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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 119-125

Knowledge, attitude and practice survey of prashana survey of prashana in neonates among Ayurvedic practitioners


Department of Ayurveda, Central Council for Research in Ayurvedic Sciences, Regional Ayurveda Research Institute, Mandi, Himachal Pradesh, India

Date of Submission28-Dec-2021
Date of Decision27-Jan-2022
Date of Acceptance30-Jan-2022
Date of Web Publication4-Jul-2022

Correspondence Address:
Chris Antony
Central Council for Research in Ayurvedic Sciences, Regional Ayurveda Research Institute, Mandi - 175 124, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joa.joa_369_21

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  Abstract 


Introduction: Neonatal period is the most vulnerable period for infections. India is the first among top 10 countries with the highest number of newborn deaths in 2019. Ayurvedic newborn care measures like prashanas should be explored for extending quality affordable care to newborns. Methods: A descriptive cross-sectional study in the form of knowledge, attitude, and practice survey of prashana in neonates was carried out using self-administered questionnaire containing 28 questions through Google Forms among 402 Ayurvedic Practitioners of India following CHERRIES checklist. Validated questionnaire was pretested before fielding it. Results and Conclusion: 55.4% of the participants agreed that prashana should be administered to all neonates and 91.5% agreed that it improves the health of the neonates. 53.4% preferred Swarna bhasma and 30.8% preferred elemental gold rubbed on stone in prashana. The dose of ghee was one to three drops (46%) and of honey was one to five drops (52%). 87.4% reported no adverse events due to prashana. Reduction in illnesses, improvement in intellect or school performance, growth, speech, etc., were the major positive responses received. Majority followed Acharya Kashyapa in prescribing prashana. The survey has brought to light the various methods of practice of prashana and also the lack of precise doses of Swarna bhasma, ghee, honey, etc. It will help in guiding the practitioners in implementing prashana in neonates and future research on its effects on neonatal mortality and morbidity including long-term effects on immunity, intellectual and behavioral outcomes.

Keywords: Neonatal care, prashana, prelacteal feeds, Swarna bhasma


How to cite this article:
Antony C, Chandla A, Vyas K, Sannd R. Knowledge, attitude and practice survey of prashana survey of prashana in neonates among Ayurvedic practitioners. J Ayurveda 2022;16:119-25

How to cite this URL:
Antony C, Chandla A, Vyas K, Sannd R. Knowledge, attitude and practice survey of prashana survey of prashana in neonates among Ayurvedic practitioners. J Ayurveda [serial online] 2022 [cited 2022 Sep 28];16:119-25. Available from: http://www.journayu.in/text.asp?2022/16/2/119/349771




  Introduction Top


The health standards of a community are reflected in its neonatal mortality and morbidity indices. The contribution of neonatal deaths in under-five mortality is greater in Southern Asia (62%) and India is the first among top ten countries with the highest number of newborn deaths in 2019.[1] At this juncture, Ayurvedic practices like prashana (medicinal electuary or prelacteal feeds) prepared from herbs, ghee, and honey (with or without gold) can be explored for providing quality affordable care to newborns.[2] However, prashana is variantly practiced by the Ayurvedic practitioners. Therefore, a knowledge, attitude, and practice (KAP) survey on prashana in neonates was conducted.

Objectives

Primary objective

To assess the KAP of Ayurvedic practitioners about the use of prashana in neonates.

Secondary objectives

  1. To document the various methods, drugs, dose, timing, and duration of prashana followed by different Ayurvedic practitioners.
  2. To document the clinical outcomes and adverse events of prashana.



  Materials and Methods Top


An online KAP survey of prashana in neonates was carried out using self-administered questionnaire through Google Forms among 402 Ayurvedic Practitioners of India following CHERRIES checklist on EQUATOR network which is specific for online surveys.[3]

Study type

Descriptive cross-sectional study.

Setting

The survey was carried out online.

Population

Inclusion criteria

Registered Ayurvedic Practitioners in India with minimum BAMS degree.

Exclusion criteria

Those who have not completed BAMS or are from other streams of medicines have been excluded.

Sampling and sample size

The sample size was calculated on Survey Monkey.[4] Confidence level of 95% and margin of error at 5% on a population of Registered Ayurveda Practitioners of around 4.5 lakhs was set.[5] Sample size obtained was 384 (rounded off to 400). Since the Ayurvedic practitioners of India composed a large disorganized population, constructing a suitable sampling frame was complex and therefore nonprobability sampling (convenience sampling) was done which was also cost-effective.

Development of the instrument

The questionnaire was drafted and subjected to face and content validation by a panel of 3 Kaumarabhritya experts with minimum 7 years' experience. There was a total of 33 questions (6 on knowledge, 7 on attitude, and 20 on practice of prashana). Content Validity Index for Individual Items (I-CVI) of 0.78 or higher, Scale-Content Validity Index-Universal Agreement (S-CVI/UA) of 0.8, and Scale-Content Validity Index-Average (SCVI/Ave) of 0.9 or higher was chosen for inclusion.[6] The mean I-CVI and SCVI/Ave obtained were 0.9384. S-CVI/UA was 0.84. Finally, 28 questions (5 on knowledge, 6 on attitude, and 17 on practice) with ICVI more than 0.78 were included. A validated questionnaire was prepared on Google Forms and pretested among 7 Kaumarabhritya Practitioners and final changes were made according to recommendations received.

A brief introduction, an electronic consent form, and baseline data preceded the questionnaire. All questions were mandatory. Close-ended multiple choices were provided in majority of the questions and, in some, options to select many answers were provided. In some, open option to type in own answers was also provided. For close-ended questions, a 5-point Likert scale was used.

Fielding of the questionnaire

The link was E-mailed and posted in social media groups such as WhatsApp, Telegram, Facebook, and LinkedIn groups of Ayurvedic practitioners across the country. E-mail contacts were harvested from all major open access journals and conference souvenirs. Known contacts were contacted over the phone and link sent. A mixed-mode survey method was implemented in which respondents were contacted by many modes and snowball sampling was also done.

Assuming a response rate of 10% (10/100 × 4000 = 400), the survey was sent to approximately 4000 Ayurvedic practitioners. Reminders were also sent. The link was published and sent until the required sample size was attained. Around 5000 practitioners were contacted. The survey was open from December 16, 2020, to March 03, 2021 till the target of 400 was covered (402 responses received till March 03, 2021).

Data management and statistical analysis

The data were collected in MS Excel and cleaned and analyzed in MS Excel and MS Word. Reports were prepared using MS Excel and Power BI. Descriptive statistics was used for summarising the data. Continuous variables were analyzed for mean, range, standard deviation (SD), etc., whereas categorical variables were analysed for percentages. Data was presented in charts and figures (tables, bar charts and pie charts).

Ethical considerations

  1. Procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2000
  2. Approval of the Institutional Ethics Committee was obtained (F. No. 4/24/2018/RARI/Tech/Vol II/681,668, 695,726 dated June 24, 2021)
  3. Electronic consent was obtained from respondents
  4. Confidentiality and anonymity of the respondents were protected.



  Results Top


Out of the 402 responses, 14 were deleted (5 duplicates, 2 non-Ayurvedic practitioners, and 7 BAMS students) giving 388 for data analysis.

Baseline data of practitioners

The mean age of the respondents was 35.15 years (range: 21–79 years; SD: 7.73 years). The proportion based on gender was: 62.63% females (243) and 37.37% males (145). The qualification and profession of participants are presented in [Appendix 1]. The mean experience in general practice was 8.49 years (range: 0–54 years). The mean experience in Kaumarabhritya practice was 4.06 years (range: 0–50 years).

Attitude on prashana

The responses on attitude and adverse effects of prashana are given in [Appendix 2] and [Appendix 3], respectively.

Practice of prashana

The responses to “Do you prescribe prashana in any form to neonates?” and ingredients of prashana are presented in [Figure 1] and [Figure 2] respectively. On forms of gold used, 53.4% (207) responded as using Swarna bhasma, 30.8% (119) as elemental gold rubbed on stone, 1.6% (6) as Swarna churna, 1.0% (4) as gold salts and 21.9% (85) did not prescribe gold in prashana. Other replies were-manufactured swarnaprashana drops, mahaswarnayog tablets, in saraswatharishta, saraswatha ghrita, etc., There was a wide range in the dose of Swarna bhasma reported, from 0.00001 microgram to 1 g. After removing outliers, the dose range was 0.0001 mg (0.1μg) to 125 mg [Figure 3].
Figure 1: Practice of prashana

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Figure 2: Ingredients of prashana

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Figure 3: Dose of Swarna bhasma

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The dose of ghee ranged from < 1 drop (<0.05 ml) to more than 25 ml (up to 500 ml). The most practised dose was 1–3 drops (0.05–0.15 ml) by 46% (123) [Figure 4]. A few responded as amalaka-pramana, gunja-pramana, anguli-parvadwaya-sammisra-pramana, unequal quantity with ghee, etc.
Figure 4: Dose of ghee

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The maximum response for dose of honey was 1–5 drops (0.05–0.25 ml) by 52% (203) [Figure 5]. Other responses included amalakabeeja pramana, unequal to ghee, etc.
Figure 5: Dose of honey

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The responses on timing, frequency, and duration of the practice of prashana are given in [Appendix 4] and the results for common medicated ghees and single drugs used are given in [Appendix 5] and [Appendix 6], respectively.

On serious adverse events or complications after giving prashana, 87.4% (339) replied in the negative. About 9.5% (39) did not practice or did not know. 3.1% (12) replied that they had seen some adverse outcomes such as avoiding feeds, indigestion, bloating and mild colic, vomiting, loose stools, green feces, constipation, and mild hyperthermia.

The utility of prashana and appetite and bowel changes are presented in [Appendix 7] and [Appendix 8] respectively. Some opined bowel changes also depend on the drug used - “abhaya (Terminalia chebula) cause loose stools and relieves constipation,” “if loose bowels noticed, honey is added in prashana” etc., Some said that loose stools are seen in infants and toddlers mostly.

When asked “do you prescribe prashana to all neonates healthy and unhealthy?” 39.6% (154) answered no and 38.9% (151) answered yes. 15.2% (59) stated that they give prashanas to only healthy babies. The contraindications mentioned are congenital/developmental structural and functional anomalies/like cleft lip and palate, inborn errors of metabolism, mental retardation, birth asphyxia and related diseases like hypoxic ischemic encephalopathy, septicemia, pneumonia, seizures, neonatal jaundice, respiratory distress, etc., requiring newborn intensive care unit care, acute illnesses like fever, respiratory infections/distress, allergic conditions, kapha diseases, indigestion, ama lakshana, lehana ayogyas, constipation, jaundice, anemia, etc., The feedbacks on prashana from parents/caretakers are given in [Figure 6].
Figure 6: Feedbacks on prashana

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Knowledge of prashana

The respondents mostly knew and practiced Kashyapa's prashana which are given in [Figure 7].
Figure 7: Drugs of Kashyapa prescribed

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  Discussion Top


The survey was first of its kind in the field of Kaumarabhritya. The representation was mainly from the younger generation. A greater participation of female practitioners is justified as the practice is among neonates which is mostly dealt by female practitioners. Maximum participation was from postgraduates (65%) which might have been due to nonresponse from BAMS practitioners and practitioners in specialities other than Kaumarabhritya.

The majority of the Ayurvedic practitioners have a positive attitude to the practice and believe it can improve neonatal health. When a large majority agreed that prashana does not cause adverse effects, there is disagreement among some. This shows the knowledge of the practitioners that impure Swarna bhasma can cause life-threatening adverse events.[7],[8] Readiness of majority of practitioners to give prashanas to their family members shows their belief in the benefits and safety of prashanas. Majority believed that prashanas can be given along with Allopathic therapies. This shows that they have not noticed adverse drug interactions. Majority believed that gold in Suvarna prashana does not cause heavy metal poisoning. When properly prepared bhasma is used in the right dose, gold does not cause any adverse effects and is found to improve health which is proved in many animal studies and experimental studies in humans.[9]

Honey might have taken the first place as an ingredient because of ease of availability and its traditional use for prashana. Medicated ghees and Swarna bhasma are also popular. The practice of Uramarunnu and other nootropic and immunoprotective medicines by some shows the knowledge of traditional practices among respondents. Single drugs should preferably be given as per prashana vidhi by Kashyapa (rubbing on stone).[10],[11] Traditionally rubbing for a maximum of 8 times is advised by experienced pediatricians of Ayurveda which ensures a safe dose for single drugs and gold in neonates. Majority (53%) preferred Swarna bhasma to other forms of gold. Elemental gold rubbed on a stone is also largely in practice and is a good method for prescribing gold in very minute doses (as in micrograms), given pure form of gold leaf is available. However, some opine that this can cause greater toxicity than bhasmas.[12] Only a few reported the use of manufactured swarnaprashana which shows preference of swarnaprashana prepared by practitioners themselves to commercially available ones or nonavailability of commercial swarnaprashanas. Many reported a dose of 1–2 mg Swarna bhasma which is a safe but larger dose in neonates. Doses < 1 mg may be considered extremely safe in neonates. Many of those who practice prashana use safe limits of Swarna bhasma (1–2 mg or lesser) but a small proportion use the adult doses of Swarna bhasma in neonates. Doses above 100 mg have been reported by some (4%) who might be ignorant of proper dosing of Swarna bhasma. A sample method of calculation of dose of Swarna bhasma as per Rasaratna samuchaya is given in [Appendix 9].[13] Doses of 1–2 mg have been proved to be safe in animal studies and no adverse outcomes were reported in clinical trials as well. Toxicity studies of Swarna bhasma in doses from 3 to 30 mg/kg have been studied which revealed that Swarna bhasma in that dose was nontoxic in rat model.[14] Oral administrations of Swarna bhasma up to 13.5 mg/kg body weight was found to be nontoxic in Wistar rats.[15],[16]

Ghee is an essential part of prashana, especially that medicated with nootropic drugs. It is a rasayana food and carries the properties of drugs which it is processed with (yogavahi).[17] Along with honey, it makes a smooth emulsion which coats the naïve gastrointestinal tract of the neonate. One to three drops (0.05–0.15 ml) reported by 46% (123) is a safe dose of ghee. A few have reported an equal dose with honey but this is considered as matra viruddha (incompatible in dose) which can act like visha (poison).[18] An unequal quantity is preferred. The dose of ghee and honey can be adjusted according to the Koshta (nature of bowels) and Agni (digestion and metabolism) of the neonate. Many of the mild adverse effects reported by the practitioners arise out of lack of knowledge about dosing of ghee and honey and prashana can be practiced safely if the correct measures are known.

One to five drops (0.05–0.25 ml) is a safe dose for honey which is an integral part of prashana due to its yogavahi effects (being the best carrier of drugs).[19]

Administering prashana to neonates any time on 1st day (approx. 37%) is a convenient timing preferred by the Ayurvedists due to lack of opportunity for newborn care. The effects on neonatal jaundice, neonatal sepsis, neonatal seizures, hemorrhagic disease of the newborn, and long-term neurological outcomes need to be methodically researched. A good number (30%) practice it before first breastfeed as per jatakarma mentioned in treatises. Many were reluctant to start during neonatal period which shows the lack of knowledge about the benefits of prashana in the neonatal period.

The continuation of prashana is in agreement with textual advice which has listed the best results of Suvarnaprashana (medicated electuary containing gold) when practiced for 6 months for intellectual outcomes especially grasping power and memory.[20] Some followed the practice on pushya nakshatra days only which is considered auspicious administration of medicines and nourishment. During the neonatal period, protection from deadly diseases is the main intended effect of prashana along with protection of the brain from the prasuti klesha (troubles caused during birth process) and mohajwara (partial loss of consciousness and inflammation) during labor.[21] Continuing prashana throughout early neonatal period (first 7 days) can help in prevention of inflammations/infections, jaundice, and bleeding diathesis. Seven days a month till 16 years sounds to be logical which is similar to prakara yogas mentioned for the prevention of diseases in children.[22]

On selection of medicated ghees and single drugs, majority followed Acharya Kashyapa. These drugs are proved to be nootropic and anti-inflammatory.[23]

Majority (87%) reported no adverse events while using prashana and 3% reported mild adverse outcomes which might be due to lack of knowledge of the right dose of drugs, especially ghee. The prevention of diseases or infections and promotion of intellect which are the two main intended benefits of prashana reported need to be studied on larger samples with longer follow up. Improvements in appetite (46%) and effects on digestion and metabolism need to be experimented for effects on gut microbiota and immunity.

The indications and contraindications of prashana in neonates reported is in compliance with textual references that lehanas should be given in nirama (devoid of ama or unmetabolised principles in the body) condition and not in saamadosha conditions especially when kapha is aggravated.[24] Acute conditions similar to graha-rogas may be avoided but prashanas can be prescribed to apparently healthy neonates for prevention of graha-roga and improving neurological outcomes even in congenital anomalies and sequelae of graha rogas. Prashana is advised after pranapratyagamana (resuscitation) and therefore can be given in stable neonates who have gone through the difficulties of normal or abnormal labor and/or asphyxia, once they have attained normal cardiorespiratory functions.[25] The concept of brain-oriented resuscitation and newer modalities of management of hypoxic-ischemic encephalopathy are under study in modern medicine like oxygen-free radical inhibitors and scavengers (superoxide dismutase, endoperoxidase, catalase, Vitamin E, Vitamin C, mannitol, melatonin, indomethacin, melatonin, calcium channel blockers, erythropoietin, etc.) and excitatory amino acid antagonists.[26] Ayurveda had already presented the benefits of brain-oriented resuscitation and anti-oxidants through prashanas, shiropichu (application of oil-soaked tampons to head), etc., Prashanas are rasayana drugs and therefore can be given once the baby is stabilised after labor. As a continuing measure, it should be given when the appetite is good and no signs of doshaanubandhatwa (presence of dosha imbalance) are seen. Proper doshashamana (pacification of doshas) and agnideepana (good digestive power) is to be attained for administering it as a preventive. The results show that Kashyapa's advice on indications and contraindications of prashana were followed by a large proportion (40%) but same proportion were not aware of the suitable conditions for prashanas (39%).

Reduction in episodes of illnesses, improvement in intellect or school performance, improved growth and speech, etc., which are the major feedbacks on prashana need to be proved in large samples with long term follow up. This can give promising results in improving developmental/neurological outcomes in preterms and small for dates.

On knowledge of prashanas, majority followed Acharya Kashyapa who was the expert in the field of Kaumarabhritya. Evidence of nonoccurrence of hemolytic disease of the newborn is quoted by even modern neonatologists in neonates who are given traditional prelacteal feeds.[27] Probiotics and prebiotics are implemented by neonatologists for the prevention of neonatal morbidity including sepsis for which prashana can be a better alternative.[28],[29],[30] These need to be studied in larger populations of neonates.

Limitations

Since a nonprobability convenience sampling was done, the sample selected might not be truly representative of the population of Ayurvedic Practitioners of India. The large proportion of BAMS practitioners were not represented appropriately. This nonresponse bias might have affected the generalisability of the study. The experienced elderly practitioners were also not much represented as it was an online survey and heeded only those with essential computer and internet skills. The doses on single drugs were not collected.


  Conclusions Top


The survey has brought to light the lack of consensus on dosing of Swarna bhasma, ghee, honey, and single drugs in prashana in neonates. The results will help in guiding the practitioners in its implementation as part of immediate and late neonatal care, paving the way for future research on effects of prashana on neonatal mortality and morbidity including long-term effects on immunity, intellectual and behavioral outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




  Appendices Top






















 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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