CLINICAL OBSERVATION: A KEY TO THE ASSESSMENT OF SUSCEPTIBILITY IN THE MANAGEMENT OF MALNUTRITION – AN EXTENDED CASE REPORT
Neena B. Ambekar, MD (Hom)1* , Sujata C. Goda MD (Hom)2, , Prashant Tamboli, MD (Hom)3
1Physician, Malnutrition Project
2Project Coordinator, Malnutrition Project, Dr. M. L. Dhawale Memorial Trust (MLDT)
3Associate Prof, Department of Repertory and Head, Department of Research, Dr. M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI)
*Address of correspondence: Dr Neena Ambekar
How to cite this article:
Ambekar NB, Goda SC, Tamboli PP. Clinical observation: a key to the assessment of susceptibility in the management of malnutrition – an extended case report. Journal of Integrated Standardized Homoeopathy 2018; 01(02).
Received on: November 29, 2018
Accepted for Publication: December 26, 2018
In the article on Malnutrition published in JISH, Vol 1 by Goda S C and et.al1, the authors had concluded that there is a significant role for homoeopathy in its management provided the similimum is accurately identified. That remains the major challenge due to two main reasons, viz Difficulty in getting reliable data from parents who are generally not at home to observe and report and difficulty in identifying characteristics when the large number of individuals from the same socio-economic-cultural background present with a common set of symptoms. The problem poses itself: how to identify characteristic expressions which would help in totality formation and prescription?
The role of observations acquires paramount importance. This leads to a fresh set of challenges. Which type of observations should the physician register as significant? Only behavioural? Are there any other categories? How long these observations should be continued? If the observations were to continue after initiation of treatment, what use would these be put to?
Homoeopathic intervention results in significant weight gain but the actual weight gain vary from case to case and it ranges from 100 to 500 gms in the first month. So how much weight gain is expected after giving the first dose? Apart from the change in weight, are there any other parameters which would point to the action of the similimum? This will give clear-cut guidelines to continue the treatment. The parallel enquiry is to understand the indications for the intercurrent/antimiasmatic remedy. These are some of the questions vital to manage children with malnutrition in an effective and efficient manner. This article explores these through sharing of some experiences of children treated, the analysis of which was included in the study described previously. Some are new learning’s acquired after understanding the project. The cases are reported in brief to highlight the issues identified as follows:
- Identifying observations which mark out as characteristics for formulating the totality
- Optimal weight gain to assess the remedy response
- Assessment of associated complaints to assess the remedy response
- Observation to indicate the need of change of remedy
- Role of the antimiasmatic remedy
Differentiating Characteristics from Common Expressions:
Each disease has some common expressions useful for diagnosis. From the homoeopathic point of view, we need characteristic individualised expressions. However, when we study a large number of cases from a closed community, we get common expressions at the mental and physical level. These are common to the community due to biological, social and cultural factors. They can be called as community characteristics2. These symptoms are placed lower in the symptom evaluation. Following is the list of symptoms which are present in most of the cases with milder intensity. Hence, these symptoms do not find mention in the cases unless they are qualified.
Fear of dark, ghost, strangers. Shyness and timidity. Crying in the initial part of interaction.
Desire Sweets, Perspiration on head, sleeps on abdomen, hunger aggravation.
Table No. 1: Normal Weight as per WHO3
Case 1: Characteristic – Physical make-up
Mast. MNW, 11 months male child from lower socioeconomic background was brought with Grade I malnutrition as per IAP classifications. His weight was in 77thpercentile. His current weight was 7 kg and expected weight was 9 kg. He had all common symptoms of malnutrition. He was having associated complaints of URTI. That also did not have any characteristic symptoms. He was on breast-feeds, rice gruel and dal water.
Physically, he was underweight but looked characteristically chubby. He had profuse perspiration on the scalp and face. He was chilly and overall a very calm and quiet child.
Calc Phos and Calc Carb came up for final differentiation. However, the observation of physical make up i.e. having chubby body in spite of being underweight was the characteristic which made way for prescribing Calc Carb. It was prescribed at monthly intervals.
Response of weight gain was immediate and within the first 3 months, he had gained substantial weight of 1 kg. He did not have episodes of URTI. The repetition of remedy was maintained and within 8 months he gained 1.7 kgs. At this stage, it was realised that his response had slowed down after the first 3 months and change in the posology was indicated. He had 4 episodes of URTI and required acute medicine. Potency was raised to 1M as there were no structural changes. Thereafter there was steady improvement. However, he had two episodes of diarrhoea during summer and 2 episodes of URTI. With each episode he used to lose weight sometimes upto 400gms. These were the indications of an active Tubercular miasm and hence Tub Bov. 1M was prescribed twice at interval of 5 months.
After treating the child for 2.4 years his percentile changed from 77 to 81 i.e. he reached the normal category of weight and remained in that category. We aim that these children reach the green zone and continue to inhabit this area through the course of treatment. There was very little cooperation from parents and even after repeated orientation the diet remained deficient.
- Observations made at physical level i.e. Chubbiness in an underweight child helped to reach to similimum.
- Weight gain of 1 kg in 1st three months and improvement in associated complaints i.e. no episode of URTI is a definite indication of remedy registration.
- Tubercular miasm expressed in terms of substantial weight loss after acute episodes needed to be taken care of through the introduction of the antimiasmatic remedy.
- Malnourished children in the absence of proper diet take longer to reach to normal weight. However, the similimum does wonders if properly administered.
Case 2: Characteristic- Behavioural pattern obtained through meticulous observation reported by father
Baby PBS of 3.1 years of age, failed to gain weight. She had lustreless hair which was the classical presenting symptom of malnutrition apart from the usual features. Her weight was 9 kgs keeping her in 65th percentile whereas her expected weight was 14 kgs. She had recurrent URTI. She had sour smelling perspiration on the head. Her thermal response was chilly. She was calm and shy.
Considering the presenting symptoms, Calc Carb 200 was given monthly and later biweekly. She gained 1.4 kgs of weight in the 1st 2 months which was substantial. However, her recurrent URTI did not change.
Her father, who was observant and keen to continue the treatment, shared his observations. She likes to run small errands like giving water etc. when asked for, buying things from shop which she does readily & without any mistake. She is very particular about her haircut. She likes to keep her hair short and tells her father whenever she wants & how she wants & makes sure that it is done so. The CHV & aangnwadi teacher said that she is very intelligent but does not talk (“ hushar aahe pan bolat nahi”). She has been very regular in the aanganwadi. She was observed to be playing actively & when the other child took some toys from her, she did not say anything & kept playing with the remaining toys. She knows when the van enters the pada & immediately tells father to take her for the medication or starts walking to the anganwadi on her own. She behaved timidly during the follow up but whenever we leave & pass by her home, she smiles & waves her hand.
Based on these observations she was given Silicea 200, initially biweekly and later on weekly. Five doses of Tub Bov as an antimiasmatic remedy were given. During 1 year and 7 months of giving Silicea she had gained weight of 3 kgs. Her weight percentile changed from 65th percentile to 70th percentile.
- Non responsiveness of the acute conditions in spite of gain in weight may point to a missed similimum
- A sensitive parent (this time the father!) was able to correct the line of action.
- We may be able to make additions to the images available in ‘Children types’ of Borland. One is able to see the peculiar sensitivity of a Silicea child through minute observations conveyed. One can understand the source of the meticulousness and love for perfectionism that one sees in adult Silica patients.
Case 3: Characteristic- mental expressions and developmental delay
Baby RSS, female of 1 year and 9 months from lower socioeconomic background was having Grade II malnutrition with URTI and tendency for recurrent boils. Her weight was 7.6 kgs and she was in 66th percentile. Her expected weight was 11.5 kgs. She had all common symptoms of malnutrition. URTI also did not have any characteristic symptoms. She had tendency to develop boils in summer. Her diet was deficient.
She was lean and had perspiration on face and neck. She had habit of teeth grinding during sleep. She was chilly. Her milestones were normal except one i.e. delayed speech. She had not yet started speaking a word until the case definition. She would cry very loudly and was extremely irritable. Her mother used to always carry her. It was not clear if she had fear of stranger or dislike. Nevertheless, she did not like anybody approaching her and cried out loudly. She would cry for a long time till mother picked her up!
Chamomila and Natrum mur were two closely coming remedies. Considering the irritability, dislike of people approaching and patchy delay in the milestones, Natrum Mur was selected. Natrum Mur 200 1 dose a month was given initially and later potency was stepped up as required.
The response to the similimum was very quick. After the 1st dose, the child gained 600 gms in the 1st month. In 1 year and 2 months she gained 3.2 kgs. She had cold twice for which she took allopathic medicine. She got chickenpox in summer after which the rate of weight gain reduced. There was a little dilemma about introducing the antimiasmatic remedy. But since there was a reduction in the infection rate and overall improvement, the potency of the Constitutional was raised to 1M and she was back on track. Another important change was reduction in her irritability which
reduced drastically after the 1st dose and she was no longer a cranky baby. She happily allowed the physician to examine her. Her speech improved and within 7 months of treatment she started speaking sentences. In the 2nd year of treatment, she suffered from scabies. Scabies is a common contagious disease in this area. Considering the infection, she was given Tub Bov as an antimiasmatic remedy. However, there was no much change in weight and the susceptibility after antimiasmatic remedy. On retrospective analysis, one can conclude that there was no clear cut indication for antimiasmatic as there were no fluctuations in the growth and infection rate was also not high. Her mother delivered the 4th baby girl during this period and she was not having sufficient time to take care of the patient and the nutrition needs were never fulfilled.
Overall there was drastic reduction in the frequency of URTI, change in the mental state and in the milestones. She gained weight consistently with a change in weight percentile by from 66 percentile to 77.57 percentile.
- Observation of behaviour and the development pattern helped in differentiating remedies and selecting the similimum.
- Gaining weight consistently from the 1st month of about 200 gms every month was a sure indication of remedy registration.
- Proper analysis of the remedy response i.e. consistency, helped to understand the role of the antimiasmtic remedy.
- Similimum had helped in overall improvement including weight gain. However, due to lack of proper nutrition, the child has not yet reached the normal category.
Case 4 – Characteristic – Concomitant
Baby AKL of 1 year 4 months, having weight of 8 kgs was in 75thpercentile. Her expected weight was 10.7kgs. Again, there were no characteristics symptoms. Along with this she had tendency for recurrent cold and cough. There was dyspnoea especially aggravated during rainy season. She also had discharge from ear since long and on a daily basis.
She was lean and had perspiration on the forehead. Her thermal state was towards chilly. She liked sweet taste. She was on breast feed and weaning had been started. She was irritable and disliked strangers. She was not of a mixing type and used to play alone.
Based on her irritability and non-mixing nature, Natrum Mur 200 was given once a month. After 2 months there was no major change in frequency of cold and also in the weight. In fact she had lost 100 gms in this period and her ear discharge had rather increased. Her weight percentile had dropped to 69.78. Physician gave Merc Sol in frequent doses to take care of the discharge. The discharge stopped immediately and her irritability also decreased considerably. Nat mur was not repeated and it was observed that the child gained 300 gms in one month. Later, she was kept on Merc Sol 200 at monthly intervals. Subsequently her weight gain was consistent. She did get cold and cough but they settled faster. She gained around 2 kgs in 1 year and 5 months in spite of the fact that her diet remained deficient. Her weight percentile changed from 69.78 to 75.23
- Poor response of weight definitely indicated that the remedy was not acting. After the administration of the similimum there was a substantial weight gain in a short time.
- Concomitant complaint of ear discharge acted as a key for unlocking the approach to the totality. What was prescribed as an acute turned out to be a deep acting
- Similimum shows overall improvement at both physical and mental levels
- Proper diet along with similimum is a must for change in percentile
Cases 5 and 6: Grade III malnutrition – Concomitant expressions/complaints of significance.
In one of the cases, the child was on 59th percentile when the case was defined. Without any medicine, the child had moved to 63.7 percentile in 3 months. After Calc Phos 200 monthly it again dropped to 60.8, the irritable behaviour continued and the frequency of acute URTI remained same. Calc Phos was given weekly for 5 months, which brought the weight percentile to 63.19, but the rest of the behaviour and the acutes continued to be the same. The characteristic irritability allowed the physician to change from Calc Phos to Chamomilla which improved the irritability and the frequency of acutes reduced significantly. The percentile changed from 63.19 to 69.65 in 11 months. Chamomilla 1M helped this child better keeping in mind the high sensitivity
The second case with 57.7 percentile had worm infestation. This concomitant complaint helped in selecting Cina as the constitutional. With the first dose of Cina, there was an increase of 400 gms. The worm infestation settled gradually but there was a fluctuating response in weight gain. With the first dose of Tuberculinum, there was a weight gain of 300 gms and with the second dose there was a weight gain of 700 gms in 2 months. Now the child’s weight percentile is 63.19. In this case it was observed that whenever there was a break in treatment, there was no weight gain. This also proves that the susceptibility definitely improves with the similimum. We will need to evaluate the role of Tubercular miasm and antimiasmatic force in cases having worm infestations.
- Lower grade of malnutrition does not necessarily indicate poorer susceptibility.
- Concomitant complaint of worm infestation helped to select the similimum.
- Poor weight gain in spite of giving the remedy surely is an indication to review the totality.
- Characteristic behaviour helped in selecting the similimum.
- Characteristics in the case:
Experience of treating the series of malnutrition cases once again proves that Homoeopathy is a science and an art. It is a science as once the similimum is administered; it immediately produces changes at both mental and physical levels. It is an art as physician must identify the individualising symptoms from the maze of symptoms. It is further challenging when one encounters common symptoms in the paediatric age group and in specific community set ups. Physician with experience can differentiate common symptoms of the community and pick up the characteristics. Susceptibility can express characteristic expressions at any level. The peculiarity may be at the mental level. One needs to be more observant in identifying the patterns looking at the consistency of behaviour. It can be at physical make up where one can identify the peculiarities or unexpected findings like chubbiness in a malnourished child. Physical concomitants that Dr. Boenninghausen has stressed upon come to rescue in some cases. So identifying peculiarities in a case is a major challenge for the physician which he can overcome by following principles of observations laid down by Dr. Hahnemann.
- Observations for assessing the change in the susceptibility:
Dr. Kent says that a well taken case is half cured. It’s true as it helps in finding the similimum. However, as he has correctly said it’s a job half done. Therefore, physician must follow Dr. Kent’s other guidelines and assess remedy response. One of the clear-cut indications about the signs of remedy registration is changes seen at all levels. The first in cases of malnutrition is the weight gain. After observing many cases, the conclusion is that around 200 gms is the average weight gain in the first month of treatment after giving one dose.
Another change is in the behavioural expressions. All extreme behaviours start normalizing-an irritable child will mellow down and timid child will open up. Change in associated complaints is another indication for long-term analysis. If one has to conclude about sure shot indications of remedy registration in a short time, then weight gain and changes in expressions on which the remedy has been prescribed must be observed. One can see immediate change in these expressions.
- Behavioural patterns for remedy selection:
Two broad behavioural patterns are observed. One theme is of irritability and another is of shyness and timidity. Chamomila, Cina, Nat Mur, Merc Sol, Tub Bov are the remedies indicating the 1st theme and Silicea, Calc Carb, Calc Phos are remedies indicating 2ndtheme 4-5.
- All the three remedies, Nat Mur, Chamomilla and Cina do not like to be approached. Nat mur is irritable but expresses it through eyes and looks. Along with it there is lot of obstinacy and rigidity. Hence, child will cry immediately when mother puts it down and for long until someone approaches him/her. This possibly indicates that they do not like to be disturbed. Fierce crying indicates Chamomilla or Cina. Chamomilla is pacified if carried and Cina is slightly better on carrying but the crying continues even on carrying. In Chamomilla the cry is in spells and it gradually increases in intensity. Child cries immediately after being kept down by mother. Cina doesn’t like anyone coming near to them. Their cry is loud and shrill. Merc Sol also has irritability though not intense as previously mentioned remedies, but they throw a lot of temper tantrums.
- Silicea appears to be more understanding, adjusting type, meticulous and particular. They are shy and take long time in answering the physician. Calc Carb and Calc Phos come very close and most of the times they are difficult for differentiation. But the fears are more intense in Calc Carb then in Calc Phos. There is more slowness and child speaks very slowly. Calc Phos takes some time to mix up but once child is comfortable it mixes very well with others. A lot of times the physical data helps in their differentiation. This needs to be studied further to have clear cut guidelines for differentiation. It will be a useful and interesting study.
- Role of antimiasmatic remedy:
Antimiasmatic remedies in cases of malnutrition are indicated only when the response slows down after the initial registration of the remedy. There would be no subsequent weight gain. It was observed that Tub bov was frequently indicated. But in these cases there was a tendency for recurrent infections. So one should not jump to the conclusion that malnutrition is a predominantly tubercular activity. Many cases do not require an antimiasmatic remedy and these children may be psoric in nature. More study is required to conclude about it.
- Posology in Malnutrition:
Majority of the cases required 200th potency in infrequent doses i.e. once a month and in very few cases weekly doses were found necessary. Majority of the cases were given 200th potency in infrequent doses i.e. once a month and later weekly doses were found necessary in a majority of cases. In cases where there are no signs of further improvement, the changes have been seen by raising the potency and not by increasing the repetition. Thus one can conclude that if the selected remedy is accurate, one need not requires too much repetition.
- Deep acting remedy is indicated for the management of malnutrition
- Accurate observation of expressions is the key to remedy selection. These can rarely be obtained from the parents when they are asked to share. But usually, the physician needs to be alert in case taking and over the first few follow ups.
- Consistent behavioural expressions are indicators of mental characteristics. These can well be included in the drug picture of remedies and can expand our personal knowledge of these images.
- Characteristics can be at the physical make up or as concomitant illnesses.
- Weight gain of approximately 200 gms the first month can be expected by giving 1st dose of similimum.
- There is a role of antimiasmatic remedy in cases having recurrent infections and worm infestations. However, further work is needed to conclude on this point.
- Goda SC, Ambekar NB, Tamboli PP, Broker DR, Exploring the role of Homoeopathy in the management of malnutrition in children in the age group of 1 to 4 years: A pilot study, Journal of Integrated Standardized Homoeopathy (JISH), 2018;01(01):12-20
- Goda CR, Tamboli PP et. al, Role of homoeopathic treatment in scabies infection in adivasi children attending ashram shalas (resident schools), Indian Journal of Research in Homoeopathy 4, No. 2, April-June 2010, 33-40
- WHO reference for weight chart
- Paul Hersue, The homoeopathic treatment of children (2009), B Jain Publications, New Delhi, Pg: 3, 139
- Master FJ, Clinical observations of children remedies, (2010), B Jain Publications, New Delhi, 220, 234, 272, 303, 471