A Hand Book of Pediatric Procedures for Ayurvedic Pediatricians

About The Book

This book is a distillate of pediatric procedure related information from Modem Pediatrics, Panchakarma, Kayachikitsa and Samhitas, along with the inputs from internet and the clinical experiences of author and other pediatricians. This handbook has been designed primarily to serve as a guide for performing modem and Ayurvedic pediatric procedures in an Ayurvedic setup, in a clinically efficient and legally justified manner. Point wise format, clear cut therapeutic indications and self speaking illustrations are the hallmarks of this book. As brief, yet instantly enlightening subjective background behind various elements of an Ayurvedic (and modem procedures as well) procedure has been provided frequently (e.g., in boxes), the practitioners and researchers from other systems of medicine interested in Ayurveda, may also find this book useful. It will also cater to the 'Pediatric procedures' chapter of the new CCIM syllabus for MD (Kaumar bhritya/Bala roga), PG Diploma in Pediatrics (Ay) and BAMS courses.

About the Author

Dr Mayank Srivastava is amongst the young promising Ayurvedic pediatricians. He graduated from SKD Govt. Ay. College, Mzn. (U.P.) and thereafter completed his post graduation in Kaumarbhritya (Ayurvedic Pediatrics) from the prestigious institute, "Institute of Medical Sciences", BHU, Varanasi (U.P.) in 2007. Since then, for almost last 7 years, he has been actively teaching and practicing Ayurvedic Paediatrics.

Presently he is working as Associate Professor and HOD in Dept. of Kaumarbhritya in Himalayee Ayurvedic Medical College and Hospital, Dehradun (U.K.). He is also a reputed Pediatrician and Neonatalogist in the holy city of Rishikesh (U.K.), well known for his skills in Pediatric emergency management and rational Ayurvedic management of the various Pediatric illnesses. He is a visiting paediatrician in various nursing homes and schools of Rishikesh.

He has a wide experience and in depth knowledge of the theoretical and practical aspects of Kaumarbhritya. He has presented papers, participated and chaired scientific sessions in national and international seminars and has many publications in his name as well. In nutshell, he is an outstanding writer, a proficient teacher and a skilled practitioner of Kaumarbhritya, the Ayurvedic Paediatrics. Hence this book will be of immense benefit to the practicing doctors and the trainee student .

Foreword

Ayurveda, the science of life, helps the person lead a healthy and happy life by alleviating all sorts of pain. Entire Ayurveda is classified into eight branches and Kaumarbhritya is one of them. Dalhana while commenting on Sushruta Samhita Uttartantra 1/5, mentioned the name of Kaumarbhritya's specialized text books namely Parvataka, Jeeva- kam, Bandhaka etc, which are presently unavailable. Enumeration of these specialized books on Kaumarbhritya suggests its importance as an independent and well-developed branch of Ayurveda.

Information regarding the specialized knowledge of Kaumarbhritya is available since Vaidika kala (Rigveda 517817-9,' Atharvaveda 1111/5; Atharvaveda 8/6/13,' Bodhayan Grihyasutra; Paraskara Grihyasutra). In Brihattrayi, information about the procedures to prevent and treat various disorders related to the children are available - some are performed in children right at the time of their birth such as Prana-Pratyagamana and Garbhodaka-vaman; whereas many more are performed thereafter, such as use of Tricyle and Shodhana karma procedures in the management of Phakka roga (done as per their respective indications).

Procedures may also serve diagnostic purpose. Various subjective and objective parameters are used to know the health status of a child. Out of these parameters, some are used to confirm the diagnosis and in turn help in planning a judicious management. Kashyapa too has suggested a clinical diagnosis to assess the health status of children'. Clinical features of 'Arogya' can be confirmed by various subjective & objective parameters and need use of different procedures. This shows the importance of objective parameters as hematological, biochemical, stool & urine examination in diagnosis and management of diseases in children.

So the procedures are very essential, both in diagnosis and management of various pediatric disorders. But good books devoted to pediatric procedures having modem as well as Ayurvedic aspects are not presently available.

Dr. Mayank Srivastava is a young author, dynamic teacher, good clinician and orator. Properly drawn on his experience, he has published this literature to offer a complete and lucid discussion of each procedure.

To make the subject more perceptible, he has classified all the procedures, broadly into two categories - 'Modem' and 'Ayurvedic' procedures. The book includes most of the modem procedures used to manage emergency conditions of children in day-to-day practice and they should essentially be learnt by each pediatrician in order to save the life of more and more children; while the Ayurvedic procedures are mainly related to Kaumar-panchakarma i.e. those Panchakarma procedures which are commonly performed in children. Panchakarma procedures, which were mentioned in Ayurvedic classics hither and thither, have been collected systematically in this book and explained from the pediatric point of view, in a to the point manner. This has further augmented the usefulness of this book for the postgraduate and graduate students. '

"A Hand Book of Pediatric Procedures for Ayurvedic Pediatricians" has generously used photographs, algorithms and text- boxes for explaining the subject-topics. This book has taken initiative to make a lucid presentation of all those procedures which are mandatory in grooming of the medical students and practitioners in the field of Ayurvedic pediatrics.

Study of this book will equip the students with ample skill to perform the procedures easily with a minimal effort. This book will be useful to the BAMS, PG-Diploma, PG students and for all those who are engaged in active care of the newborns, infants and children.

Finally, I congratulate the author of this book for his excellent effort in bringing forth a worthful contribution in the field of Kaumarbhritya, the Ayurvedic pediatrics.

Preface

Procedures are merely procedures. They should better be viewed 'condition specific' rather than the 'system of medicine specific'. In that sense, most procedures have an unparalleled utility and as such one must not abstain from performing it merely because it was born in another system of medicine. The essentiality of a procedure in a health issue may range anything from it being safely avoidable, to it being an essential part of management or even life saving. For clinically and medico legally judicious management of a case, an Ayurvedic pediatrician must be able to perform all the necessary Ayurvedic and modern procedures with an equal degree of expertise.

The literatures available on modern pediatric procedures usually lack the clarity on issues which albeit not required by the practitioners of modern pediatrics, are essential for grooming of an Ayurvedic pediatrician. Coming to Ayurvedic procedures, these are less often practiced in children and whatsoever performed, are written in standard texts primarily keeping in mind the grownups; also their indications in children are vaguely defined. Thus there exists a big lacuna in Ayurvedic pediatric practice when it comes to having a single resource book focussed exclusively on performing all necessary Ayurvedic and modern procedures in children. This often leads to mismanagement. Keeping this in mind and to fill that void, this book has been written from the perspective of an Ayurvedic pediatrician.

This book being a blend of all important modern and Ayurvedic pediatric procedures along with their clear cut therapeutic indications (needs user's discretion), will primarily serve following purposes:

A single hand book for performing all commonly needed modern or Ayurvedic pediatric procedures in an Ayurvedic set up .

Acquaint an Ayurvedic pediatrician with some important legal aspects of pediatric procedures.

To cater to the 'Pediatric procedures' chapter of the new CCIM syllabus for MD (Kaumarbhritya/Bala roga) , PG Diploma in Pediatrics (Ay) and BAMS courses.

Conscious efforts have been made to maintain a point wise approach in the book, bundled under various titles and subtitles, so that the reader can read and coin prehend easily and thus perform the procedures with confidence. Practical tips have also been notified (as "N.B.") at many places. For a better insight into the procedure (especially Ayurvedic), wherever needed, a brief subjective background behind various elements of a procedure have been provided (as in boxes). As such, the practitioners and researchers from other systems of medicine may also find this book useful. As a picture speaks better than thousand words, this book has been generously enriched with self speaking illustrations. All this has made this book both concise and thorough, making it an ideal companion book while performing common procedures in Ayurvedic pediatric practice.

I am greatly indebted to my honourable teachers Prof. Madam P.V. Tiwari, Dr. B.M. Singh sir and Dr. Sangeeta Gehlot madam for their incessant inspiration, guidance and affection, which went long in completing this work. During the' preparation of this book I was constantly reminded 'of the countless lessons I learnt from my talented mentor Dr. B.M. Singh, our seniors and other hospital staff of BHU, Varanasi. I express my heartfelt gratitude towards my family who have been readily sacrificing 'their' precious part of my time, in order to make me complete this and the forthcoming endeavours. The publisher, Mr Atul Kumar also deserves special thanks for accepting my ideas and publishing this book in a format conventionally different from the routinely published Ayurvedic books. My sincere thanks to one and all behind this book.

As Ayurvedic pediatrics flourishes further, procedures which have been knowingly withheld to reduce the volume of the book, may find place in forthcoming issues. Constructive criticism and suggestions are always welcome for improving the future editions.

Introduction

Procedures may be needed in management of both emergency and non emergency conditions. Emergency procedures if performed timely and with due precautions are often life saving in children. In general, it takes comparatively more time to perform a procedure in a child than an adult. Each unsuccessful attempt is traumatic not only for child but also for the parents, doctor and assistant. So the procedures should be mastered by observation, performing under supervision and thereafter repetitive performance. After all, 'Practice makes a man perfect'!

Procedure room and lightening

There should be a strategically located separate procedure room, having good illumination facility. It should be spacious and comfortable (preferably air conditioned) to the patient, doctor and assistant as well. It should be well equipped with all necessary equipments (of various sizes), drugs, oxygen, specimen collecting containers, etc. Their presence should be verified daily and also before taking the child to procedure room.

Consent

In medical practice, anything beyond routine requires an 'informed consent'. It is essential to obtain a well informed consent in vernacular language prior to the procedure, preferably in hand writing of the major/ parent/ legal guardian and duly signed by them.

The consent should cover following points:

 The proposed procedure or treatment,

 The indications,

 All inherent and potential hazards associated with the Tit or procedure (risk - benefit ratio of the procedure),

 Likely effect if the patient remains untreated,

 Any alternative procedure available.

This is because legally, the onus of disclosure of information lies with the doctor, whereas the right to decide the manner in which his/her body will be treated lies with the patient. It is worth mentioning here that the widely practiced broad spectrum 'blanket consent' has no legal validity.

Consent in medical emergencies:

Medical and not legal considerations are of greater importance in life- threatening conditions. So in cases of medical emergency or unconsciousness, all considerations regarding consent will be set aside and a doctor should do whatever is necessary to save the life 'of .a patient I save him from permanent disability I from unnecessary pain and sufferings. It implies that in life threatening situations, doctors would not be required to consult with parents of minor patients in contrast to in normal course of events where consent is needed for decision making. However, the doctor should do only that which is necessary for patient's well being; if during an emergency procedure, some coincidental & non-urgent problem is encountered, it should be dealt later, after obtaining the consent.

Who can give a legally valid consent?

 As per IPC section 90, consent given by a child under 12 yrs age (minor) is invalid.

 Any person of sound mind who has attained the age of 18 yrs may give a legally valid consent.

 Patient in age group of 12-18 yrs, if having sufficient understanding and intelligence to enable him/her understand the nature and consequences of It or procedure, can themselves give consent and in such cases, parental consent is not necessary.

 If a patient cannot give consent himself for reasons as being minor unconscious I not in sound state of mind, 'proxy consent' can be obtained from legal guardian or a near relative.

A procedure should not be performed against the desire of parents.

Presence of guardians during procedure

A flexible attitude must be adopted as to whether child's parents should be allowed during a procedure or not. Presence of parents can make anxious children cooperate better. But those parents, who refuse to observe the procedure, should not be forced as they may develop vasovagal syncope. The nature of procedure and operator's own confidence to manage the situation even in presence of parents, should also be duly considered.

Counseling the child

Affectionate and gentle handling is important to reduce their anxiety and fear. Older children may be given a reasonable explanation regarding the procedure, as this may decrease their anxiety and increase their cooperation for the procedure. Gently talking to the child throughout the procedure is often reassuring to them and helps in a smooth completion of the procedure. Praise the child before, during and after the procedure.

Restraint

A common problem in all pediatric procedures is the proper restraint of infant. In this regard, availability of an experienced assistant is an asset. For some procedures, restraining the child by wrapping him/her in a sheet (mummy wrap)

(Source: Medical emergencies in children, 5th edn. Meharban Singh.

Sagar publications, N.Delhi; 2012).

N.B.: Children, who can sit by themselves, are more comfortable in sitting rather than lying down position during a procedure. Making them lie, may at times frighten even a calm looking child.

Contents