AYUSHDHARA ISSN: 2393-9583 (P)/ 2393-9591 (O)

An International Journal of Research in AYUSH and Allied Systems

Review Article

UNDERNUTRITION IN CHILDREN: AN AYURVEDIC PERSPECTIVE WITH SPECIAL REFERENCE

TO KARSYA
Manjusha.M1*, Roshni Anirudhan2
*1PG Scholar, 2Professor and HOD, Dept of Kaumarabhrithya, Govt. Ayurveda College, Thiruvanathapuram,
Kerala, India.

KEYWORDS: Under nutrition, ABSTRACT

protein energy malnutrition, Undernutrition is a major health problem affects particularly in
Karsya. preschool children (<6 years) with its dire consequences ranging from
physical to cognitive growth and susceptibility to infection. Under-
nutrition is a condition in which there is inadequate consumption, poor
absorption or excessive loss of nutrients. Nutritional supplementation
and nutritional interventions are the conventional method for preventing
this condition. But even after providing proper nutritional requirements,
under weight is getting a serious issue for parents. Kaumarabruthya
considered health problems of children are different from adults because
of their under developed body (Alpakayatha), immature Dhatus
(Aparipakwa Dhatu), less Dosha, Dushya and Mala (Dosha Dushya Mala
Alpatha), unstable digestive power (Aniyatha vahni) etc. Jatharagni
*Address for correspondence become very weak in children so they cannot digest and assimilate most
Dr.Manjusha. M of the Guru Aharas. A Dhatu is evolved and transformed into next Dhatu
Final year PG Scholar as a result of Pakaprakriya (biotransformation). Vridhi and Kshaya of
Department of Dhatu depends on the strength of Jatharagni. If Agni impaired in Dhatus,
Kaumarabhrithya such evolution cannot take place and leads to the formation of Ama and
Govt. Ayurveda College, causing Srothorodha, which results insufficient production of Rasa Dhatu
Thiruvananthapuram, Kerala. along with other Dhatus chronologically. Parigarbhika, Phakka,
Ph.no: 9847601846 Balashosha, Shuska Revati and Karsya are the conditions mentioned in
Email: Ayurveda similar to under nutrition. Agnideepana, Pachana, Srotho-
[email protected] sodhana, Samsamana and Laghu Santharpana can be adopted as the line
of management in Karsya.

INTRODUCTION
In India, the prevalence of undernourished (WHO) defines malnutrition as "the cellular
children is highest in the world with imbalance between the supply of nutrients and
consequences of mortality, morbidity, low energy and the body's demand for them to ensure
productivity and economic growth. According to growth, maintenance, and specific functions”.[2]
NFHS 3 Survey, 43% under-five children in India Inadequate consumption, poor absorption or
were underweight, and 48% were stunted. Kerala excessive loss of nutrients leads to this condition.
accounts for 23% of under-weight, 24.5% of But even after providing proper nutritional
stunted and 16% of wasted children, according to requirements underweight is getting a serious issue
the latest estimates of UNICEF in 2011.[1] for parents. Good nutritional status not only
Undernutrition affects the child at the most crucial depends upon the adequate amount of food intake
period of time of development which can lead to but also based on the proper digestion, absorption
permanent impairment in later life. Undernutrition and assimilation of the ingested food materials.
is used synonymously with malnutrition and Nutritional supplementation and nutritional
malnutrition denotes both undernutrition and interventions are the conventional method for
overnutrition. The World Health Organization preventing this condition. Kaumarabruthya
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 AYUSHDHARA, 2019;6(3):2207-2214
considered children are different from adults due to women resorts to fasting (Upavasa), observance of
the peculiarities like, they are delicate in nature religious rites (Vrathakarma), aversion to the intake
(Soukumaryatha), under developed body of fats (Sneha Dweshi) will aggravates Vata and the
(Alpakayatha), immature Dhatus (Aparipakwa foetus does not grow and remaining in womb for a
Dhatu), GIT not fit to eat all type of food long period without quickening. In newborn period
(Vividhaannaanupasevatha), less Dosha, Dushya and undernutrition throws the baby at risk of nutrition-
Mala (Dosha Dushya Mala Alpatha), undeveloped related chronic diseases in later life.
secondary sexual characters (Ajatha Vyanjanam), Infants and Young Children
cannot tolerate stress of any kind (Aklesa Saham), Disorders of breast milk or inadequate
unstable digestive power (Aniyatha Vahni), cannot breastfeeding are the major causes of
express the needs (Vak cheshtayorasamartham), undernutrition below the age of six months because
fond of Madhura rasa (Madhura rasa sathmyam) they mainly depend on breast milk for their
and poor immunity (Asampoorna Balam).[3] The nutrition. Hence, Acharyas have discussed
normal state of Jatharagni in children helps in abnormalities of breast milk well in detail. Among
proper digestion and assimilation of food they the Doshic abnormalities of breast milk, Vata Dushta
consumed, which in turn helps in the proper growth Stanya, becomes tasteless and the child becomes
and development of the child. Agni is maintained in emaciated. The child gets reduced of his strength
its normal state with the help of Vata (Samana because of this milk which is poor in
Vayu) Pitta and Kapha and should be in equilibrium unctuousness.[4] Acharya Charaka says that a child
state. The status of Agni in children is weak because taking Pitta Dushta Stanya will have a warm body
of children are predominant of Kapha Prakriti, they always and gets afflicted with anemia and jaundice.
are more fond of Madura Rasa (Madhura Acharya Kashyapa also explains a condition,
Sathmyam), and they have unstable digestive power “Ksheeraja Phakka”[5] which is caused due to breast
(Aniyatha Vahni). A Dhatu is evolved and milk vitiated by Kapha Dosha and which diminishes
transformed into next Dhatu as a result of the baby’s digestive fire, and leads to obstruction of
Pakaprakriya (biotransformation). If there is no the Rasavaha Srotas causing emaciation, weak and
Agni in Dhatus, such evolution cannot take place. withered body resulting in motor function
Vridhi and Kshaya of Dhatu depend on the strength insufficiencies. Qualitative and quantitative
of Jatharagni. Proper digestion and assimilation reduction in the milk of mother causes Ksheeraja
cannot take place if Agni get impaired and leads to Phakka in children. Acharya Vagbhata cites a
the formation of Ama. Ama by the virtue of its disease called “Kumarashosha”[6] which is caused
quality of Daurgandhatwa, Picchilatva, Tantumatva, due to milk vitiated by Kapha Dosha where the child
Guruta, obstructs the minute vessels causing suffers from anorexia, rhinitis, fever, cough,
Srothorodha, which results the nutritive materials emaciation and slimy pale appearance of face and
cannot reach their destination. Ultimately there is a eyes. Chakradatta calls this condition as
sequence of reduction of chronological formation of “Ahitundika” or “Ahindika”.[7] After six months, the
Dhatus. Consumption of food that of no nutritive major cause for undernutrition is improper
value is incapable to form Rakthadhatu. weaning practices and infections. Weaning foods
Consequently the volume of blood depletes and its can cover the nutrient needs in infant, only if it is
function gets retarded, since nutritive nutrition is rich in energy. The risk of infection also increases as
hampered and the degenerative process leads to infants lose immunity. Undernourished children are
Karsya. at high risk of permanently stunted growth and
Undernutrition at Different Age Groups development if left unattended. Such an extreme
Growing fetus and newborn babies condition has been explained by Acharya Kashyapa
Undernutrition in pregnancy may lead to called “Phakka”[8] where the child ends up in severe
anemia or infections which can drastically affect the acute malnutrition ultimately causing motor
health of the growing fetus. The inadequate diet and disability in the child.
nutrition of the mother is directly responsible for  School-age Children and Adolescents
intra-uterine growth retardation and low birth Lack of nutrients and anaemia slow down
weight. Ayurveda explains the similar conditions the process of growth in school children compared
Upavishtaka and Nagodhara.[4] The well formed and to their healthy peers. A child who is physically
matured fetus will remaining the womb by weak will be mentally weak, and cannot be
inhibition of growth, because of bleeding by the expected to take full advantages of schooling.
intake of hot (Ushna), and sharp (Theekshna) things Nutrient needs are at peak during puberty as there
by a pregnant women. In Nagodhara, pregnant
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 Manjusha.M, Roshni Anirudhan. Undernutrition In Children: An Ayurvedic Perspective with Special Reference to Karsya
is dramatic increase in growth both physically and Shuska Revati
mentally. Increased incidence of anaemia in girls is Shushka Revati one of Graha (Demon)
prevalent at this age due to start of menstruation. affecting the child represents infectious spectrum of
Nutritional Deficiency Disorders Mentioned in diseases resulting Sarvanga kshaya (Emaciation). In
Ayurveda: this child though fed with enough quantity of high
Bala Sosha and Ksheeraja Phakka quality food ends up in malnutrition. When it
Balasosha and Ksheeraja phakka are becomes chronic child presents with Anna Dwesha
mentioned by two different authors. The causes of (aversion to food), Vivarnata (loss of lustre)
Bala Sosha are Shlaishmika Sthanya Sevana (intake Nanavidha Sakrita (variegated colour stools), Udara
of Kapha Dushta Sthanya), Seethambu (drinking Granthi (abdominal nodular swellings),
cold water), Diva swapna (excessive day sleep) Jihvayanimnata (geographic tongue). Child shows
done over period leads impairment of Agni which progressive emaciation at the outset the clinical
further leading clinical features of Arochaka condition which can be correlated with abdominal
(reduced digestive capacity), Prathishyaya (Running tuberculosis.[12]
nose), Jwara (fever) and Kasa (Cough); these Karsya and Underweight
conditions if not detected early may leads to Sosha Karsya is a condition resulting from less
(Emaciated). In Ksheeraja Phakka due to the intake intake, Vatadushta Stanya[13] or secondary to
of breast milk vitiated by Kapha Dosha leads to Agni debilitating disorder where child becomes
Dushti results in Bahuvyadhi (Infectious disease) undernourished. Nutritional deficiency where the
and Kshaya (failure to thrive). weight loss (under weight) is main event can be
Parigarbhika[9] and Garbhaja Phakka considered as Karsya and can be viewed under
Abrupt stoppage of breast milk or child on Apatharpanajanya Vyadhis. The word “Karsya” is
feeding breast milk of pregnant women which has derived from the root “Krish” which means to
Alpa Poshakamsha (poor nutrients) leads to become lean or to become emaciated. According to
Parigarbhika/ Garbhaja Phakka and the vitiated Amarakosha, Krusha means Alpa-decreased body
Stanya of pregnant mother diminishes the Agni of weight and Krushata is the result of Soshita Rasa
the child causing Dhatu Dushti and vitiation of Dhatu causing decrease in Mamsa of the body[14]
Kapha Dosha with features such as Kasa (cough), Acharya Dalhana has given the meaning of
Agnisada (impaired digestive fire), Vamathu Atikarsya as the reduction in Upachaya, Rupa, and
(vomiting), Tandra (stupor), Jwara (fever), Aruchi Bala.[15] In our Samhitas there is no direct reference
(anorexia) and Koshta Vrudhhi (pot belly). The available regarding the symptoms of Karsya. Hence
reference of “Sandashi Jataharini”[10] is also seen in the signs and symptoms of Atikarsya can be
Kasyapa Samhita which is similar to Parigarbhika, considered as sign and symptoms of Karsya.
where Karsya is found as an early symptom Clinical Features (Rupa of Karsya)[16]
Vyadhi Sambhavaja Phakka[11] (Various diseases  Sushka, Sphig,Udara, Griva (Emaciated buttock,
leading to Karsya) abdomen, neck region)
Vyadhija Phakka mentioned by Kasyapa  Dhamanijala Santata (Prominent venous
refers to severe forms of malnutrition. The clinical network)
features like Shushka Sphik (wasting of buttocks),  Twak Asthi Sosha (Skin bone appearance)
Shushka Bahu (wasting of upper limbs), Shushka  Sthula Parva (Prominent joint)
Uru (wasting of thighs), Mahodara (pot belly),
Patient can’t tolerate
Mahashira (head appears big) due to relatively
wasting in body parts, Nischeshta Adho Kaya  Ativyayama (excessive exercise)
(inability to walk) etc., represents grades of protein  Kshut, Pipasa, (Hunger, Thirst)
energy malnutrition.  Ati Sita Ushna maithuna (excessive cold, hot,
sexual intercourse)

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 AYUSHDHARA, 2019;6(3):2207-2214

Etiology of Undernutrition
Nidana

Aharaja Viharaja Manasika

Ativyayama
Rookshaannapanam Ativyavaya Chinta
Alpa Bhojanam, Veghadharanam, Bhaya
Vishamabhojanam Veghodheeranam Soka
Kashaya, Katu, Tiktha Langhanam Krodha
Rasa- Sevana

Vata Vridhi
Agnimandya
Ruksha Guna Vridhi

Upasoshana of Rasadhatu Jatharagni Mandya Dhatwagni Mandya

Rasakshaya Malformation of Rasadhatu Malformation of other Dhatus

Rasakshaya Dhatukshaya

Absence of Prinanam or Alpa Prinanam

Alpa Poshanam of Dhatu

Mamsa, Meda and Tvacha Sushkata Karsyam

The etiological factors of nutritional deficiency

disorders can be broadly classified under 3 separate Viharaja
headings. Sareerika: Excessive purification therapies (Kriya
Aharaja Atiyoga), excessive exercise (Ativyayama),
Quantitative: Less food intake (Alpashana), intake Suppression of natural urges (Malamutradi
of nutritionally deficient food (Pramithashana), Nigraha), excessive learning (Ati Adhyayana),
absolute no food intake (Anashana), Fasting excessive exposure to wind (Vata Sevana),
(Langhana). excessive exposure to sunlight (Atapa Sevana), child
Qualitative: Food which causes dryness (Rooksha labour (Ati Bharagamana).
Annapana), excessive intake of astringent
(Kashaya), Spicy (Katu), Bitter (Tiktha Rasa).
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 Manjusha.M, Roshni Anirudhan. Undernutrition In Children: An Ayurvedic Perspective with Special Reference to Karsya
Manasika  Agni - Mandagni
Anger (Atikrodha), worry (Ati Chinta), fear (Ati  Udbhavasthanam - Amasaya
bhaya).[17]  Srotas affected- Rasavaha, Rakthavaha,
Others Medovaha, Mamsavaha
Milk protein allergy/lactose intolerance  Type of Srotodushti - Sangam
(Ksheeralasaka), Unwanted child (Anatha), Worm  Rogamarga - Abhyantharam
infestation (Krimi), Inflammatory bowel disease  Vyakthasthanam- Sphig (buttocks), Udara
(Grahani), Infective diarrhoea (Visuchika), body (Abdomen), Griva (Neck), Twak, Asthi
constitution (Vatika prakriti), Chronic debilitating
 Vyadhiprakaram - Chirakari
disease (Chirakalina vyadhi).
 Sadhyasadhyatwa - Kricchasadhya
Infants and children are particularly
susceptible to undernutrition because of their high Upadravas of Karsya[18]
demand for energy and essential nutrients. Dyspnoea (Swasa), Cough (Kasa), Wasting
Inadequate diet and affliction by diseases, (Kshaya), Emaciation (Sosha), Poor digestion
qualitative and quantitative reduction in the breast (Agnisada), Gaseous tumour (Gulma), Spleen
milk of the mother is the main cause in infants. In enlargement (Pliha roga), Piles (Arsas), Abdominal
Ayurveda, Doshic disorders of breast milk explained disease (Udara roga), Bleeding disorders (Rakta
by Acharyas such as Vataja, Pittaja or Kaphaja is an pitta), Fever (Jwara) are the main Upadravas of
immediate cause for undernutrition in infancy. Any Karsya.
pathology pertaining to gastrointestinal diseases or Management of Undernutrition
respiratory disorders, diseases like intestinal Mala Karsya can occur due to Kaphavarana,
absorption, tuberculosis, intestinal parasitic where srothas being covered by Kapha resulting in
infestations, diabetes and other metabolic disorders improper Dhatu Parinama as in Kumarasosha here
often end up secondary malnutrition. In closely the treatment can be adopted as Amapachana,
spaced families when pregnancies occur rapidly, Srothosodhana etc, for reducing the Avaranatwa,
perhaps every year the incidence of undernutrition which can be taken as the general line of treatment.
is much higher. The incidence of malnourished As specific line of treatment all Acharyas have
children is also seen to be higher where mothers observed the importance of Brimhana therapy.
are daily labourers who find little time to take care According to Acharya Charaka, Brimhana therapy
of child‘s feeding and rearing. More often than not should be Laghu Santarpana in nature. Because in a
“mothering” is done by an elder sibling which is also Krisha patient Agni, Sharira Bala and other related
an underlying cause of undernutrition. aspects are functioning poorly. Acharya Sushruta
Etiopathogenesis (Samprapthi) described that proper application of Samsodhana,
The causative factor of Karsya aggravate Vayu Samshamana Aahara and Achara are helpful in
which ultimately vitiate the Agni. (Vata, Agni and preventing, controlling as well as eradicating the
Rasa are interrelated). This vitiated Agni, disease. The principle of management of Karsya due
subsequently leading to the formation of Ama. to Kapha Avarana should be in following manner.
Following the absorption of Ama in gastrointestinal 1) Agnisthapana by Pachana and Deepana
tract the system treats the Ama as a toxic material. 2) Srothosodhanam
Ama migrates to the heart and spread through the 3) Samshamana
rest of the body channels. Ama by the virtue of its 4) Ahara
quality of Daurgandhatwa, Picchilatva, Tantumatva,
5) Achara
Guruta obstructs the minute vessels and causing
Srothorodha, which results the nutritive materials Agni Deepana: In Karsya, the first line of
cannot reach their destination. Ultimately there is a Samshamana Chikitsa is to improve the proper
sequence of reduction of chronological formation of functioning of Agni through the Aushadhis, Pathya
Dhatus. Consumption of food that of no nutritive Ahara and Vyayama.[19]
value is incapable to form Rakthadhatu. Pachana: In Samprapti of Karsya it can be seen that
Consequently the volume of blood depletes and its the Ama has an important role in the manifestation
function gets retarded, since nutrition is hampered of the disease. So to treat Karsya, the prerequisite is
and the degenerative process leads to Karsya. to adopt Ama Pachana Chikitsa. Pachana Dravyas
Samprapthi Ghataka like Shunti can be administered.[20]
 Dosha - Vata, Kapha Samsodhana: Karsya being an Apatarpanajanya
Vyadhi, Brimhana therapy is indicated. But Mridu
 Dushya - Rasa dhatu
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 AYUSHDHARA, 2019;6(3):2207-2214
Samsodhana can be advised to the Krisa patient[21] mainly by Agni, Doshas, Dhatus and Malas. The
while considering the Vata Kopa and Agni Mandya. normal state of Jatharagni in children helps in
Samsodhana should be adopted to enhance the proper digestion and assimilation of food consumed
quality of absorption and assimilation of nutrients which in turn helps in the proper growth and
provided through Brimhana and Balya Chikitsa. development of the child. Agni is maintained in its
Samsodhana therapy is of two types. normal state with the help of Vata (Samana Vayu),
i) Bahir Parimarjana Pitta and Kapha and should be in equilibrium state.
ii) Antaha Parimarjana Individual who used to consume the food having
sweet taste, taking heavy meal Kapha Dosha get
Bahir Parimarjana can be obtained through Taila
aggravated causing diminished activity of Agni
Abhyanga and Snigdha Udwartana which are
resulting in slow digestion. The status of Agni in
indicated in Krisa patient.
children is unstable because children are
Antaha Parimarjana: In the context of Atikarshya, predominant of Kapha Prakriti, children are very
Acharya Charaka says that Doshavasechana should fond of Madura Rasa (Madhura Sathmyam), and
be performed. Acharya Sushruta and Vagbhata they have unstable digestive power (Aniyatha
recommend Brimhana Vasti having Mridu, Snigdha Vahni). A Dhatu is evolved and transformed into
properties to be given in Karsya.[22] next Dhatu as a result of Pakaprakriya (biotrans-
Samshamana: Shamana therapy is conservative formation). If there is no Agni in Dhatus, such
treatment. It is mainly employed in the form of drug evolution cannot take place and Mandagni leads to
treatment according to severity of disease as well as the production of Ama and causing Srothorodtha
the condition of the Rogi.[23] Some examples of which leads to deficient production of subsequent
Samshamana drugs are Aswgandha Churna,[24] Dhatus. “Karsya “is a condition in which the Dhatu
Aswagandha ghrita[25], Karshyahara[26] Yoga etc. Parinama gets affected resulting in Dhatu Kshaya,
Rasayana: Acharyas opines that Rasayana and Vatakopa occurs in Karsya due to Dhatukshaya.
Vajikarana, Balya, Brihmana type of drugs should Vitiation of Vata Dosha can lead to Agni Dushti or
be administered specially the drugs belonging to Agni Dushti can in turn leads to Vata Prakopa and
Madhura Skanda along with Withania somnifera Pitta Dushti which results in improper digestion
(Aswagandha), Pureria tuberose (Vidari), Asperagus and assimilation of ingested food causing Aamatva
Racemosus (Shatavari) Sida cordifolia (Bala), and Sama Rasa formation. As per Asraya-Asrayi
Abutilon indicum (Atibala), Sida veronicaefolia, Bhava, Rasa Dhatu is the abode of Kapha Dosha; so
(Nagabala) recommended by Acharya Susrutha.[84] Rasakshaya cause Kapha Dushti i.e, Kapha Kshaya.
Pathyaapathya [28] In short all the Tridoshas are involved in the
Ahara and Vihara Samprapthi of Karsya. Srotosodhana, Deepana,
Different dietetic and nutritional regiments Brimhana and Rasayana are the treatment
are employed in the management of Karsya. principles of Karsya. In Ayurveda no much
Particular mention is available on the usage of meat description is found regarding Karsya especially in
soup of domestic marshy aquatic animals (Gramya, children. According to Acharya Kashyapa described
Anupa Mamsa), milk (Dugdha), curd (Dadhi), ghee “Vyadhi Sambhavaja Phakka” and it is similar to
(Ghrita) Shashtika and Sali rice (Shashtika, Shali), malnutrition. “Balashosha” and “Kshiraja Phakka”
wheat (Godhuma), Masha, sugar candy preparations are nutritional deficiency disorder mentioned by
(Ikshu Rasa, Nava madya). It is claimed that Acharya Vagbhata and Acharya Kashyapa
preparations of Mamsa are unique preparations respectively. Similarly, “Parigarbhika” and
causing maximum Brihmana. The Ahara Vargas “Garbhaja Phakka” are caused by child on feeding
mentioned in the context of general etiology of breast milk of pregnant mother which has Alpa
Karsya can be considered as Apathya Ahara Varga, Poshakamsha (poor nutrients). “Shuska Revati “one
hence should be avoided by the patients. On the Graha (demon) affecting the child represents
other hand, various food preparations having infections spectrum of disease resulting Sarvanga
Brihmana, Balya and other allied activities should Kshaya (emaciation) and child becomes emaciated
be consumed by the patient.[29] Viharas are sleep, even though consuming food of many kinds. All the
joy, comfortable bed, abstinence from anxiety, disease described in Ayurveda texts is related to
regular oil massage etc. each other and possible to correlate to malnutrition
like protein energy malnutrition (PEM).
CONCLUSION
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Cite this article as:

Manjusha.M, Roshni Anirudhan. Undernutrition in Children: An Ayurvedic Perspective with Special
Reference to Karsya. AYUSHDHARA, 2019;6(3): 2207-2214.
Source of support: Nil, Conflict of interest: None Declared

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