Homoeopathy in the management of asphyxia neonatorum

Dr Jaimin D. Adroja

Abstract:
Birth asphyxia occurs when a baby doesn’t receive enough oxygen before, during, or after birth, affecting their brain and other organs. Symptoms can vary, but some of the most common include: Before birth.Low pH levels in the baby’s blood At birth ,Poor skin color, such as pale or bluish ,Low heart rate ,Weak muscle tone and reflexes .

Key words :  HOMEOPATHY  and ASPHYXIA NEONATORUM

Definition
Asphyxia refers to combination of hypoxia, hypercapnea and metabolic acidosis. It may lead to multiorgan dysfunction and may cause death. Birth asphyxia has been variously defined as Apgar score less than 7 at I minute, no breathing at birth or gasping respiration at birth

Pathophysiology
Anaerobic utilization of glucose, production of lactic acid and accumulation of C02 leads to acidosis. This biochemical changes cause constriction of pulmonary arterioles and raise the pulmonary arterial pressure. This results in reduced filling of left heart and right to left shunts, In asphyxiated term appropriate babies blood glucose is significantly increased during first nine months due to mobilization of glycogen stores as a result of Increased release of catecholamines and ACTH. Severe and prolonged hypoxia in preterm and gowth retarded babies is followed by depletion of cardiac glycogen and tendency towards hypoglycemia. Petechial hemorrhages due to anoxic capillary damage, intracellular collection of Na and inappropriate release of ADH are associated with development of cerebral edema.7

Etiology

Intrauterine
Uteroplacental insufficiency, abruption placentae, prolapsed cord, matemal hypotension, Vasa previa, placenta previa, fetomaternal haemorrhage, erythroblastosis fetalis.

Intrapartum
Cephalopelvic disproportion, shoulder dystocia, breech presentation, spinal cord transaction, umbilical cord compression, tetanic contraction, abruption placenta.

Postpartum
Maternal medication, trauma, previous episodes of fetal hypoxia-acidosis,congenital myasthenia gravis, myopathy, myotonic dystrophy, choanal atresia, severe obstructive goiter, laryngeal webs, severe immaturity, pneumothorax, pleural effusion, diaphragmatic hernia.

Diagnosis:
Asphyxia is diagnosed by antenatal, intranatal and post natal observations. Before birth, the clinical parameters of foetal distress are exaggerated foetal movements followed by a loss of foetal movements, variations in foetal heart rate as indicated by slowing or irregularity and visceral over activity in the form of passage of meconium in a non-breech presentation, Other diagnostic tests for foetal distress Include foetal scalp blood sampling to assess pH, Oxytocin challenge test, maternal urinary oestriol assessment, amniocentesis, amnioscopy and ultrasonography. Large caput is also considered a risk factor.

Assessment

1. Perinatal assessment of risk includes awareness of pre-existing maternal or fetal problems that may predispose to perinatal asphyxia ascertained by USG, Biophysical profile, non-stress tests, and measurement of urinary estriol. B. Clinical presentation

Can be variable. Common clinical scenarios include a postdated infant with asphyxia, meconium aspiration, pulmonary hypertension, pneumothorax or birth trauma, (Manual of neonatal care)

C. Low Apgar scores
Apgar examination is a rapid scoring system based on physiologic response to the birth process is a good measure to assess the need to resuscitate a new born. At an interval of I minutes and 5 minutes after birth each of the five physiological parameters is observed or elicited by a qualified examiner. Full term infants with normal cardiopulmonary adaptation should score 8-9 at I minute and 5 minutes

Apgar score of 4-7 warrant close attention to determine whether the infants status will improve and to ascertain any pathological conditions contributing to the low Apgar score. By definition an Apgar score of 0-3 represents either a cardiopulmonary arrest or a condition caused by severe, bradycardia, hypoventilation or central nervous system depression

	Score
l.	Respiration	Nil	Slow	Crying
2.	Heart Rate	Nil	< 100	> 100
3.	Tone	Toneless	In between	Flexed
4.	Response to Catheter	Nil	Grimace	Sneezing
5.	Colour	Cyanosis	In between	Pink

APGAR scoring method²

1. Umbilical cord or first blood gas determination

Resuscitation ABCD approach

• Represents securing a patent airway by clearing rneconium or amniotic fluid by suctioning.
• Represents breathing, If neonate is apnoeic or hypo ventilated and remains cyanotic ventilation should be initiated with a well fitted mask attached to a anesthesia bag and manometer,100% oxygen should be administered. The pressure generated should begin at 20-25cm H20 with a rate of 40-60 breaths/min.

C- Represents circulation and external cardiac massage. If artificial ventilation does not improve bradycardia, if asystole is present or if peripheral pulses cannot be palpated, extemal cardiac massage should be performed at a rate of 120 compressions/min with compressions and breath at a ratio of 3: I

D- Represents the administration of drugs. If bradycardia is unresponsive to ventilation or asystole presents then administration of drugs has to be done5

Effects of Asphyxia Central nervous system

Hypoxic-ischemic encephalopathy, IVH, PVL, cerebral edema, seizures, hypertonia, hypotonia

Cardiovascular system
Myocardial ischemia, poor contractility, tricuspid insufficiency, hypotension Pulmonary- Persistent pulmonary hypertension, respiratory distress syndrome,

Renal- Acute tubular or cortical necrosis

Adrenal- Adrenal hemorrhage

Gastrointestinal- Perforation, ulceration, necrosis

Metabolic- Inappropriate ADH, hyponatremia, hypoglycemia, hypocalcemia, myoglobinuria

Integument- Subcutaneous fat necrosis

Hematology- Disseminated intravascular coagulation 5

Factors other than asphyxia that may delay the onset of respiration after delivery

Central nervous system injury or abnormality present prior to labour

• Drugs depressmg the central nervous system
• Maternal hypocapnea

Trauma, especially to the central nervous system

Prematurity,in particular surfactant-deficient,stiff lung

• Sepsis,especially group B streptococci
• Muscle weakness due to prematurity or primary muscle disease
• Anemia,hypovolaemia

Congenital malformations

• Obstructing the air way or preventing lung exapansion
• Neurological, impairing respiratory control

HOMOEOPATHIC MATERIA MEDICA
Laurocerasus- Lack of reaction especially in chest and heart affections. Asphyxia neonatorum, cyanosis and dyspnoea, small and feeble pulse, threatened paralysis of lungs, gasping for breath. Antim.Tart- Great rattling of mucus with little expectoration, coughing and gasping consequetively, oedema and impending paralysis of lungs, pulse rapid ,weak, trembling4 Neonatal asphyxia- ailments from eclampsla, maternal hypertension, maternal diabetes, premature birth (very common), malpresentations like cephalopelvic disproponions, placenta previa, use of pethidine a few hours before delivery. Asphyxia due to respiratory distress syndrome. At the time of birth, the child is pale (like m china, if child is blue Laurr and Op; if child IS red: Acon) and breathless, even when the umbilical cord is still pulsating. comatose or drowsy, much mucus in oropharynx and trachea. Modalities: worse from cold bathing,

On examination: Apgar score between 4-7, Apnea, P02-decreased, PC02-increased, respiratory acidosis, Cyanosis•H•, central as well as peripheral,

Face pale or dark red with blue lips, gasping respiration, rattling of mucus in lung and throat, tachycardia followed by bradycardia, thread pulse 15

Rarely any other medicine needed than this one for meconium aspiration. Infant should respond by coughing up the meconium even if it remains as if life less²¹

Borax venata – Neonatal asphyxia due to congenital cyanotic heart disease. Bluish face, nose, eyes, finger tips and toes, the child suffocates and suffers prostration (Lach, Laur),

Arrested respiration in infants when lifted or made to lie down in the cradle. Desire to take deep breaths during fever (Bry). On examination: Cyanosis.

Hyocyamus niger — Slow irregular respiration, with a loud inspiration Stertorous breathing after concussion or head injury.

Lachesis mutans —Neonatal asphyxia leading to cardiac failure, initial warning symptom that could indicate is difficulty in feeding, frequent short breaths taken by the child who is able to breath better when held against shoulder.

Moschus — Gasping respiration, irregular stridulus respiration, cyanosis and threatened asphyxia. Opium — Strertorous breathing, rough inspiration and loud puffing expiration, especially during sleep, and after convulsions.

On examination – central neurogenic hyperventilation, chest x-ray-Pulmonary oedema, Cheynestokes respiration, Irregular respiration, sometimes slow sometimes hurried, respiratory acidosis.

Aconite :Apoplectic from, the babe is hot, purple-hued, pulse less and breathless, or nearly so

Antimonium-tart [Ant-tl. : Suffocative form; rattling of mucus in throat; child pale and breathless, although the cord still pulsates

Belladonna [Bell] : Apoplectic fonn•, face very red, eyeballs injected, pupils dilated

Camphora ICamph] :Where Ant. tart. fails, for the same symptoms

China (Chin) :Syncope, after profuse haemorrhage

Laurocerasus [Laurl : Face blue, with gasping for breath and nearly imperceptible breathing; twitching of muscles of the face. Cord till pulsating¹³

Late APGAR scoring (5 minutes and above) with low scoring below 5 have potential to develop cerebral palsy. With homoeopathic management, the chances of cerebral palsy are brought down considerably24

Antim-tart: cleans the mucus of aspiration, oedema of the lungs and enhances delivery of oxygen to the capillaries and stimulates respiratory centre.

Carbo veg: Enhances the oxidation by improving the oxygen carrying capacity due to improved circulation. Laurocerasus: Enhances the oxygen utilization at cellular level, so stimulates and rehabilitates dying cells. Camphor: Used in extreme cases, Emergency. Icy coldness of body with cyanosis, gasping respiration.

Åspidospemia: Used in stimulating respiration in central and peripheral respiratory paralysis.

Kali-phos; Used in recharging the nervous system (white matter)

Out of a total of 125 cases I have failed in a very few (about 5-6) cases which were associated with congenital malformation, injury or infection.

To prevent a possible sinking of the restored vital energies, we have to resort to internal remedies, a single globule of a high attenuation of the proper specific remedy being sufficient, which is Aconite in asphyxia apoplectica; Cinchona in asphyxia ansemica, and Ipecacuanha for the asphyxia suffocatoria. ¹⁰

Repertory
In Boericke’s Repertory, the chapter Generalities contains rubric Asphyxia — Asphyxia neonatorum where Ant.t and Laurocerasus are given, In this Ant. t is more frequently and clinically verified ⁴

In Synthesis 9. I – Repertory, the Chapter Respiration contains rubric Asphyxia — children, new born where Antimonim tartaricum and Camphor are given as three mark medicines.7

In Phatak’s Repertory, under the rubric Asphyxia neonatorum Antim tart, camphor and Laurocerasus are given as the important remedies 6

In Murphys ⁹ Repertory under the chapter children ,Asphyxia (rubric), infants, (subrubric), Ant.taH, camphor, laurocerasus are the 3 mark remedies remedies followed byaconite, arnica, belladonna, opium.ln the chapter emergency,Asphyxia newbom Infant-cuprum met is also given as 3 mark remedy ¹⁸

Management Plan in Neonates

1. a) The physician should first differentiate an indisposition from an illness.
2. b) If the indisposition doesn’t get rectified by managing the precipitating factors then a remedy has to be given based on the available totality
3. e) If the totality is available the indicated remedy may be prescribed to the child,
4. d) Understanding the Mother’s (MO) constitution is important especially when there is no clear picture in the child. Constitutional remedy (C.R.) of mother or remedies related to C.R. can be thought of in these situations 25

Brief work on the related topics

• In a symposium and workshop by Programme for Global Pediatric Research (PGPR), in May 2005? pediatric scientific researchers in the world came in an assumption that approximately one million babies die each year as a result of factors commonly referred to as “birth asphyxia” and many infants who survive asphyxia must cope with lifelong mental and physical handicaps. The studies emphasized that the outcome of birth asphyxia is not only death but also impairment. So the antepartum and intrapartum along with neonatal factors looked out to reduce the incidences.3
• Homeopathic medicines are selected after a full individualizing examination and
• Case-analysis, which includes the medical history of the patient, physical and mental constitution, family history, presenting symptoms, underlying pathology and possible causative factors etc. The indicated homeopathic remedy tries to correct this disease The focus is not on curing the disease but to cure the person who is sick, to restore the health. The symptoms listed against each homeopathic remedy may not be directly related to asphyxia because in homeopathy general symptoms and constitutional indications are also taken into account for selecting a remedy.

Dr. Jaimin D. Adroja BHMS
L.R.Shah Homeopathy College, Anandpar, Rajkot
Guided by Dr. Rakesh Kumar Shrivastava
[Professor and H.O.D.,Department Of Organon of Medicine and Philosophy]
Email: jaiminadroja3@gmail.com