Unique contributions of Keraleeya Ayurveda in pediatric health care.

Childhood is considered as the most important phase in life, which determines the quality of health, well being, learning and behaviour across the lifespan. This may be the reason for giving the foremost position for Balacikitsa among Ashtangas (8 branches) of Ayurveda. The regional growth of indigenous medicine gave significant contribution for the development of primary health care. Kerala has major contribution of many authentic textbooks of Balacikitsa like Arogyakalpadruma, Vaidya Tarakam etc. These are more practically oriented and it can be considered as a physician's quick reference hand book. Many new diseases which are not mentioned in classical textbooks have found their place in these books. Medications like Praakaara yoga, Uramarunnuprayoga were administered in children as a mode of immunization, which helps in the maintenance of health and prevention of disease. Many diseases like Karappan (balavisarpa), Shakarogas etc. were common in Kerala and various indigenous treatment modalities were developed for such diseases. Single drug Prayogas with herbs like Mayaphal (galls), Tripadi (DesmodiumTriflorum L.), etc. and yogams like Nalikerakwatha (Putapakakalpana), Mukkuti (Takrakalpana) etc. were practiced commonly. Many effective therapies like Shashtikapindasweda, Thalapothichil (Sirolepa) etc. are an inevitable part of Balacikitsa. In this paper, an attempt is made to compile the theoretical concepts and unique practices of Balacikitsa in Kerala and to convey it's importance. The present article also addresses, how these vernacular books and traditional knowledge waned away from the Mainstream Ayurveda.

Background

“Kaumarabhrthya” the branch which deals with Balacikitsa (pediatric health care), has been given the foremost position among Ashtangas of Ayurveda by Acharya Kashyapa [1]. Kaumarabhrthya deals with healthy upbringing of infants, purification of mother's milk and also cure for diseases of infants caused by intake of vitiated breast milk or Balagraha (evil demons) [2]. Acharya Hareeta included antenatal care and post natal care in this field [3]. Early childhood is a critical period in development, as rapid gain in physical, cognitive, and socio-emotional domains constitutes the “building blocks” of children's later growth [4]. Pediatric health care can be brought under the broad concept of Kaumarabhrthya.

Literature is the foundation and record of human experience. Ayurveda has a long history of being enriched by different types of contributions in different stages befitting the geographical, climatic and cultural situations of various regions, based on their thoughts and lifestyle. Considering classical literature as a base material and imbibing the wisdom from other indigenous knowledge, many regional books were compiled in different states of India periodically considering the contemporary needs. The earlier repositories of Ayurvedic knowledge like Brihathrayi have briefly documented the information on Kaumarabhrthya. Later on, Acharya Kashyapa wrote a detailed treatise on Kaumarabrthya Tantra, which still remains as an important pediatric reference in Ayurveda. However, this is available only in an incomplete state. Now, Kaumarabrthya has developed in to an important branch in Ayurveda.

The regional growth of indigenous medicine in Kerala significantly contributed to the development of primary child health care. The frame work of Ayurveda has an inherent capacity and flexibility to imbibe such changes. Many kriyakramas like Patrapotalisweda (fomentation with leaves of medicinal plants tied inside a cloth) and Pizhichil (oil bath), developed from the traditional practices in Kerala, are now practiced globally. This can be considered as unique contributions of those physicians who practiced in Kerala. Similarly, the knowledge hidden in regional textbooks should be adopted by the entire science community and brought to mainstream practice for further development of this speciality. Also, exclusive formulations, treatment modalities and many new diseases mentioned in these texts which are not found elsewhere make them unique and very much contributory. Application of such knowledge in clinical practice helps to tackle many of the serious epidemics, that our society is facing in the current era.

This paper provides a bird's eye view of the literary contributions and ancient traditional medical practices in the field of Balacikitsa in Keraleeya. The article also deals with, how these vernacular books and traditional knowledge waned away from the mainstream Ayurveda.

Review of related literature

Regional textbooks of Balacikitsa like Arogyakalpadruma, Koumaramanjari, Balarogacikitsamanjari, Vaidyatarakam, Parambarya Balacikitsa and Balacikitsa Grantha were analysed. Some other traditional books of Ayurveda, e-publications and journals were also referred for the present work. All these textbooks are unique to Kerala tradition and all the original versions were written in Malayalam language.

Among these regional textbooks, Arogyakalpadruma, which belongs to the 19th century, is authored by Vaidya Kaikkulangara Ramavarier. This scripture is written in Sanskrit language using Malayalam script in the available textbooks. Text ‘Koumaramanjari’ is written by K. Gopalapillai, who was a high school headmaster and it was published by K C Narayanapilla in 1934. ‘Parambarya Balacikitsa- Sidhoushadangalum Cikitsanubavangalum’ of Samrat publishers is written by Kodiakattil K S Vasuvaidyar. This book was written on the basis of his treatment experience. The Kodaikattil family at Trichur is well known for Balacikitsa. ‘Vaidyatarakam’ is written by Vaidya Kalanidi Sree N. Narayanan while ‘Balrogacikitsamanjari’ is written by Panachirethu Krishnapilla. There are many textbooks published in the name of Balacikitsa in different regions of Kerala. The period and authors of those Balacikitsa Granthas are unavailable. The Balacikitsa Grantha that is quoted in this article was published by Vidyarambam Publishers, Alappuzha in 1982. Many traditional textbooks including Balacikitsa Grantha could be availed from the online library of Vaidyaratnam Moos. These textbooks were written in 20th century.

Even though an English version of text ‘Arogyakalpadruma’ is available, translated version of other regional books mentioned above do not exist. Even though the text ‘Arogyakalpadruma’ being included in schedule −1 of Drugs & Cosmetic Act, it is not a part of graduate or post graduate curriculum of Ayurveda.

Observations

History of Balacikitsa in Kerala

Ayurveda got it's present status, as the ‘Unique practice of Kerala’, during the course of systematization and institutionalization in the early twentieth century. The term ‘Ayurveda’ was not used anywhere in Kerala before that. Till that time, Nattuvaidyam (indigenous medicine) was the term used widely to represent all kinds of indigenous medicines like Siddha, Ottamooli, Vishavaidyam and Balacikitsa. Thus, amongst all the indigenous medical practices, it associated its identity with that of the region and also with the nation, elevating its role as a unique indigenous knowledge of the nation.

Ayurveda, practiced by the literate Vaidyas especially of upper caste, who knew Sanskrit was found to be more authentic than that which practiced by lower caste Vaidyas. The ambivalence existed in the attitude towards books written in vernacular languages and later they were marginalized as non-authentic sources. Learning of Ayurveda was purely based on Sanskrit text and all institutions started using Brihathrayi texts in teaching. The argument that, the vernacular texts were the redacted versions of the Samhita texts were used for this purpose. But upon analysing certain vernacular texts like Cikitsamanjari, Sahasrayogam and Yogamritam, it was observed that most of the texts are from Alathyur Grantham (a pre-eighteenth century text), which has affinity with home medicine rather than the yogam.

Caste based categorization helps in weeding out the lower caste practitioners (who were already part of the tradition) from the field of Ayurveda. They were specialists in particular areas of medical practice, such as Balacikitsa (paediatrics), Vishavaidyam (toxicology), Ottamooli (single remedy), and Kannuvaidyam (eye diseases). They strictly used particular texts and language for their transmission. By the second half of the twentieth century, Ayurveda became the classical medicine and other assorted medical practices became Nattuvaidyam [5].

Elite contributions of regional textbooks

These books were written with a purpose to provide a concise and simplified version of Balacikitsa to the physicians of Kerala. It is postulated on the basis of former literary works like Mahasaara, Bhela Samhita, local health traditions and folklore. They addressed issues such as health of an individual, contagious diseases, seasonal diseases and public health.

On analysing the existing literature on Balacikitsa, it can be classified into two categories:

Theoretical concepts mentioned in classical texts and contributions in the field of diagnosis.

Therapeutic contributions involving existing preventive measures in child health care, diseases prevalent in Kerala and its remedies through traditional medical practice.

Though they are mutually overlapping, this categorization is done for better understanding. The materials highlighted in this section are found missing in Samhita Granthas. Such information will be of great use in the present era.

Contributions in diagnostic perspectives

This section deals with the theory of knowledge and justified belief. The eleven fold classification of age in a different perspective like Jathamatra, Pakshateeta, Ekaabdha are explained [6] and Balacikitsa is discussed in two perspectives i.e. preventive and treatment aspects [A.K.D 1/7]. Discussions regarding the treatment to infant in neonatal period especially before 15 days of age were also discussed. If any disease occurs in the new born within 15 days after birth, treatment is given to the mother because the child depends solely on mother's milk during the period. But Hethuviparitha (treatment against the cause of the disease) and Samanacikitsa (pacifying therapy) in very small doses can be administered in children, if they are seriously ill [A.K.D 1/58-60]. ‘Prashana’ a unique way of Prakaara, the administration of such drugs even up to 12 years is mentioned here [A.K.D – Chapter 35]. Posology with respect to different therapeutic forms and in accordance with the age [month-wise and year-wise] is well explained [A.K.D 2/117-126].

Some of the diseases caused by unidentified vectors called Balagraha/Skandha (evil demons) like Pakshipeeda, Ashtavidha Balapeeda, Bhootagraha can be included under this heading. Amongst these, a descriptive analysis of Shakuni Graha (bird natured graharoga), which differs variously in pathogenesis is given. It is named as Pakshi (bird) peeda. Four types of pakshipeeda like Vandhya, Sthree, Purusha and Kliba are explained. The general treatment and some Daiva vyapashraya Cikitsa like chanting of Pakshidurga mantra with the application of Matrikabhasma over the forehead and joints is advised [A.K.D 34/1, 15-36]. Ashtavidha balapeeda like neela, Chumappa, Neerpeeda, Kazhukan, Sundhari, Adappan, Anushtan and Swedana are also explained. Unfortunately it is abandoned in today's era due to lack of scientific justification [7]. Varieties of Bala Apasmara like Pashukarni and Edupp are mentioned [B.C-Chapter 4]. Rakshakarma of such diseases is also narrated [A.K.D 1/48-56]. As far as written history goes back, people have named and classified what they observe. When a person doesn't know the cause, they rely on observations. This is especially true in case of psychiatric diseases like Balagraha where causes are largely unknown, but identifiable pattern of thought and behaviour exist. Hence, we can describe it well enough to study treatments, thereby helping to design treatments [8].

Therapeutic contribution

Immunological contribution

Prevention being the primary tool for health maintainence, the role of immunology in literature is really important. Ayurvedic medicines especially Rasayanas enhance the body's overall natural resistance to the disease causing agent rather than directly neutralizing the agent itself. The preventive measures mentioned in Praakaara Yoga and Uramarunnuprayoga can be studied as an Ayurvedic approach of way of immunization, as this is also age specific [9]. This plays a key role in the maintenance of health and prevention of disease.

Praakaara Yoga is an indigenous method of enhancing body immunity, which is narrated only in the text Arogya Kalpadruma. It protects the children from the disease just as Praakaara (fence) protects a house from enemies. In this, the drug schedule starts with birth and continues up to the age of 12 years. In the whole regimen of Praakaara Yoga, good number of drugs are used at various developmental stages. The drug combinations detailed are as per the age of the child. It is advisable to consume each formulation along with a suitable adjuvant, for seven consecutive days in a dose varying with corresponding age [A.K.D 35/558-566]. For example, a child of 15 days should be administered the powder of Panchanga of Bilwa (Aegle marmelos (L.) Correa) with Amalaki swarasa (Phyllanthus emblica Linn.) for seven days. Moordha seka of Vacha (Acorus calamu L.) mixed with Tripadi rasa (juice of Desmodium triflorum (L.) DC), is also advised in the early neonatal period [A.K.D 35/3]. Opinion of the ancient scholar, Sarngdhara was considered while fixing the dose of the recipes of Praakaara Yoga.

Vachadhatryadi Avaleha prepared by using the most repeated drugs in Praakaara yoga, having immunomodulatory activity, were subjected to experimental and clinical trial in 1999. In the clinical study, the drug significantly enhanced antibody formation and moderately suppressed the immunological oedema [10]. Another two studies were also done to assess the efficacy of Praakaara yoga in 2012 and 2013. The drug was administered in 3rd and 6th month in the first study and in the 2nd study it was administered in 1- 1½ years [11], [12]. Both the studies showed significant results when compared to the control group.

Ura-marunnu is a traditional babycare practice comprising of a group of drugs administered to the child in the form of paste. This is widely practiced in the states like Kerala, Tamil Nadu and Karnataka. Different ingredients of Uramarunnu which are prevalently used in Kerala are Avartaki (Caesalpiniaceaeauriculata Linn), Vacha, Jatiphala (Myristica fragrance Houtt.), Mayaphala (Quercus infectoria Oliv.), Karpuravalli (Plectranthusamboinicus Lous.), Lakshmana (Ipomoea sepiasia Koenig Ex. Roxb.), Tripadi, and Koshataki (Luffa acutangula Linn.) [13]. Any of these drugs alone or as group are triturated with breastmilk/honey/butter/cow's milk and administered once in a week, after 28 days till the age of 2 years. Dosage is the drug obtained with a single rub on an abrasive material. There is no proper standardization on its dosage. Sticking to the concept of Oushadamatra mentioned in Sharghadara Samhita, dosage can be restricted to 1–2 ratti. It is a preventive and curative aid for digestive disorders like colic pain, Krimiroga (worm infestation), Swasakasa (respiratory disorders) and Graha in infants and children, and also helps in proper development of milestones [14].

Contributions to the disease field

Many new diseases were introduced in old Balacikitsa textbooks and their treatments were also mentioned. Skin diseases like Karappan (Balavisarpa), Shakaroga (skin disease of extremities and head), and Varppan are narrated. Karappan, which are limited to 9 types in adults are elaborated in to 51 types in children [A.K.D 13/63]. Eight types of Shakharoga which occurs only in the four sakhas are also described. It occurs due to the vitiation of Kapha, Rakta and Vata. They are Raktolbuda, Ajagallika, Gallaka, Asrasopha, Kupaka, Indrarmma, Idhmaka, and Dadhmika [A.K.D 20/1-5]. Vatashonitha is named as Rakthasthamba. Rakta anvastha which is included in Vathasonitha, is a term used to denote various conditions that result because of the exaggerated movement of raktha through different parts of the body by the vitiated vata. They are 18 in number. They are broadly divided into Nija and Agantu. Different types of Varppan like Manal varppan, Neer varppan are explained under Rakthasthamba (Vatashonitha in adults), based on the Dhatus vitiated [A.K.D 18/300-330].

Several new diseases like Kundalaka, Jatara vrana, and Raktalasaka are described. Kundalaka is a Raktha mamsasritha roga which manifests in three ways based on three doshas [A.K.D 19/1,2]. Symptoms of Jataravrana include discolouration of tongue, continuous crying, crying increases on touching stomach, greenish veins on abdomen, bloating, diarrhoea and fever [A.K.D 19/19,20]. Another disease named ‘Ulbarus’ which occurs due to vitiation of Dosha or Vrana in Garbhasaya or due to vitiation of Rakta, are manifested as carbuncles on the body of the child. It is either present at birth or formed soon after birth. Such children will suffer from cracking of skin of palm and sole and excessive hairloss. Ulbarus is of 7 types and the clinical manifestation is similar to that of Phiranga [A.K.D 19/33-35]. Rakthalasaka is a condition, where Kapha blocks the passage of Raktha, and this stagnant Rakta gets mixed with Kapha and forms masses, which enlarge and become painful, itchy, cold, heavy and whitish or reddish in colour [A.K.D 19/53-55]. Different types of Vranas like Nakhavrana, Januvrana, Gopavrana, Veethivrana, Urovrana, Kakshavrana, and Siravrana are explained [A.K.D – chapter 22]. In Kshudraroga context, some conditions like Kandalika, Padasabda, Dehasphutana, Dehasweda, and Dehadurgandha and methods to remove thorns from the body are narrated [A.K.D 24/93-102].

Contributions to medical care

Due to the close association with traditional practices, many new and effective drugs which are not mentioned in Samhitas and Nighantus found their place in the treatment of diseases. Analysis of Rasapanchaka and therapeutic application of locally available drugs like Ishvaramuli (Aristolochia Indica L.), Mayaphala, Tripadi, Lakshmana, Karpooravalli, Koshataki (Luffa acutangula Linn. Roxb.), Jathi (Myristica fragrans Houtt.), Avarthini (Helicterus isora Linn.), Rudraksha (Elaeocarpus ganitus Roxb) can be seen. Drugs like Sahadevi (Vernoniacinerea Linn.), Nandyarvatta (Tabermontana divaricata Linn.), Lavali (Mussaenda frondosa Linn.) are commonly used in ocular diseases (see Table 1).

Table 1

Ilustration of single drug usage in Keraleeya Balacikitsa Grantha.

Drugs	Indications	Administration	Mode of action	Textbook
1. Jiraka (Cuminum cyminum Linn.)	Vomiting of breast milk	Kalka is applied over nipple	Pachana, deepana, laghu	Balaroga cikitsamanjari[15]
2. Mayaphala (galls on Quercus infetoria Olivier)	Malamutra Vibandha(difficulty in passing urine and stool)	Internal administration of Kalka of drug Mayaphala.	Vatanulomana	Balarogacikitsa manjari[15]
3. Ervaru (samoola) – (Cucumis sativus. L)	Malamutra Vibandha	Kalka of pulp, seed and root of cucumber is applied over umbilicus.	Mootravarodhashamana, mootrala	Balarogacikitsa manjari[15]
4. Durvapatra (leaves of Cynodon dactylon Linn.)	Nabhipaka (inflammation of Umbilicus)	Nabhi lepa with kalka of tip of Durva leaves fried in ghee.	Rakthapitta kaphaapaha	Balarogacikitsa manjari[15]
5. Machinga rasa (Swarasa obtained by incising the top portion of small immature Coconut fruit)	mouth ulcer, excessive salivation	Internal administration in mouth ulcer.	Vata-Pittahara, Shophahara	Cikitsa manjari[16]
6. Machinga rasa	If the infant after birth doesn't cry or open his eyes.	Used as eye drop with milk.	Tikshna	Bala cikitsa, Chapter 3
7. Godhuma (Tricticum aestivum.Linn.)	Urakshata (chest injury)	Internally used as kwatha with honey.	Vranaropana, Vata-pittahara	[Arogyakalpadruma, 5/19]
8. Pippali (Piper longum Linn.)	Swasakasavikara (respiratory disorders)	Pippali churna is administered with honey.	Vatakapha hara	[Cikitsamanjari, Verse -11]
9. Amrabeeja (Mangifera indica Linn.)	Pravahika (IBS)	Mango seed powder should be soaked in salt water and this water is used internally	Vatanulomana	Balarogacikitsa manjari
10. Jiraka	Rakthathisara (Anal bleeding)	Internal administration of Jeeraka churna with honey and ghee	Kaphavatahara, grahi	[Cikitsamanjari, Verse-37]
11. Vibeethaki beeja (Terminalia bellerica Roxb.) or hareethaki beeja (Terminalia chebula Retz.)	Balashukla (Corneal opacity)	Prepare Collyrium with its kalka in honey or breast milk.	Kaphapittahara, Chakshushya, shophagna	[Balarogacikitsa manjari, Chapter 4]
12. Vrischikali (Heliotropium indicum Linn.)	Ocular inflammations	Make paste of the leaves in breast milk and apply over forehead	Chakshushya, Netrya, Pittakapha hara, ropana	[Arogyakalpadruma, 26/3]
13. Sahadevi (Vernoniacinerea Linn.)	Conjunctivitis	Plant juice is mixed with honey and used as eyedrops	Vatakaphahara, Antiviral, antifungal, antibacterial	[Arogyakalpadruma, 26/22]
14. Kulatha (Dolichos biflorus Linn.) and Madhu (Honey)	Inflammation of ear	Honey processed in fried Kulatha is used as eardrops.	Madhu-Rooksha,Tridoshagna, Vishada, Srothoshodaka, Yogavahi andAnti-inflammatoryKulatha-kaphavatahara	[Balaroga cikitsamanajri, Chapter 2]

Exclusive formulations

Some examples of modified formulations seen in these regional textbooks of Ayurveda are Nalikera kwatha, Bhmasma kanji, Varavu kwatha and Varattu kwatha.

Nalikera/Karikkin kwatha mentioned in Vaidyatarakam textbook is a Putapaka kwatha. It is a decoction prepared in Nalikera phala (fruit of Cocos nucifera Linn.), indicated in Samanya Visarpa Cikitsa. It is effective in 18 types of Karappan [17]. As two types of Mukkudi preparations are seen in classics, Mukkudi can be included under Pramathyakalpana as well as Takrakalpana. Administration of Mukkudi in diseases like Udara (∼ascitis), Arsha (∼haemorrhoids), [A.K.D 6/24-29] Grahani (∼IBS), Athisara (∼diarrhoea), Apasmara (∼convulsion disorder), and Visarpa [V.T 14/9-19] is a speciality of Keraleeya cikitsa.

Bhasma kanji, a modified Anna kalpana is indicated in shopha (oedema) [A.K.D 8/106]. In Varattu kwatha mentioned in Vaidyataraka textbook, kalka of certain drugs are pasted on some leaves. It is folded and again covered with banana leaves and roasted in fire. Certain metals like gold are rubbed in the swarasa obtained from above preparation and administered in fever, cough and chest congestion [V.T 9/124-131]. Adappu kashaya is also a similar prayoga mentioned in the same text [V.T 9/124-131]. Ajamodadi Varavu kwatha is an example of Varavu Kwatha mentioned in Parambarya Bala cikitsa [18].

Some exclusive types of Tailas like Rasataila [A.K.D 17/59-61], Shashtikataila [A.K.D 17/89-95], Muttathaila [V.T 20/109-114], Bhunagaditaila [19] Panthataila/Eritaila, [V.T 40/137-144] Kukkudataila [V.T 40/123-137] were also practised commonly. Thambula bhasma, is a Putapaka preparation administered in Shula (pain) [A.K.D 8/25-26].

Many of the commonly and widely practiced yogas like Dhanwantharam gutika, Swasanandham gutika are the contributions of old Balacikitsa textbooks.

Kriyakrama (Special Therapeutic procedures): Some of the kriyakrama practised commonly in children are Uzhinh Kulippikal (Abyanga before taking bath), Thalapothichil/Sirolepa (covering scalp with medicaments) and different types of Dhara (Table 2).

Table 2

Certain kriyakrama practised in Keraleeya Balacikitsa.

Kriyakrama	Indication	Textbook
Abyanga (massage) with coconut milk and bath is given with water boiled with tender leaves of Vata (Ficus benghalensis Linn.).	Healthy baby	[Arogyakalpadruma 1/43-44]
Body massage of Taila processed with Durva swarasa (Juice of Cynodon dactylon Linn.) and Navaneetha (Butter).	Karshya (Emaciation)	Yogamrtham[20]
Siro Abyanga (hair oil massage) with Navaneetha.	Healthy baby	Yogamrtham[21]
Navaneetha mixed with Durva swarasa is applied.	In case of vitiated blood	Cikitsa manjari
Siroabyanga with ghee or oil purified by heating with bronze piece (This helps to remove the moisture effectively).	Pinasa (common cold) and Jwara (Fever)	Cikitsa manjari -Chapter 13
Abyanga with oil, which is added with Gairika (Red ochre) and Anjana (Collyrium).	Keshya (Hair vitalizer) and Krimigna (Wormicide)	Yogamrtham[22]
Thala/Sirolepa (application of herbal paste over scalp) with Rasnadi or Kachuradi or Triphaladi churna.	Jwara, Jathrurdwaroga (Disease occurring above the clavicle), Murcha (Giddiness), Pralapa (Delirium)Thala is indicated in almost all types of visarpa too.	[Vaidyatarakam 22/30-31]
Thala with Neetumutta (egg of weaver ant) kalka in breast milk and butter [23].	Epilepsy	Sarvarogacikitsanool
Many exceptional Sweda prayoga (fomentation therapies) like- Erandadi Ushmasweda (steaming using water boiled with medicated water), Shashtika pindasweda (using processed shashtika rice), Danyamla dhara pouring warm dhanyamla all over the body, Patrapatolasweda (using leaves).	Vatavyadhi	[Arogyakalpadruma 17/34-38]
Sarvangadhara including head with Takra processed with inflorescence of coconut tree and Amalaki.	Gastric ulcer	[Cikitsamanjari,chapter-33]
Seka with Mastu (watery portion of curd).	Injury due to Snuhiksheera (Euphorbia nivulia Buch- Ham)	[Arogyakalpadruma 26/70]
Procedures like Padangushta nakalepana (applying herbal paste over toes and nails) and Pada tala (sole) lepana with paste of Padma, Lodra and honey at bed time.	Diseases affecting vision	[Arogyakalpadruma 26/11]
Seka (pour) with the juice of Bringaraja (Eclipta alba (L.) Hask) over head and smelling Bhumyamalaki (Phyllanthus urinaria Linn.). Repeated Virechana is advised with a combination of Draksha (Vitisvinifera Linn), Vrishchiva (Boerhaavia diffusa Linn.) and Pathya (Terminalia chebula Retz.) in honey.	Kamala (Jaundice)	[Arogyakalpadruma 8/70-71]
It is advised to do Vasthi (medicated enema) with Uruba taila and Saindhava.	Vridhi	[Vaidyatarakam 30/60-62]
Blood letting using medicinal leeches.	Localised swelling over lid	[Arogyakalpadruma 26/61]
Draining of pleural fluid from pleural space using Trikurchayantra.	Urasthoya (Pleural effusion)	[Vaidyatarakam 25/129-133]

Practices of Kerala Tradition: In Kerala, experts from different castes and families, belonging to different Vaidya traditions like ‘Chatharu nair’ are specialised in Balacikitsa. Among these, few physicians who have been using traditional knowledge and regional textbooks as a guidance for treatment in Balacikitsa were interviewed as a part of this study. All of them were general practitioners. They have inherited the knowledge of regional textbooks through family apprenticeship and self study of many regional textbooks of Balacikitsa. They gained expertise in this field by practicing this knowledge in their clinical practice. Though there is consensus among these practitioners regarding the formulations, indications and use, certain formulations as per experience of some experts showed good result in diseases which is not mentioned in indications. An illustration of such formulations are given below (Table 3) (Supplementary file).

Table 3

Interview with subject experts.

Formulation	Indication in classics	Indications in practice	Name of Physicians	Tradition
Vatanguradikashaya. [A.K.D 19/43-46]	Ulbarus	Herpes Zoster	Dr.sasikumar Nechiyl, MD (Rasasastra)	Dravidan vaidya tradition, Cherupulassery
Balamrtha Rasayana. [A.K.D 14/37-15]		Breast cancer
Balagopathmajaadikwatha. [A.K.D 18/88]	Charalvarppan	Lichen planus
Ksheeridrupallavadi lepa. [A.K.D 14/1,2]	Visarpa	Vidradhi, all stages of tonsillitis	Dr.Manikandan. K. P, BAMS, PGCCH	Chatharu nair vaidya tradition, Mezhathur
Ashtachurna in Marichapramana. [A.K.D 8/28]	Emergency medicine in Udarashoola	It is also given as a preventive drug of many Graha.	Dr.B. Prabakaran, DM (Ayu)	Ashtavaidya Guru parambarya, Kannur
Indravalligrtha		Asthma.	Dr. Rajeev Shenoy,	Shenoy vaidya tradition, Cherthala
Shankupushpadikwatha [V.T 6/40-47]	Balapeeda	As a preventive drug in Bala Apasmara
Kombanjadigutika [V.T 9/71-78]	Jwara, Visarpa, Balapeeda, and Apasmara	As a preventive drug in Bala Apasmara
Vettumarangutika administered in the form of Gudavarthi (Anal suppository)	Anubutha	To stop Epileptic convulsions
Cheriyarudrakshadi kashaya		Bala Apasmara

Analysis

In ancient times, the study of Ayurveda was not divided in to branches as today. Later, when the science developed to the extent of exploring the minutest cells in the body, the precise knowledge about each domain became inevitable. As a part of reductionism in medical science, Kaumarabrithya developed as a separate branch. After the Samhita period, different authors compiled the information available in Samhitas and indigenous medicine. Consequently various Granthas like Arogyakalpadruma were written in regional languages giving utmost importance to the diseases prevalent in Kerala and the drugs available during that period. During the refashioning of institutionalized and systematized Ayurveda, diverse medical practices existed and Ayurveda adopted many of the popular practices into it, except those written in vernacular languages. As a result, many of these regional textbooks didn't come to light. So even after many years this knowledge remains as a hidden data to majority of Ayurvedic fraternity.

Contributions in diagnostic perspectives

Classification of age, is based upon the therapeutics and mode of action of the drug used in that period. In Bruhatthrayi too, we can see the classification of lifespan. But it is obvious that, both are done in different perspectives. Though posology is mentioned in almost all texts, monthwise and year wise description of dosage is not mentioned anywhere. This indicates that, authors of those regional textbooks have a clear and specific idea about the pharmacodyanamics of drugs and gastrointestinal tract of children.

Therapeutic contribution

Immunomodulatory contribution

Praakaara yoga and Uramarunnnu recipes can be practised as an effective baby care measure right from the birth of a child. Some of the drugs in Praakaara yoga and Uramarunnu seem to be overlapping.

Advantages

Immunomodulatory regimens offer an attractive approach as they don't have any side-effects like the existing drugs used in vaccination. They are Rasayana drugs (∼immunomodulators), which enhance the immune responsiveness of an organism against a pathogen by non-specifically activating the immune system. On analysis, most of these drugs have properties like Deepana (∼increases appetite), Pachana (∼kindles the digestive fire), Grahi (absorption), Mutrala (∼diuretic), Shulahara (∼analgesic), Krimigna (∼antihelmintic), and Kapha nissaraka (∼expectorant) property. They are Vyadhikshamatvakaraka (∼increases immunity) and Medhya (∼nootropic drugs) too. Hence, proper and scientific use of these formulations increases immunity and protect the child from various diseases [12]. The Deepana, Pachana and laghu properties of these drugs help in correcting the Agnivaigunya (deranged digestion) and thereby pacifies the vitiated Kaphadosha. In 10–12 years age group, drugs in Praakaara yoga are administered in the form of Gritha kalpana, which substantiate the fact that, the children of that age group are more prone to diseases due to vitiated Pitta and Vata. As only lipids could cross the blood brain barrier, it acts as the best brain booster. Along with this, the Yogavahitwa and Balya property of ghee makes it as an apt kalpana in this context.

Analysing the various combinations of Uramarunnu used in the different parts of the state, variations were observed in the ingredients of Uramarunnu. All combinations have Sangrahi, Deepanapachana, Vyadhishamatwa, Nidrakara, Medya, Shulagna, Grahi and Bhutagna property, predominantly. Eventhough many Anupanas are in use, breast milk is considered as the best, as it is Janmasatmya as well as Dhatuposhana. Swadupaakarasa and Vatapittahara property of breast milk will provide a soothening effect to the highly Tikshna and Ruksha property of the drugs. Also, milk can complement the transmission of active ingredients through the lipid vehicle form [13].

Disadvantages

The pace of development in modern medical science and it's pediatric care, coupled with communication gap in between traditional practitioners, had waned off almost all traditional practices from our culture. Other reasons are, the unavailability of few drugs mentioned in this Praakaara yoga and Uramarunnu yoga and the fast lifestyle. Clinical evidence of these practices are not documented. Also, side-effects are often observed by practitioners due to improper administration and over dosage of these drugs. As Praakaara yoga is concerned, it is not practical to routinely prepare these combinations, each month for every child up to the age of 12. As it should be administered in fresh form, drug modification also has limitations.

Contributions towards knowledge of disease

Many new disease conditions like Rakthanavastha are well explained. These can be taken as a detailed form of crude and abbreviated samprapthi of many diseases narrated in Samhitas. Treatment with cheap and easily available drugs were in practice in almost all region. In medical textbooks belonging to Kerala, it is quite usual to see the drugs available in that region. Many single and combined prayoga of Rudraksha can be seen in old Grantha in the context of Balapeeda, Graham, Apasmara and Visarpa. Magnets have positive (+) and negative (−) poles just as every cell in the blood. It helps to enhance the blood circulation, due to the attraction of opposite poles. When there is a streamlining of blood circulation most of the illness get automatically healed and the person feels better and rejuvenated [9].

On analysing the innovations in pharmaceutics, it is evident that, they might have developed due to the properties like palatability, good digestibility and enhanced bio availability. In this era, where there exist a scarcity of herbal drugs, practice of formulations with minimum drugs without compromising the quality is essential.

Due to the restrictions in adapting conventional routes of administration in children along with emergency management, new treatment methodologies developed. Most of the main stream therapies like Vamana(∼emesis) and Nasya (∼nasal drops) are contraindicated in children, this crisis might have lead to the development of many new therapies like Shirolepa and Dhara in children. In ocular inflammations, certain drugs are mentioned to apply over forehead instead of topical application over affected area. This may reduce the risk of ocular irritation, as children are less tolerant to strong medications [24]. Padangushtanakha lepana (anointment of drug over foot, toe and nail) and Padatala lepana (anointment over sole) mentioned for Nakthandya (nightblindness) can be justified with the principles of Reflexology [25]. From this, it is clear that, the observations and trials done in those period could find out the most suitable drugs which could break the pathology indirectly, by acting on some other areas/nerve endings of the body.

Conclusion

On the basis of historical studies, it is evident that the attempt to standardize learning of Vaidya ended up delegitimizing all other practices of Vaidya that used hundreds of regionally available vernacular texts. English or Sanskrit versions of such books will enlighten the budding Ayurveda community. Research works has to be carried out to establish the efficacy and applicability of this unique legacy for documentation and evidence creation. Besides expressing the rich tradition of Ayurveda, incorporating regional and indigenous knowledge and healing practices, the paper shows that Ayurveda is a dynamic and continuously evolving science, thus challenging the stereotypical notion of it being a 'closed' and 'stagnant' medical system.

Sources of funding

None.

Conflict of interest

None.