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VOL 5

ISSUE 2 (2017) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE eISSN-2348-0173 pISSN-2395-3985

Nagda H.T., Patel K., Approach to Developmental Delay in Children – An Anukta Vyadhi, Int. J. Ayu. Alt. Med., 2017; 5(2): 77-81

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REVIEW ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

Index Copernicus Value (2015) – 80.04

APPROACH TO DEVELOPMENTAL DELAY IN CHILDREN – AN ANUKTA VYADHI

Hetal T. Nagda1*, Kalpanaben Patel2

1. Ph.D. Scholar, Tilak Maharashtra Vidyapeeth, Pune & Associate professor, Department Of Kaumarbhritya, Shri J.G. C.H.S Ayurved Medical college, Ghatprabha, Contact No. +91 9987456112,9833924534, Email - drhetal.n@gmail.com

2. Dean , Professor & HOD, Dept. of Kaumarbhritya, I.P.G.T. & R.A., Gujarat Ayurved University, Jamnagar, Email - drkspatel2007@gmail.com

Article Received on - 30th May 2017 Article Revised on - 19th June 2017 Article Accepted on - 20th June 2017

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REVIEW ARTICLE *Corresponding Author Hetal T. Nagda Ph.D. Scholar, Tilak Maharashtra Vidyapeeth, Pune & Associate professor, Dept. of Kaumarbhritya, Shri J.G. C.H.S Ayurved Medical college, Ghatprabha, Contact No. +91 9987456112, 9833924534, Email - drhetal.n@gmail.com

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ABSTRACT: Delayed developmental disorder is not a single entity but various conditions

causing developmental delay in children. With advancement in diagnosis & treatment prevalence rate of developmental delay is increasing day by day. In Ayurved granthas various references are found which have some correlation with this condition but there is no single Vyadhi that can be correlated directly with developmental delay. As described in Charak samhita, there are innumerable disease & each of them cannot be named but it can be treated successfully by focusing on Dosh- Dushya Samurchnna . Keeping this as the main reference point an attempt is made to put light on diagnosing & Treating Developmental Delay in Children from Ayurvedic Perspective.

Key Words: Developmental Delay, Anukta-vyadhi, Phakka roga, Samuthan, Adhisthan

INTRODUCTION For healthy status of the child, development is equally important parameter as growth. With change in era & lifestyle newer diseases are surfacing like developmental delay which doesn’t have direct correlation to any diseases in Ayurvedic classics. But by following directives regarding Anukta Vyadhi & by applying principle of treatment described in Ayurvedic texts, this condition can be elaborated from Ayurvedic etiopathogensis and hence treated with precision. An attempt is made here to do so. METHODOLOGY All Samhitas with respective commentaries

have been referred. Various paediatric books are referred for

better understanding of developmental delay. Various journals are referred for research

article for Delayed Developmental entities. Conceptual finding are presented for

discussion. Literary Review of Developmental delay from Conventional Science: Development specifies maturation of different biological functions at an anticipated age.[1] It is intimately related to the maturation of central nervous system. [2] It is a continuous process from conception to maturity. [2] A child is said to have developmental delay when he/she doesn’t attain the specified developmental milestones at the expected time. [3]

Developmental disability is considered the most important source of vulnerability among children, especially in developing countries.[4] According to an Indian Council of Medical Research (ICMR) task force study carried out at three different centers (Delhi, Jaipur, Lukhnow) the prevalence rate of Developmental disability among children below six year of age was found to be 8.8 per thousand in Delhi, 6.5 per thousand in Jaipur & 12.6 per thousand in Luckhnow.[4] The most important component of neurological history is a child’s developmental examination.[5] A large number of methods have been standardized to assess the development of children.[6] In one of the most popular tool Denver Development screening tools – 2, 125 performances based & Parent report items are used to screen child’s development in four different areas of functioning.[7]

1) Gross motor 2) Fine motor & Adaptive 3) Language 4) Personal & social.

Literary Review of Anukta Vyadhi: As described in Charak Samhita, there are innumerable diseases & each of them cannot be named but still it can be treated successfully by understanding the triad of Prakupit Dosh, Hetu or Samuthan & Adhisthan of Vyadhi.[8] In Sushrut Samhita also similar reference is found stating disease cannot occur without the vitiation of Dosha & this is key point in treating unknown diseases not describing in Ayurvedic classics by converging its symptoms & correlating

APPROACH TO DEVELOPMENTAL DELAY IN CHILDREN – AN ANUKTA VYADHI

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it with involvement of Dosha in it.[9] By the narration of both the above quotations, it is clear that the Vyadhi’s are innumerable & are having involvement of Dosha - Dushya affecting specific Adhisthan (Sthan Samshray ) due to the influence of variety of Nidans (Etiological factor). Thus Anukta Vyadhis can be treated by correcting Dosh Vaishymya.[10] Literary Review of Developmental delay from Ayurvedic Perspective: Delay in development is a multi-factorial condition & there is no single entity

described in Ayurvedic Classics that can be directly correlated to this condition but there are various references found in text which can be kept into consideration while dealing with this disease. One such reference is about Phakkaroga described in Kashyap Samahita; the cardinal symptom of Phakkaroga states that child is not able to walk by the age of 1st year of life. [11] Following table explains other symptoms of Phakkaroga which can be attributed to associated symptoms with Developmental delay.

Table 1: Symptoms of Phakkaroga & Developmental Delay

Other Symptoms of Phakka roga [11] Associated symptom of Developmental Delay Ksheen Mamsa Muscle wasting Samshushka Sphik & Bahu Rigidity in joints. Mahodar Shiro Mukh Macrocephaly Nicheshtha Adhar kayo Diplegia Nitya Mutra Purish krita Incontinence of bladder & Bowel Mand Cheshta Decreased movement

Few other conditions described while describing Phakkaroga are Pangu (Crippled), Jada (Partially Deaf), Muka (Aphonic), Badhira (Deaf). Manas & Indriya also gets affected in Phakkaroga. [11] Delayed walking can also be seen due to orthopaedic causes; but after evaluating entire spectrum of symptoms described by Kashyapacharya, Phakkaroga looks more of Neurological origin. Thus Chikitsa siddhant of Phakkaroga can be applicable in the treatment of motor component of Developmental delay from Ayurvedic perspective.

DISCUSSION Reference of Phakk roga helps in understanding one aspect of Developmental delay, but to understand other aspects reference of Anukta Vyadhi can be used, where determining triad of Dosh, Samuthan & Adhishthan is important in treating unknown diseases.[8] To understand Dosh involvement exploring symptoms of the disease can be the approach. Establishing Dosh association in Developmental delay: Following table includes some of the developmental objects (Symptoms) that get delayed.[12]

Table 2: Delayed Developmental objects (Symptoms)

Gross motor Fine motor & Adaptive Language Personal social Lift Head Grasp rattle Respond to bell Smile responsively Pull to sit- no head lag Follow object 180 Turns to rattling sound Smile spontaneously Sit no support Reaches Turn to voice Feed self Stand holding on Pass cube Single syllable Indicate want Stand alone Take 2 cubes Combine syllables Wave bye bye Walks well Thumb finger grasp Dada/mama specific Drink from cup Runs Scribbles One word Use spoon or fork Walks up steps Tower of 4 cube Two word Remove Garment Jump up Thumb wiggle 6 words Put on clothing Heel to toe walking Copy ‘0’ Combine words Dress no help

Out of all 4 different region; Gross motor & Fine- Adaptive Delay is mainly associated to movement (Cheshta) & Language is related to speech (Vani). Personal Social development also comprises movement but the core feature here is knowledge of a particular behaviour which can be attributed to Buddhi. Vayu is Pravartak of all the Cheshta

(movement) in the body & is also responsible for Vani (Speech).[13]. Depending upon its Sthan (site in body) this Vayu is further sub divided in to 5 sub types. In the following table specific site of Vayu & its specific Karma is described.[14]

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Table 3: Vata & its Specific Karma

Name of Vayu Sthan Vicharan sthan Vishishth Karma Praan Murdha Ura, Kanth Dharan of Budhhi, Hriday, Indiriya & chitta

Shthivan, Kshvathu, Udgar, Nishwas, Annapravesh Udaan Ura Nasa, Nabhi, & Kanth Vaak Pravruti, Prayatna, Urja, Bala, Varna, Smruti Vyaan Hriday Sarva Sharir All Chesta of body Samaan Agni Samipa Koshta Anna Grahan, Pachan, Vivechan & Munchan Apaan Apaan (Guda) Shroni, Basti, Medhra, Uru, Shukra, Aartav, Mala, Mutra & Grabha Nishkraman.

Thus similar to any other disease all Dosh may get vitiated in Developmental delay but predominant Dosh in this condition is Vata Dosh, Specifically Vyaan Vayu, Praan Vayu & Udaan Vayu.

Establishing Samuthan / Hetu in Developmental Delay: Following references are found in Ayurvedic classics that can be related to Hetu or Samuthan of Developmental delay.

1. Akupit Vayu is Responsible in forming Prakrut Garbha-akruti & Kupit Vayu causes defect in Garbha-Akruti.[15] This can be taken as Structural defect in fetus, which can also be one of the reasons for delay in Development.

2. Another reference found in Charaka Samhita Sharir sthan states that Beeja, Aatmakarma (Purva janma krut karma), Asshay Dushti (Genital organ Dushti), Kaal dosh, Matru aahar vihar dosh can cause Dusthi in Samsthan, Varna & Indriya Vikruti in fetus.[16] These Vikruti in turn can cause Delayed development in child.

3. A little more specific reference found in Ashtangsangraha, where in Acharya Vagbhat has mentioned very clearly that if a pregnant female follows Vata Prakopak Aahar – Vihar, then vitiated Vata will will affect the Garbha (Fetus) & will cause Various Vata disorder in child viz Badhirta (Deafness), Muktva (Unable to speak), Minmintava (Stammering), Gad –gad (Stuttering), Khanja (Limping), Kubjatva (Deformity in body), Vamanatva (Short stature), Hinanga, Adhikanag & other similar Vata Predominant Diseases.[17]

All these etiological factors can be grouped under prenatal and antenatal causes of disease & prevention of them becomes important line of treatment.

Establishing Adhisthan: From mentioned symptoms it is evident that Developmental delay is a disease of nervous system where in developing brain is affected creating symptoms in entire body. From this it becomes clear Adhisthan of Vyadhi is Uttamang [18] & its Vyakti Sthan is Sampurna Sharira.

Summarizing the Samprapti of Developmental Delay:

Dosh – Predominantly Vata Dosh (Vyaan Vayu, Praan Vayu, Udaan Vayu)

Dushya – Rasa Dhatu, Mamsa Dhatu, Majja Dhatu

Smauthan – Prenatal & Antenatal Adhisthan – Uttamang , Vyakti sthan Sarvang

Sharira.

Other factors to be considered: From all above discussion it is evident that the predominant Dosh involvement in Developmental delay is Vata Dosh hence the chief line of treatment in this condition is harmonizing Vata Dosh with Vatahar, Balya, Brihaniya & Medhya treatment. But Developmental delay being a multi-factorial disease with a Varity in its etiology causes very diverse symptoms & hence for archaic specific treatment other aspects of disease need further evaluation & association from Ayurvedic Perspective.

Prognosis from Sadhyasadhytva Point of view:Being a disease occurring in children Developmental Delay falls into Krichchhsadhya group.[19] But considering other factors outcome of treatment will vary.

1. Presence of Hetu, Purvaroopa, Roopa : The lesser the no present in the disease better the outcome, which is evident by the fact that Global Developmental delay has bad prognosis as compared to Delay in any one or two area.

2. Identification of Hetu : Genetic condition or Beeja Dushti leading to developmental delay like Down syndrome will have a diverse perspective than Developmental delay from other etiological factor.

3. Roopa :It is observed clinically that children with Developmental delay may have associated complaints viz. Mental Retardation, convulsions, Visual impairment, Hearing impairment, Structural Defect, Excessive drooling of Saliva, Constipation like viz. With rise in no. of associated complaints, intricacy of disease rises, growing the chance of poor prognosis. Also Vikalp Samprapti differs with each associated complaints which will modify line of treatment. Following table simplifies it.

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Table 4: Vikalpa Samprapti & Line of Treatment

Associated Complaints Vikalpa Samprapti Modification in Treatment Mental Retardation Mati mandatva. Additional Medhajanan Convulsion (Aakshepak) Chal Guna of Vata increased Sthira Gunatmak chikitsa Visual Impairment Netragat Vikar Kriyakalp Chikitsa Hearing impairment Further investigation for Deafness & its management Drooling of Saliva Muscle weakness of oral cavity Local Balya Chikitsa Constipation Ruksh Guna of Vata increased Snigdh, Vatanuloman Chikitsa Hypotonia Mamsa Shaithilya Stambhan Chikitsa

4. Chronicity of disease: More chronic disease

bear poor prognosis. This fact is applicable to Developmental delay too; the earlier the diagnosis the better will be prognosis. Thus child diagnosed in first or second year of life has better prognosis than diagnosed at later age.

5. Complications: Presence or absence of complications like contractures or strictures is another deciding point of prognosis, the lesser the presence the better the outcome of disease. Associated structural defects like congenital cataract or CHD needs surgical intervention increasing the complexity of the condition & hence the consequence.

Thus all these points to be observed in any child with developmental delay for precise outcome of treatment. CONCLUSION It’s true that there is no direct correlation of developmental delay in Ayurvedic text, but by combining & applying various Ayurvedic principles like Anukta-Vyadhi, Dosh – Dushya Samurchhna, Samuthan, Adhisthan, Sadhyasadhytva, this complex disease can be simplified in Ayurvedic terminology & treated impeccably. REFERENCES 1. O.P. Ghai, Ghai Essential Pediatrics, CBS Publisher, New

Delhi, 6th Edition, 2004, p.1 2. R.S. Illingworth, The Development of the Infant & Young

Child, Churchill Livingstone, 9th edition, reprint 2006, P. 83 3. Dr. M. K. C Nair, Module on Early Stimulation, Child

Development Centre, Thiruvananthpuram, 2004, P.11 4. Dr. Bela shah, Dr. Narendra kumar, Prevention of

Developmental disability ICMR Bulletin, April- June 2007, Vol-37 , P. 1-2

5. Kligman, Behrman, Jenson& Stanton, Nelson Text book Of Pediatrics, 18th edition, Reed Elsevier India Pvt.LTd. New Delhi, print 2008, Volume 2, P. 2433

6. Meharban Singh, Pediatric Clinical methods, Sagar Publication, New delhi, second edition, Reprinted 2003, P.66

7. O.P. Ghai, Ghai Essential Pediatrics, CBS Publisher, New Delhi, 6th Edition, 2004, p.44

8. Agnivesha, Charak Samhita Chakrapani Commentary, edited by Jadavji Trikamji Acharya, Sutrasthan 20/3, Chaukhmba Sanskrit Sansthan, Varanasi, Reprint 2001, p.108

9. Sushruta, Sushruta Samhita ,Dalhan commentary, Nibandhsangraha, Sutrasthan 35-19 edited by Vd,Jadavji Trikamji Acharya, Chaukhmba Orientalia, Varanasi, Reprint 2002, p.153

10. Vaidya Asmita Amrut et.al., Chikitsa Siddhant of Anukta Vyadhi (Unknown Diseases), Int. J. Ayu, Alt. Med., 2014;2(4):19-23

11. Vriddhajivak, Kashyap Samhita, The Vidyotini Hindi Commantary by Shri Satyapala Bhishagacharya Chikitsasthan Phakka chikitsa Adhyay /3-17 , Chaukhambha Sanskrit Sansthan, Varanasi, Eighth Edition, Reprint 2002, P. 139-140

12. Dr. M. K. C Nair, Child development 2000 & Beyond, Prism books Pvt. Ltd, Reprint 2002, p.214

13. Agnivesha, Charak Samhita Chakrapani Commentary, edited by Jadavji Trikamji Acharya, Sutrasthan 12/ 8, Chaukhmba Sanskrit Sansthan, Varanasi, Reprint 2001, p.79

14. Vagbhata, Ashtang Hridaya, commentary of Arundatta and Hemadri,Sarvangsundari and Ayurved Rasayana, Sutrasthan12/4-9 edited by Pandit Hari Sadashiva Shashtri Paradkar Bhishagacharya , Chaukhambha Surbharti Prakashan, Varanasi, Reprint 2002 ,P 193

15. Agnivesha, Charak Samhita Chakrapani Commentary, edited by Jadavji Trikamji Acharya, Sutrasthan 12/8, Chaukhmba Sanskrit Sansthan, Varanasi, Reprint 2001, p. 79

16. Ibid., Sharirasthan 2/29, p.305 17. Vriddha Vagbhata, Ashtang Sangrah, Commentary by Indu,

Shashilekha by Dr. D.V. Panditrao & Vd.Ayodhya Pandeya ,Sharirasthan 2/50, C.C.R.A.S, Delhi print 1991, p.450

18. Agnivesha, Charak Samhita Chakrapani Commentary, edited by Jadavji Trikamji Acharya, Sutrasthan 17/12, Chaukhmba Sanskrit Sansthan, Varanasi, Reprint 2001, p.99

19. Ibid., Sutrasthan 11/11-20, p. 66-67

CITE THIS ARTICLE AS – Nagda H.T., Patel K., Approach to Developmental Delay in Children – An Anukta Vyadhi, Int. J. Ayu. Alt. Med., 2017; 5(2): 77-81

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