Phytotherapy with Hordeum Vulgare: A Randomized Controlled Trial on Infants with Jaundice

Jaundice is a disease of early days of life due to accumulation of bilirubin under the skin, mucus membranes, and sclera. Jaundice can be caused by incompatibility between the blood of mother and foetus, haematoma dissolution, bruising of the baby’s body, infection, liver diseases, and hematologic diseases, such as G6PD deficiency [1,2], and unknown causes [3]. Jaundice or indirect hyperbilirubinemia is one of the prevalent diseases among infants in Iran [3] and other regions worldwide. It has been reported that approximately 60% of term infants and 80% of preterm infants acquire jaundice in the first week of life [1]. This disease is the cause of 75% of infants’ hospitalizations [4], and imposes stupendous costs on health care system [5]. Jaundice is a complicated disorder due to hyperbilirubinemia. When unconjugated bilirubinemia begins to increase, it may cause neurotoxicity and brain damage in infants [6] such that chronic jaundice can lead to a dangerous complication called bilirubin encephalopathy or kernicterus. Kernicterus can cause neurological disorders, auditory nerve damage, choreoathetoid, cerebral palsy, and other problems [7].

Phototherapy is considered a common and leading treatment for jaundice since long time. Despite having certain advantages and being considered to be significant around the world, it may cause a number of short-term complications such as disruption in maternal-infant emotional interaction, disturbance of thermal equilibrium, dehydration, electrolyte imbalance, "bronze baby" syndrome, disturbance of infant circadian rhythm, decrease in the duration of exclusive breastfeeding, and DNA damage [8,9].

It is therefore necessary to search for new therapies. Currently, medicinal plants are considered a good source for preparation of new drugs, not only for jaundice but also for other diseases [10–14]. Complementary medicine plays a significant role, accompanied with modern medicine, such that in addition to phototherapy, several herbal drugs are used to treat jaundice in Iran [15]. Barley (Hordeum vulgare L.) is an herbaceous plant from family Poaceae. H. vulgare is used to treat several diseases, including jaundice, in Iranian traditional medicine [16].

Use of traditional medicinal plants can be a simple and accessible approach to treat neonatal jaundice with few side effects. Because H. vulgare flour is widely used as an effective phytotherapy according to ethnobotanical studies, this study was conducted to investigate the effect of H. vulgare flour on jaundice.

Materials and Methods

In this double-blind, randomized controlled trial, 70 term infants hospitalized due to jaundice in the neonatal care unit of Hajar Hospital of Shahrekord, Southwest Iran in July-December, 2014 were enrolled [Table/Fig-1]. The inclusion criteria were: being term, healthy, and over three-day-old, having total serum bilirubin level in between 12 mg/dl to 18 mg/dl, weighing 2500-4000 gm, breastfeeding, no increase in direct bilirubin by over 2 mg/dl, and no risky symptoms such as lethargy, lack of breastfeeding, fever, blood incompatibility of mother and baby, polycythemia, anaemia, and family history of severe jaundice.

[Table/Fig-1]:

Consort flow diagram of the study.

The presence of clinical and laboratory infection, dehydration, G6PD, incompatibility of blood types (ABO), positive Coombs test, direct bilirubin levels of over 2 mg/dl, total bilirubin of over 18 mg/dl and allergic reaction to H. vulgare flour were considered exclusion criteria. The infants were randomly and alternately divided into two groups (n: 34 and 36) by random number table. At the beginning of the study, all parents provided informed consent to their infants’ participation in the study. Breastfeeding continued when the infants stayed in the hospital. The protocol of this study was approved by the Research Committee of the Shahrekord University of Medical Sciences (the approval code: 91-10-25).

Once every 24 hours, the blood samples were taken to assess bilirubinemia levels. The infants in the control group received full-time phototherapy alone using LED except when the infants were breastfed and the case group did phototherapy, per the protocol in the control group, and topical H. vulgare seed flour three times a day. H. vulgare flour (150 g) was sieved and then applied on the whole body of the infants in the case group except head, face, and around umbilical cord. Then, the flour was rinsed and phototherapy started.

Afterwards, complete blood count, the mothers and the infants blood type, reticulocyte count, Coombs test, G6PD, and total, direct, and indirect bilirubinemia were examined. At baseline, the two groups were matched for hospital stay, birth weight, direct and indirect bilirubin level. The required samples were taken and sent to laboratory.

Statistical Analysis

After a sufficient number of infants were enrolled and the data were gathered, analysis of covariance (ANCOVA) and paired t-test in SPSS 16.0 were used to compare the data of the two groups.

Results

Overall, 70 infants (36 cases and 34 controls) were studied. A total of 21 (30%) infants had blood type A, nine (8.12%) blood type B, 38 (54.2%) blood type O, and two (2.8%) blood type AB. Sixty five (92.8%) infants were found as Rh positive and the rest Rh negative. Regarding birth order, 35 (50%) infants were the first child of the family and the rest second-ninth child. Only one (1.42%) infant was the ninth child of the family.

At baseline, direct and indirect bilirubin levels of the two groups were compared and were not found to be significantly different (p>0.05). The duration of hospital stay was apparently in the two groups. There was no significant difference in weight, baseline direct bilirubin, and baseline indirect bilirubin between the cases and the controls [Table/Fig-2].

[Table/Fig-2]:

Comparison of hospital stay, weight, and bilirubin level between the two groups at baseline.

Variable	Groups	Mean (standard deviation)	p-value
Hospital stay (Day)	Phototherapy + H. vulgare flour	3.16±1.04	0.34
	Phototherapy	2.91±1.18
Weight (gm)	Phototherapy + H. vulgare flour	3.03±0.45	0.22
	Phototherapy	3.17±4.88
Baseline indirect bilirubin	Phototherapy + H. vulgare flour	14.55 2.52	0.13
	Phototherapy	15.30 1.57
Baseline direct bilirubin	Phototherapy + H. vulgare flour	0.42±0.17	0.27
	Phototherapy	0.46±0.17

According to ANCOVA, there was a significant difference in mean indirect bilirubin level between the two groups at discharge (p< 0.05), such that the mean indirect bilirubin level was higher in the control group. No significant difference was seen in direct bilirubin level between the two groups at discharge (p>0.05) [Table/Fig-3].

[Table/Fig-3]:

Comparison of direct and indirect bilirubin levels between the two groups at discharge.

Variable	Groups	Mean±SD	p-value
Indirect bilirubin at discharge	Phototherapy + H. vulgare flour	9.92±1.37	0.009
	Phototherapy	10.71±1.13
Direct bilirubin at discharge	Phototherapy + H. vulgare flour	0.58±0.17	0.51
	Phototherapy	0.55±0.15

Discussion

This study was conducted to investigate the effect of H. vulgare flour in decreasing jaundice. According to Iranian traditional medicine, H. vulgare is used to serve several purposes, including jaundice treatment, in many regions of Iran [15,16].

Phytochemical and phytotherapeutic investigations have indicated that H. vulgare contains fibrous, water-soluble compounds such as β-glucans which can exert hypocholesterolemic effects and contribute to the regulation of glycaemia. H. vulgare has various properties, including antilactagogue, anti-inflammatory, antioxidant, diuretic, aphrodisiac, antiprotozoal, antiviral, demulcent, astringent, febrifuge, digestive, expectorant, hypocholesterolemic, antimutagenic, refrigerant, sedative, stomachic, tonic properties, and emollient. It can be used as a compress to treat wound, as well [17]. Presumably, antioxidants absorbed by the skin, can enhance liver function and improve hepatocytes activity, that facilitate the process of converting indirect bilirubin to the conjugated bilirubin.

H. vulgare can induce antioxidant effects because of having phenolic compounds and certain compounds such as tocopherol, catechin, and lutein. The ethanolic and methanolic compounds in H. vulgare can serve as metal chelating agents [18,19]. This plant can be used as a food to enhance liver function and serve as a hepatoprotective agent [20]. Since vitamins A, E, and D are absorbed through skin epithelial liposomes [21], the carrying role of active compounds of H. vulgare flour can be considered for phospholipid-containing liposomes in skin epithelial cells.

Jaundice is associated with increase in oxidative stress. Laboratory studies have demonstrated that use of some H. vulgare species can help oxidative stress markers decrease and antioxidant markers increase in rats. As a result, H. vulgare stops adverse histological and biochemical changes in the liver [22] and is useful to regulate liver enzymes [20].

The significance of H. vulgare antioxidant properties is because of the fact that oxidative stress in infants with jaundice leads to decrease in certain antioxidants such as glutathione and ascorbic acid. This condition is exacerbated after phototherapy, which can intensify neurological damage in infants [23]. Besides that, the improvement of liver function is an important issue which should be considered to treat jaundice.

The phenolic components of H. vulgare are relatively high and have antioxidant activities [24–27]. Antioxidants can be effective in treating some other disorders [28–33]. Therefore, H. vulgare, which contains high level of antioxidant activity, may be effective in these conditions, too.

Unconjugated or indirect hyperbilirubinemia in the first or second week of life can be due to increased production of bilirubin and liver inability to excrete bilirubin [23]. During phototherapy, bilirubin absorbs optical energy and the bilirubin existing in skin is converted, by several photochemical reactions, to certain products that can be excreted through kidneys and bile [23].

A limitation of the present study is that the effective compounds of H. vulgare flour were not extracted. Moreover, the action mechanisms of this flour were not investigated. Future studies are recommended to investigate the effects of oral consumption of H. vulgare-based purified products on jaundice or the preventive effects of these compounds before delivery in newborns at risk.

Conclusion

H. vulgare flour can cause decrease in indirect bilirubin and has no contribution to reducing direct bilirubin and duration of hospital stay. As it is important to treat jaundice rapidly and prevent severe associated complications, H. vulgare can be used as a complementary therapy to treat jaundice.

[1]. National Institute for Health and Care Excellence. Neonatal jaundice London: Royal College of Obstetricians and Gynaecologists; 2010 [cited 2016 5/6]. Available from: https://www.nice.org.uk/guidance/cg98/evidence/full-guideline-245411821  [Google Scholar]

[2]. Kalakheti BK, Singh R, Bhatta NK, Karki A, Baral N, Risk of neonatal hyperbilirubinemia in babies born to ‘O’ positive mothers: a prospective cohort study Kathmandu Univ Med J 2009 7(25):11-15.  [Google Scholar]

[3]. Najib KS, Saki F, Hemmati F, Inaloo S, Incidence, risk factors and causes of severe neonatal hyperbilirubinemia in the south of Iran (fars province) Iran Red Crescent Med J 2013 15(3):260-63.  [Google Scholar]

[4]. Maisels MJ, McDonagh AF, Phototherapy for neonatal jaundice N Engl J Med 2008 358(9):920-28.  [Google Scholar]

[5]. Trudnak Fowler T, Fairbrother G, Owens P, Garro N, Pellegrini C, Simpson L, Trends in complicated newborn hospital stays & costs, 2002-2009: implications for the future Medicare Medicaid Res Rev 2014 4(4)  [Google Scholar]

[6]. Bhutani VK, Wong RJ, Bilirubin Neurotoxicity in Preterm Infants: Risk and Prevention J Clin Neonatol 2013 2(2):61-69.  [Google Scholar]

[7]. Maisels MJ, Managing the jaundiced newborn: a persistent challenge Can Med Assoc J 2015 187(5):335-43.  [Google Scholar]

[8]. Waite WM, Taylor JA, Phototherapy for the treatment of neonatal jaundice and breastfeeding duration and exclusivity Breastfeed Med 2016 11:180-85.  [Google Scholar]

[9]. Ramy N, Ghany EA, Alsharany W, Nada A, Darwish RK, Rabie WA, Jaundice, phototherapy and DNA damage in full-term neonates J Perinatol 2016 36(2):132-36.  [Google Scholar]

[10]. Shayganni E, Bahmani M, Asgary S, Rafieian-Kopaei M, Inflammaging and cardiovascular disease: Management by medicinal plants Phytomedicine 2015 :piiS0944-7113(15)00356-6  [Google Scholar]

[11]. Bahmani M, Sarrafchi A, Shirzad H, Rafieian-Kopaei M, Autism: Pathophysiology and promising herbal remedies Curr Pharm Des 2016 22(3):277-85.  [Google Scholar]

[12]. Vahedi G, Khosravi AR, Shokri H, Moosavi Z, Delirezh N, Sharifzadeh A, Fungicidal effect of Origanum vulgare essential oil against Candida glabrata and its cytotoxicity against macrophages J Herbmed Pharmacol 2016 5(2):78-84.  [Google Scholar]

[13]. Gupta A, Chaphalkar SR, Anti-inflammatory and anti-microbial activities of aqueous leaves extract of Butea frondosa J Herbmed Pharmacol 2016 5(2):85-88.  [Google Scholar]

[14]. Sarrafchi A, Bahmani M, Shirzad H, Rafieian-Kopaei M, Oxidative stress and Parkinson’s disease: New hopes in treatment with herbal antioxidants Curr Pharm Des 2016 22(2):238-46.  [Google Scholar]

[15]. Fakhri M, Azadbakht M, Yousefi SS, Mousavinasab SN, Farhadi R, Azadbakht M, Medicinal plants for treatment of neonatal jaundice by community of Attars (Traditional Healers) of Several Urban Areas in Mazandaran Province, Northern of Iran Br J Med Med Res 2016 14(11):1-13.  [Google Scholar]

[16]. Marwat S, Hashimi M, Khan K, Barley (Hordeum vulgare L.) A prophetic food mentioned in Ahadith and its ethnobotanical importance American-Eurasian J Agric Environ Sci 2012 12(7):835-41.  [Google Scholar]

[17]. Sinha A, Meena A, Panda P, Srivastava B, Gupta M, Padhi M, Phytochemical, Pharmacological and therapeutic potential of Hordeum vulgare Linn.-A review Asian J Res Chem 2012 5(10):1303-08.  [Google Scholar]

[18]. Zhao H, Dong J, Lu J, Chen J, Li Y, Shan L, Effects of extraction solvent mixtures on antioxidant activity evaluation and their extraction capacity and selectivity for free phenolic compounds in barley (Hordeum vulgare L.) J Agric Food Chem 2006 54(19):7277-86.  [Google Scholar]

[19]. Duh P-D, Yen G-C, Yen W-J, Chang L-W, Antioxidant effects of water extracts from barley (Hordeum vulgare L.) prepared under different roasting temperatures J Agric Food Chem 2001 49(3):1455-63.  [Google Scholar]

[20]. Shah P, Parmar M, Thakkar V, Gandhi T, Protective effect of Hordeum vulgare linn. on acetaminophen-induced liver damage J Young Pharm 2009 1(4):336  [Google Scholar]

[21]. DeSandre RJWGH, Stevenson ESDK, Neonatal jaundice and liver disease. Fanarroff AA, Martin RJ Neonatal–Perinatal medicine 2006 8th edPhiladelphiaMosby:1419-66.  [Google Scholar]

[22]. Khalaf G, Mohamed A, Effect of barley (Hordeum vulgare) on the liver of diabetic rats: Histological and biochemical study Egypt J Histol 2008 2:245-55.  [Google Scholar]

[23]. Ayyappan S, Philip S, Bharathy N, Ramesh V, Kumar CN, Swathi S, Antioxidant status in neonatal jaundice before and after phototherapy J Pharm Bioall Sci 2015 7(Suppl 1):S16-S21.  [Google Scholar]

[24]. Sies H, Oxidative stress: from basic research to clinical application Am J Med 1991 91(3c):31s-8s.  [Google Scholar]

[25]. Sharafati R, Sharafati F, Rafieian-kopaei M, Biological characterization of Iranian walnut (Juglans regia) leaves Turk J Biol 2011 :635-39.  [Google Scholar]

[26]. Karimi A, Moradi MT, Total phenolic compounds and in vitro antioxidant potential of crude methanol extract and the correspond fractions of Quercus brantii L. acorn J Herbmed Pharmacol 2015 4(1):35-39.  [Google Scholar]

[27]. Rafieian-Kopaei M, Baradaran A, Rafieian M, Oxidative stress and the paradoxical effects of antioxidants J Res Med Sci 2013 18(7):628  [Google Scholar]

[28]. Rafieian-Kopaei M, Nasri H, Re: erythropoietin ameliorates oxidative stress and tissue injury following renal ischemia/reperfusion in rat kidney and lung Med Prin Pract 2014 23(1):95  [Google Scholar]

[29]. Madihi Y, Merrikhi A, Baradaran A, Rafieian-Kopaei M, Shahinfard N, Ansari R, Impact of Sumac on postprandial high-fat oxidative stress Pak J Med Sci 2013 29:340-45.  [Google Scholar]

[30]. Rafieian-Kopaei M, In vitro evaluation of antioxidant properties of ten Iranian medicinal plants Iran Red Crescent Med J 2014 16(6):e10264  [Google Scholar]

[31]. Rafieian-kopaei M, Shahinfard N, Rouhi-Boroujeni H, Gharipour M, Darvishzadeh-Boroujeni P, Effects of Ferulago angulata Extract on Serum Lipids and Lipid Peroxidation Evid Based Complement Alternat Med 2014 2014:680856  [Google Scholar]

[32]. Bahmani M, Zargaran A, Rafieian-Kopaei M, Saki K, Ethnobotanical study of medicinal plants used in the management of diabetes mellitus in the Urmia, Northwest Iran Asian Pac J Trop Med 2014 7:S348-S54.  [Google Scholar]

[33]. Bahmani M, Shirzad H, Majlesi M, Shahinfard N, Rafieian-Kopaei M, A review study on analgesic applications of Iranian medicinal plants Asian Pac J Trop Med 2014 7:S43-S53.  [Google Scholar]