin which the preparation is having maximum efficacy is also evaluated to fix the idealtime for its administration. Studies on growth and development are of prime importance as far as the pediatricfield is concerned. The amplified concern is due to the fact that under nutrition is still aburning problem even with so many intervention modalities are administered through outthe globe. Under nutrition, defined in public health by poor anthropometric status, ismainly a consequence of inadequate diet and frequent infection, leading to deficiencies incalories, protein, vitamins and minerals. Under nutrition and underweight is mostprevalent among children under five years of age, especially in the weaning and post-weaning period of six to 24 months. The broad objective of the study is to get an ideal palatable complementary feed,which can meet the nutritional requirements, as well as to reduce the weaning associatedclinical conditions existing in the population. The search for such a complementary feedbegins with the formulation under consideration, Priyalamajjadi yoga. Discussion, summary and conclusion 161
  • 174. Department of Koumarabhritya The formulation under consideration here is ideal as a complementary feed due tothe following reasons 1. Presence of considerable amount of vegetable oils with EFA such as linoleic acid. 2. Carbohydrate rich, gluten free rice in the more lighter form – laja (puffed rice) 3. Presence of honey that contains fructose, easily absorbable sugar as far as young gastro intestinal tract is concerned. 4. Highly palatable as the preparation is sugar based. Though the formulation is having the above said qualities, it is not given as the firstand foremost feed to start complementary feeding because of the fact that the formulationis not congenial to the population under consideration. As far as the classics areconcerned feed to a child should be congenial (satmya) too. Therefore, it is better to startwith a traditionally used complementary feed rather than Priyalamajjadi yoga, though it isclassically explained. Therefore, the study starts with a profound problem of nutritional inadequacy,progressing with the aim to find out a solid solution from the traditional wealth ofAyurveda, by fixing the efficacy of a complementary feed explained in the science with abroad objective to evaluate its ideal time for administration in weaning. The study setting was to assign participants from the Immunization Department ofthe institution as per the inclusion and exclusion criteria. The study was conducted inchildren with normal growth and development. For a better evaluation and to find out theideal period of administration of the classical complementary feed under consideration, Discussion, summary and conclusion 162
  • 175. Department of Koumarabhrityathree groups were selected. The groups were selected as per the stage of complementaryfeeding and considering the rate of growth in different age groups of children. Thegroups were again divided in to one study and control cluster. The study clusters in allthe groups received the formulation under consideration and parents were educated withspecific dietary patterns suitable for the age group. Parents of the control clusters in allthe groups were educated with specific dietary patterns sufficient for the age.10.2 Statement of the major findings The socio demographic data is having high significance in a nutritional study.The data reveals 32 out of the total participants that is 55 (58%) had attended only schooland falls in poorly educated group. the rest that is 23 (42%) attended college and isconsiderably educated. The economic status of the sample showed 49% (27 out of 55)were in the poor economy group and 36% (20 out of 55) in the middle income group.Only five were there in the high income group. Seventy five percent of the participantswere urban dwelling the rest falling in rural area. The above factors show some crucial aspects in nutrition. More than 40% of theparticipants were poorly educated, urban dwellers with poor economic status. Deprivededucation affects complementary feeding negatively due to the lack of knowledge of itsimportance and improved weaning practices. It also affects hygiene and morbidity rate isincreased. Poor economic status indicates reduced resources and poor nutritionaladequacy. The problem multiplies with urban dwelling as the families are forced to livein a high cost environment with lack of resources. Therefore a comparatively low costcomplementary feed with multidimensional action is of high significance. An enquiry to the weaning practices of the participants revealed that thecomplementary feeding patterns of the population are not ideal and it needs urgent Discussion, summary and conclusion 163
  • 176. Department of Koumarabhrityaattention. 22 out of 55 (40%) participants started weaning at the age of fourth month.36% (20 out of 55) started at fifth month and only 20% (11 out of 55) started at sixthmonth. Only four percent (two out of 55) even waited for above six months. Seventy-one percent (39 out of 55) taken Ragi as their first feed for complementary feeding whichis traditionally practiced. A considerable number of children had taken tined food as theirfirst feed (16% - nine out of 55). Even though others not take it as the first feed, most ofthe families included tined food in the feed list during later stages of complementaryfeeding. The ease of preparation of the feed replaced the many beneficial effects of ricebased and vegetable based complementary feeds. An investigation in to the first month ofcomplementary feeding exposed the fact that only 29% (16 out of 55) had startedvegetables in any form as a complementary feed. The rest 71% (39 out of 55) had notstarted vegetables during the first month of weaning and even after that. The above factstell us about the importance of a proper education regarding the weaning practices and adietary advice to the parents for their children, specific to the age. Therefore in thepresent study setting proper dietary education were given to the parents as per the age ofthe participants in all the groups, both in study and control clusters. Charts were preparedaccording to the directions of food and nutrition board and supplied to ensure the practice. The results of the interventions on growth in the study and control clusters in allthe three groups were evaluated by using statistical methods. The results are consolidatedbelow. In Group A, in which the participants were in the beginning of theircomplementary feeding, the study cluster with the Priyalamajjadi yoga along with thecomplementary feeding pattern, showed a statistically significant difference in all theparameters taken in to consideration when compared to the control group in which the Discussion, summary and conclusion 164
  • 177. Department of Koumarabhrityaparticipants received the dietary advice alone. Length gain in the study cluster showed astatistically significant difference with P value 0.016 over the comparison. Gain inweight (P <0.001), head circumference (P 0.025), chest circumference (P 0.030) as wellas mid upper arm circumference (0.015) showed statistical significance in thecomparison. In Group B in which the participants were in the established stage of theircomplementary feeding, only gain in length and weight of the study cluster showedstatistically significant difference, when compared to the control cluster (P 0.18 and 0.48respectively). In Group C, in which the participants were having an established dietary pattern,none of the parameters in the study cluster showed a statistically significant differencewhen compared to the control cluster. It can be inferred that the efficacy of the Priyalamajjadi yoga is evident in GroupA, in which the child is in a drastic phase of growth. The dietary advice given seems tobe very adequate as proper weight gain is noted in all the groups with in therecommended percentiles. Priyalamajjadi yoga is having an enhancement effect on thegrowth of the children particularly in the just started weaning group. In Group B that contains nine months of age children and having a weaninghistory of at least two months, the effect of the formulation in comparison with the dietaryadvice given seems to be constrained only for weight and length. The enhancement effectseen in the first group is reduced when came to the second group. This may be becauseintroduction of more feeds that give sufficient nutrients to both the clusters and theformulation is having a marked effect only on the weight and length of Group B studycluster, as the parameters seems to be very sensitive when compared to others. The above Discussion, summary and conclusion 165
  • 178. Department of Koumarabhrityafact is more evident in the established dietary group, in which homely foods were given tothe children and had at least four months of complementary feeding. The effect of theformulation is not evident in this group. The low response of the formulation in both theabove groups may be due to the labile nature of the digestive fire, due to the introductionof new foods, which has to be evaluated in future. Therefore, Priyalmajjadi yoga is having a significant effect on the growth of thechildren if administered in the initial phase of weaning, in which the other dietaryadditions are minimal. In another way, Priyalamajjadi could be act as an effective initialcomplementary feed by converging the properties of many other feeds into one. It wasalso seen that the formulation is having significant effect on gain in length and weight ofthe children in Group B also. This indicates that the formulation can be used up to 11months for the enhancement of the weight and length of the children under one year ofage along with an ideal dietary advice. The effect of the formulation along with complementary feed was assessed on thedevelopment of the children using TDSC chart for assessing the developmentalmilestones. Only children having normal developmental pattern for the age wereassigned to the study. After the completion, the same was evaluated and found that all thechildren in different groups attained the developmental milestones in time and had nodifference between the study and control clusters in all the groups. Assessment of weaning associated conditions such as loose stools, regurgitation,constipation, colic etc were evaluated along with other morbidity conditions. Weaningassociated conditions such as loose stools and constipation showed a considerableobserved difference. During the intervention period in Group A, three participants in the Discussion, summary and conclusion 166
  • 179. Department of Koumarabhrityastudy group showed loose stools, while none in the control group developed thecondition. On statistical evaluation, the difference shown was not significant. A largesample may be necessary for a definite conclusion in this aspect. Single patients fromGroup B and Group C in the study cluster also developed loose stools none in the controlgroups developed the conditions. The laxative effect of the priyala due to sara propertymay be the reason for this. However, considerable difference is noted in constipation inall the groups in the control and study settings. Five in the control cluster of Group A, sixin the control cluster of Group B and two in the control cluster of Group C had developedconstipation but none developed the condition in the study cluster of any of the threegroups. In group A and Group B, the observed difference had a statistical significance too(with P values 0.039 and 0.017 respectively). One of the major problems associated withweaning is constipation that is not there in the study group received the Priyalamajjadiyoga along with the same diet that of the control group. The saratwa property of the drughelps in this aspect and it is very valid too.10.3 Mode of action of the formulation The food formulation under consideration here Priyalamajjadi yoga, is having adirect effect on the growth and development of the children due to its inherent properties.Three of its major drugs (priyala, yashti madhu and sitopala) are brimhana, a propertythat propels proper growth of the structural entities and development and maturity offunctional constituents in the body. Medhya – the property that helps to enhance theintelligence – is there in Yashtimadhu, which can positively help in the functionalmaturity of the brain. Sara guna of priyala is having two positive effects. The first one isto counter one of the weanling dilemmas – constipation, by inducing a laxative effect. Discussion, summary and conclusion 167
  • 180. Department of KoumarabhrityaSecond benefit is, due to the anulomana nature attained by the laxative action of thepriyala , it helps to alleviate apanavayu which further normalizes other vata. This in turnhelps in the homeostasis of the three humours of the body, which regularize the digestivefire leading to a proper metabolism. Priyala is having brimhana and vrishya properties,which helps in the proper growth and development of the body components. Preenana,the property that nurture the mind, is there in the drug priyala, which helps in thecognitive development. Laja or puffed rice is laghu, which makes it easily digestible and assimilable innature, a property just opposite to the above drugs explained. Presence of laja reducesthe heaviness of the formulation and creates an ideal environment for the digestion of thesame by increasing the digestive fire. Moreover, laja is the drug choice for Chardi(vomiting) and atisara (diarrhea). Its addition in the formulation will reduce two of themajor weaning associated conditions- regurgitation and loose stools. For the same reasonit helps to regulate the vamanopaga nature (helps in emesis) of Yashti madhu andpossibility of increased number of loose stools due to the Saratwa of priyala. Theformulation is easily digestible as a heat process, which again makes it easily digestibleand assimilable, prepares it. For proper growth of the infant diet with sufficient calories is essential. The infantduring first year of life requires high protein diet. Diet during this period must containEssential Fatty Acids, which are vital for Growth & Development of brain (Neuronaldevelopment). This is because it can cross the blood-brain barrier effectively. On study,it was noted that Priyala seeds contain 21. 6% protein and they contain Essential FattyAcid in the form of Linoleic acid. Sugar in very little quantity is good source of energy inthe form of carbohydrate (glucose). Discussion, summary and conclusion 168
  • 181. Department of Koumarabhritya10.4 Strength and weakness of the study The study was able to satisfy its objectives quite comfortably. The methodologyadopted fro the study helped to attain another objective – the ideal time for administrationof the formulation during the complementary feeding. However, the data collectionmethods and assessment criteria remained sufficient to draw conclusions, sample size ineach group were not sufficient for the same. This was particularly affected for theassessment of morbidity. No conclusions regarding the sustained efficacy of the intervention as the studyproper in each group was only for two months and no follow up was done. Lack ofparticipants satisfying the inclusion criteria and difficulty in keeping the children in touchwith the intervention forced to make the constraints. The study says nothing about the duration of administration of the formulation asit considers only two months as the period of intervention.10.5 Suggestions for future research 1. The results may be reviewed with much larger samples. 2. The duration of administration of the formulation may be considered along with a follow up for the sustained effect. 3. The question of over nutrition and other ill effects if any, on prolonged administration may be considered. 4. A multi disciplinary approach to make the formulation more stable and more user friendly. 5. A detailed experimental research to evaluate the nutritive value of the formulation. Discussion, summary and conclusion 169
  • 182. Department of Koumarabhritya 10.6 Conclusion 1. Priyalamajjadi yoga is having a significant effect on the enhancement of growth and development of the children during the first year of life. 2. The effect is particularly evident in children in the initial stage of complementary feeding noted by the significant changes in length, weight, head circumference, chest circumference and mid upper arm circumference. 3. The effect of the formulation constrained only to weight and length in children under established stage of complementary feeding. 4. The food formulation is not having any particular effect in growth and development of the children above one year of age. 5. Participants in all the groups had normal developmental patterns. 6. The ideal time for administration of the formulation is in the early stages of complementary feeding for the above reasons. 7. Administration of the formulation along with usual dietary patterns will help to reduce constipation associated with complementary feeding. 8. The formulation may be used for a duration of two months to enhance weight and length of children less than one year of age, if they are otherwise normal.Discussion, summary and conclusion 170
  • 183. Department of Koumarabhritya References 1. World Health Organization publication on nutrient adequacy of exclusive breast feeding for the term infant during the first six months of life, 2002 2. Ghai essential pediatrics, sixth edition, page 1 3. Nelson’s text book of pediatrics,fifteenth edition Chapter 11 4. Nelsons text book of pediatrics,fifteenth edition Chapter 12 5. World Health Organization technical report on child growth standards, 2006 6. IAP text book of pediatrics, third edition, page no 73 to 98 7. Park’s textbook of preventive and social medicine 19th edition, chapter 10/page no 480 8. World Health Organization publication on nutrient adequacy of exclusive breast feeding for the term infant during the first six months of life, 2002 9. Textbook of pediatrics, Udani, page no 369 10. Textbook of pediatrics, Udani, page no 369 11. World Health Organization publication on nutrient adequacy of exclusive breast feeding for the term infant during the first six months of life, 2002 12. Nelson’s text book of pediatrics, fifteenth edition, chapter 16 13. World Health Organization international code of marketing of breast milk substitutes, 1981 14. World Health Organization publication the optimal duration of exclusive breast feeding, 2002 15. IAP text book of pediatrics, third edition, page no102 to 109 16. Nelson’s text book of pediatrics fifteenth edition, chapter 43 17. Nelson’s text book of pediatrics fifteenth edition, chapter 44 18. Nelson’s text book of pediatrics fifteenth edition, chapter 44 19. Susrutha Samhita Sutrasthanam 1/7 20. Charaka Samhita Sareerasthana 3/2 21. Charaka Samhita Sareerasthana 4/26 22. Charaka Samhita Sareerasthana 4/22 23. Susrutha Samhita Sareerasthana 2/52References and bibliography 171
  • 184. Department of Koumarabhritya 24. Susrutha Samhita Sareerasthana 2/53 25. Susrutha Samhita Sareerasthana 2/54 26. Charaka Samhita Sareerasthana 4/14 27. Susrutha Samhita Sareerasthana 1/14 28. Susrutha Samhita Sareerasthana 2/31 29. Charaka Samhita Sareerasthana 6/11 30. Charaka Samhita Sareerasthana 6/12 31. Kashyapa Samhita Sutrasthanam 28/6 32. Charaka Samhita Sareerasthana 8/75, Kashyapa Samhita Sutrasthanam 28/6 33. Susrutha Samhita Sareerasthana 10/23 34. Susrutha Samhita Sutrasthanam 46/3,Kashyapa Samhita Khilasthana 4/3-6 35. Charaka Samhita Sareerasthana 7/16 36. Charaka Samhita Vimanasthana 8/113-130 37. Kashyapa Samhita Khilasthana 3/117,118 38. Ashtanga Hridaya Utharasthana 1/40,2/33 39. Arogyakalpadrumam 1/4,5 40. Susrutha Samhita Sareerasthana 10/42 41. Bhela Samhita 17/1,2 42. Charaka Samhita Sutrasthana 25/38 43. Kashyapa Samhita Khilasthana 4/3-6 44. Kashyapa Samhita Khilasthana 5th chapter 45. Ashtanga Sangraha Sutrasthana 1st chapter 46. Charaka Samhita Sareerasthana 6/14-16 47. Ashtanga Hridaya Utharasthana 2/30 48. Hareetha Samhita 8th chapter 49. Susrutha Samhita Nidanasthana 10/19-22 50. Madhava Nidana Purvakhanda, 7th chapter 51. Astudy on the prevalence of vitiated breast milk and efficacy of Patadi gana kashaya in purification of breast milk and prevention of associated disorders in infants, Preetham Pai, 2006 52. Susrutha Samhita Sareerasthana 10/31 53. Susrutha Samhita Nidanasthana 10/25References and bibliography 172
  • 185. Department of Koumarabhritya 54. Susrutha Samhita Sareerasthana 10/30, Ashtanga Hridaya Utharasthana 1/27 55. Charaka Samhita Chikitsasthana 30 56. Ashtanga Hridaya Utharasthana 2/44,45 57. Kashyapa Samhita Chikitsasthana 17/4 58. Sarangdhara Samhita Purvakhanda, 7th chapter 59. Bhaishajyaratnavali, Balarogaprakarana 60. Sarangdhara Samhita Purvakhanda, 7th chapter 61. Madhava Nidana Balarogaprakarana, 7,8 62. Susrutha Samhita Sareerasthana 10/29 63. Susrutha Samhita Sareerasthana 10/17 64. Ashtanga Hridaya Sutrasthana 5/25-31 65. Ashtanga Hridaya Utharasthana 1/20 66. Bhavaprakasam Dugdhavargam 24 67. Publication by Food and Nutrition Board on infant feeding 68. Kashyapa Samhita Khilasthana 5/3, Ashtanga Sangraha Sutrasthana 10/13,14 69. Kashyapa Samhita Khilasthana 3/117,118 70. Ashtanga Sangraha Sasilekha commentary by Indu chapter 1 71. Charaka Samhita Sareerasthana 8/59 72. Park’s textbook of preventive and social medicine 19th edition, chapter 10/page no 480 73. Charaka Samhita Vimanasthana 1/25 74. Madhava Nidana Balarogaprakarana, 7,8 75. Kashyapa Samhita Sutrasthana 18/25-28 76. Arogyakalpadruma 35/1-5 77. Kashyapa Samhita Kalpasthana 35/38 78. Ayurvedic Pharmacopoeia India, vol page,Ashtanga Hridaya Sutrasthana 6/121,125 79. J Ethnopharmacol. 2000 Jul;71(1-2):89-92 Puri A, Sahai R, Singh KL, Saxena RP, Tandon JS, Saxena KC. Division of Biochemistry, Central Drug Research Institute, -226 001, Lucknow, India. 80. Ayurvedic Pharmacopoeia India, vol pageReferences and bibliography 173
  • 186. Department of Koumarabhritya 81. Ashtanga Hridaya Sutrasthana 5/57,58 82. Ashtanga Hridaya Sutrasthana 6/37 83. Ashtanga Hridaya Sutrasthana5/47,48 84. World Health Organization publication on evaluation of traditional medicine 85. IAP text book of pediatrics, third edition, chapter 4, page 79References and bibliography 174
  • 187. Department of Koumarabhritya Bibliography 1. Arogya Kalpa Drumam (Malayalam) Paediatric - Ayurveda - by Kaikulangara Rama Warriar, Seventh edition - 2005 2. Astanga Hridayam of Vagbhata with ‘Sarvanga Sundari’ commentary of Arunadatta and ‘Ayurveda Rasayanam’ of Hemadri, 1996 Krishnadas Academy, Varanasi 3. Astanga Sangraha of Vridha Vagbhata with ‘Sasilekha’ commentary of Indu, edited by Late. Dr. Pandit Rao, Vaidya Ayodhya Pandey, Moulika sidhanta vibhaga, 1991, Gujarat Ayurveda University, Jam nagar, Central Ayurveda and Sidha research institute, New Delhi 4. Bhavaprakasa Nighantu of Bhavamisra, commentary by K.C. Chunekar, AMS, edited by Dr. G.S. Pandey, AMS, 10th edition, 1995 5. Bhavaprakasa of Bhavamisra poorvardha, 11th edition, 2004, Chaukhambha Sanskrit Samsthan, Varanasi 6. Ghai. O.P. - Essential Pediatrics Published by Mehta Publishers New Delhi, 5th Edition, 2000. 7. Charaka Samhita of Agnivesha with ‘Ayurveda Deepika’ commentary by Pt. Kasinatha Sastri, edited by Dr. Ganga Sahay Pandeya, Part I and II, 1st edition 1997, Chaukhambha Sanskrit samsthan, Varanasi 8. Forfar and Arneil’s Textbook of Pediatrics edited by A.G.M.Campbell Neil Mcintosh, 5th edition, Churchil Livingstone Publishers, Newyork 9. Kashyapa Samhita- Vridha Jeevakeeya tantram, revised by Vatsya, Sanskrit translation by Nepala Rajaguru Pt. Hemaraja Sharmana and Vidyotini Hindi commentary by Ayurvedalankar Sri. Satyapal Bhishagacharya, 1953, Chaukhambha sanskrit series 10. Nelson Textbook of Pediatrics, 17th edition, Richard E. Behrman, Robert M. Kliegman and Hal B. Jenson, 17th edition, reprint 2004 11. Susrutha Samhita of Susruta with ‘Nibandha Sangraha’ commentary of Dalhana and ‘Nyayachandrika’ commentary by Sri. Gayadasacharya. Edited by VaidyaReferences and bibliography 175
  • 188. Department of Koumarabhritya Yadavji Trikamji Acharya and Narayana Ram Acharya ‘Kavyatirtha’, edition reprint 1998, Krishnadas academy, Varanasi 12. The short Textbook of Pediatrics edited by Suraj Gupte, 10th silver Jubilee edition, Jaypee Brothers Medical Publishers, (P) ltd., Chaukhambha Sanskrit Prathisthan, Delhi 13. Dravya guna vijnana, Vol. I and II, Prof. P.V. Sharma, reprint 1998 Chaukhambha Bharati academy, Varanasi 14. Indian Medicinal Plants, edited by P.K. Warrier, V.P.K. Nambiar and C.R. Raman Kutty 1st edition, reprinted in 2002, Orient Longman Pvt. Ltd 15. Introduction to Kayachikitsa by C. Dwarakanatha, 3rd edition, 1996, Chaukhambha Orientalia, Varanasi 16. Madhava Nidanam of Sri. Madhavakara Vol I and II with ‘Madhukosha’ commentary by Vijayaraksita and Srikanthadatta, edited with ‘Vimala’- ‘Madhudhara’ Hindi commentary and notes by Brahmananda Tripathi, 2nd edition 1998, Chaukhambha Surabhi Prakashan, Varanasi 17. Sharangdhara Samhita of Sarangadhara with ‘Deepika’ commentary of Adhamalla, ‘Gudhartha deepaka’ commentary by Kashirama Vaidya 18. A Parthasarathy - IAP Textbook of Pediatrics, Published by Jaypee Brothers Medical Publisher (P) Ltd., New Delhi, 2nd Edition, 2002 19. Bhela – Bhela Samhita, Edited by Sharma P.V. Published by Chaukhambha Vishwabharathi Oriental Publishers and distributors, Varanasi, 1st edition 2000. 20. World Health Organization publication on nutrient adequacy of exclusive breast feeding for the term infant during the first six months of life, 2002 21. World Health Organization publication the optimal duration of exclusive breast feeding, 2002 22. World Health Organization international code of marketing of breast milk substitutes, 1981References and bibliography 176
  • 189. Department of Koumarabhritya Annexure - 1 CASE PERFORMAName Father’s nameAge Mother’s nameSex Family incomeAddress ReligionInformantAntenatal historyAge of mother at the time of pregnancyAntenatal checkups t.t injctionspoly/oligo hydramnios iron supplementationMaternal illnessAntepartum haemorrhage HTNHyperemesis DMPrevious abortions Any drug intakeX ray exposure Antenatal USSNatal historyPROM Meconium aspiration References and bibliography 177
  • 190. Department of KoumarabhrityaHome/hospital delivery Full term or pretermBirth weight Reason for assisted deliveryAny resuscitation requiredPost natalTime of initiation of breast feeding Any problem with breast feedingWhen meconium passed When urine passedAny problems in newborn periodPoor feeding JaundiceCyanosis SeizuresCephalhematoma Umbilical sepsisThe child needed hospitalizations Immunization historyWhether immunization adequate for age BCG scarDietary historyTill what age was exclusive breastfeeding?When was weaning started? With what?When was cow’s milk/formula started? Dilution ratioWhether using feeding bottle or spoon?Any change in bowel habit in relation to introduction of specific food items?Type of food Upto what age frequency Quantity References and bibliography 178
  • 191. Department of KoumarabhrityaFamily and socioeconomic historyBirth order SpacingAny consanguinity Age of motherAge of fatherPersonal historyFood AppetiteBowel BladderSleep HygieneAssessment of Growth and DevelopmentNutritional Anthropometry Before After 1 month After 2 months treatment1 Length2 Height3 U/L segment ratio4 Weight5 HC6 MUAC7 CC8 BMI9 Quetlet’s index10 Eruption of teeth References and bibliography 179
  • 192. Department of Koumarabhritya TDSC CHARTTest item1. Social smile2 .Eyes follow pen/pencil3 .Holds head steady4 .Rolls from back to stomach5 .Turns head to sound/to bell/rattle6 .Transfers objects hand to hand7 .Raises self to sitting position8 .Standing up by furniture9 .Fine prehension pellet10. Walks with help11 .Throws ball12 .Walks alone13 .Says 2 words14 .Walks backwards15 .Walks upstairs with help16 .Points to parts of a dollGENERAL EXAMINATION 1. Built 2. Posture – Normal/Abnormal 3. Appearance – Sicklooking/comfortable 4. Pulse rate 5. Temperature 6. Respiratory rate 7. Frontal bossing – Present/absent 8. Fontannels – Anterior Posterior References and bibliography 180
  • 193. Department of Koumarabhritya Pulsatile/Nonpulsatile Normal/Depressed/Bulging 9. Face – Dysmorphism/Micrognathia/Normal 10. Dentition 11. Teeth 12. Neck – Normal/Short/Webbing 13. Skin – Normal/Abnormal If abnormal Skin rash/pigmentation/icterus/oedema/purpura 14. PEM – Present/Absent 15. Limbs- Normal/Short/Long SYSTEMIC EXAMINATION 1. Respiratory system 2. CVS 3. GIT 4. CNS REFLEX 1. Sucking reflex and rooting reflex 2. Palmar grasp 3. Moro reflex 4. Landau reflex 5. ATNR 6. Parachute reflexASHTASTHANA PAREEKSHA 1. Nadi – Vatam/Pittam/Kapham 2. Mootram – Normal/Alpamootram/Bahumootram/Mootravarodham Colour-Normal/Pandu/Raktam or Neelam/Dhavalam/Krishnam/Haritham 3. Malam – Colour- Krishna varnam/Haridra/Panduswetavarnam Consistancy-Pinditam/Sushkam/DraveekritamReferences and bibliography 181
  • 194. Department of Koumarabhritya 4. Jihwa – Normal/Sweta/Pita/Harita/Nila/Krishna 5. Sabdam – Guru/Sphutam/Normal/Ksheenam 6. Sparsam- Ushnam/Seetam/Ardram 7. Drik – Dhoomram/Peetam/Jalardram 8. Akrithy – Vata/Pitta/Kapha ASSESSMENT OF MORBIDITY INDICES INCIDENCE RATEManifested Before treatment After 1 month After 2 monthssign/diseasePREVALENCE RATEManifested Before treatment After 1 month After 2 monthssign/diseaseASSESSMENT OF AVERAGE DURATION OF SICKNESSSymptom/disease Duration Before treatment After treatment References and bibliography 182
  • 195. Department of Koumarabhritya Annexure – 2 Trivandrum Development Screening ChartReferences and bibliography 183
  • 196. Department of Koumarabhritya Annexure – 3Meal patterns for children up to two years of age0-*4 months *4-6 months 6-8 months 8-12 monthsBreast milk On waking- breast On waking- breast milk On waking- breastonly milk 9 am- Mashed fruit/ milkWhenever the 8 am- Fruit juice vegetable 9 am-Multi mix***baby demands, 10 am – Mashed 11 am –Breast milk 11 am- Fruit cut toatleast 7-8 times banana 1 pm – Porridge** piecesa day 12 pm- breast 4 pm – Breast milk 1 pm- Multi mix milk 6 pm – porridge 4pm- Breast 2 pm- Dal soup 8 pm- Breast milk milk/other milk 4 pm- breast milk 10 pm- Breast milk 6 pm-Rusk/Biscuit/a 6 pm- vegetable slice of bread soup 8 pm- Multi mix 8 pm- breast milk 10 pm- Breast milk 10 pm- breast milkOne to two yearsGive modified family food avoiding spices and condiments.*Try to provide exclusive breast feeding up to 6 months of age** Porridge can be prepared by cooking the cereals wheat, rice, semolina etc with milk orwater and sugar. Fried and powdered cereals are boiled with milk for two minutes andserved by adding a little oil or ghee.***Preparation of Multimix References and bibliography 184
  • 197. Department of KoumarabhrityaYou can choose any one of the choices below 1. Cereal + pulse + green leafy vegetable 2. Cereal + pulse + milk 3. Cereal + pulse + vegetable + curd 4. Cereal + milk + fruit + nuts 5. Cereal + egg/fish/meat + finely ground nuts Three parts of cereals, one part pulse and half parts of the rest of the ingredientscan be used and made into a porridge form. Better to add a little ghee before serving.Preparation of Amylase Rich Flour(ARF) Germinate 200g of cereal or pulses by soaking them in triple volume of water for 12hours and then wrap it in a cloth for 48 hours. Then sun dry for 6-8 hours. Remove thesprout and make a powdr of the remaining grains.This should be stored in air tightcontainers and 1-2g can be served along with porridge.Points to remember 1. Wash hands before cooking and giving food 2. Make sure all the foods and utensils used to serve the food are clean 3. Keep the cooked food in closed vessels 4. Never keep the cooked food beyond 2 hoursThe above chart was supplied in regional language - Malayalam References and bibliography 185