Influence of Lime Juice on the Severity of Sickle Cell Anemia

Abstract

Background and objectives:

The pain in sickle cell anemia (SCA) is often triggered by dehydration, acidosis, and fever that are usually due to malaria. Intake of lime juice was recently demonstrated to facilitate clearance of the malaria parasite. It was therefore sought to determine whether regular intake of lime juice will ameliorate crisis, especially recurrent bone pain.

Design:

In this preliminary, open-labeled, randomized study, the effects of lime juice on the clinical and some laboratory characteristics of children with SCA were tested.

Results:

Among the 113 children with SCA studied in two hospitals, the 58 receiving lime treatment had lower rates of significant painful episodes than the 55 without lime (37 versus 83 crises in 6 months, and 0.64±0.11 versus 1.51±0.34 average rates per child, p<0.001). Also, fewer subjects than the controls had significant painful episodes (50.0% versus 92.7%); febrile illness (46.6% versus 87.3%) and admission rate (3.4% versus 34.5%) (p<0.001). The mean hematocrit of the subjects (26.23±2.03%) at the end of the study was also higher, p<0.001. However, transfusion rate, presence of hepatomegaly, splenomegaly, and jaundice was similar. Treatment with lime did not cause any significant side-effect.

Conclusions:

Regular intake of lime juice may be of great therapeutic and nutritional relevance in children with SCA.

Introduction

H emoglobin S results from replacement of glutamic acid, a hydrophilic amino acid by valine that is hydrophobic, at position 6 of the β-globin chain of hemoglobin moiety.¹ Children with sickle cell anemia (SCA) experience significant medical and psychosocial burdens.¹ They frequently have crises such as recurrent bone pains, anemia, infections, and end-organ damage. The disorder is one of the most common hereditary disorders among the black population of the world.² In Nigeria, where about 150,000 children are born with the disease annually, the prevalence ranged between 20 and 30 per 1000 live births.² Severity of the disease is commonly measured with some clinical and laboratory parameters such as frequency and severity of painful episodes, frequency of hospitalization and blood transfusion, and presence of hepatosplenomegaly and jaundice.^1,2

Some dietary constituents such as ascorbic acid, phenylalanine, and thiocyanate have been found to inhibit hemoglobin polymerization and are therefore useful in ameliorating symptoms in patients with SCA.³ However, these substances are abnormally low in patients with SCA.⁴ Lime (Citrus aurantifolia) is one of the readily available, very cheap, and frequently consumed juices in the southwestern part of Nigeria. It is rich in ascorbic acid and phenylalanine.⁵ Lime juice has also been shown recently to enhance malaria parasite clearance and offers the possibility of preventing an attack of malaria.⁶ The juice may therefore be useful for patients who need regular malaria chemoprophylaxis, especially those with SCA who are already deficient in the dietary constituents it richly contains. The objective of this study was therefore to determine changes, if any, in the clinical and some laboratory characteristics of children with SCA who were given lime juice on a daily basis for 6 months when compared with suitably matched controls.

Materials and Methods

This multicenter experimental study was carried out from July to December, 2011 at the pediatric hematology outpatient clinics of the University Teaching Hospital, Ado-Ekiti, Ekiti state, in southwestern Nigeria; and Aminu Kano University Teaching Hospital, Kano, in northwestern Nigeria. All consecutive children with SCA in stable state who were attending the hematology clinic of the hospitals for routine follow-up care were recruited. Informed consent was taken from the caregiver and/or the child when able to do so after thorough explanation of the reason(s) for the study. Also, ethical clearance was obtained from the Ethics and Research Committee of the two hospitals independently.

To qualify for recruitment into the study, the child must have attended the pediatric hematology clinic for at least 6 months prior to recruitment. In addition, the child must be in steady state (no painful episode, anemic crisis, or infection on the day of recruitment) and he/she was not on any other alternative medicine commonly used by some patients with SCA in Nigeria such as Aloe vera gel, Moringa oleifera, Solamine syrup, and Ciklavit (Cajanus cajal) suspension.⁷ Those taking hydroxyurea, Discriovite suspension and or Nicosan (Niprisan) capsule and those whose parent or caregiver did not give consent were also excluded from the study.

A structured questionnaire was used to obtain information on the sociodemographic characteristics of the child with sickle cell disease such as the age, sex, and the social class. Other data included frequency of hospitalization, blood transfusion, and significant pain episodes within the last 1 year. For the purpose of this study, a significant pain episode (or vaso-occlusive crisis) was defined as an acute painful event requiring treatment at a health care facility or at home with either (1) parenteral or an equianalgesic dose of oral narcotics or (2) parenteral or an equianalgesic dose of oral nonsteroidal anti-inflammatory drugs.^1,2

Ripe fruits of good quality were purchased from local markets at Ado-Ekiti and Kano, the capital cities of Ekiti and Kano States in Nigeria. The juice was then extracted using the L'Equip MINI Pulp Eject juice extractor. The children were divided into two groups based on a previously established block randomization list. The children in the first group were given the routine oral drugs for children with SCA (folic acid, vitamin B complex and proguanil) alone while those in the other group were given lime juice in addition to these routine drugs. Children weighing ≤10 kg were given 5 mL twice daily, those weighing 11–20 kg had 10 mL twice daily, and 15 mL twice daily for those with weight >20 kg.

After recruitment, each child was assessed monthly for a period of six month during which the frequency of significant pain episodes, febrile illnesses, presence of hepatomegaly, splenomegaly, pallor, jaundice, hospital admissions, and blood transfusions were recorded. In addition, monthly hematocrit and the serum bilirubin were monitored.

Data were analyzed with SPSS 17.0. Frequencies and proportions were determined as appropriate. The two groups were compared based on the frequency of significant pain episodes, febrile illness, hospitalization, blood transfusions, hepatomegaly, splenomegaly, and laboratory findings (hematocrit and serum bilirubin) by χ² test and independent t test. P<0.05 was accepted as statistically significant.

Results

A total of 125 children, comprising 65 subjects and 60 controls, respectively, were recruited for the study from the two hospitals. However, 12 (9.6%) comprising 7 subjects and 5 controls were excluded due to noncompliance either with intake of lime juice or follow-up visit. Hence, l13 children (58 subjects and 55 controls) were eventually studied over the 6-month period.

Sociodemographic characteristics of the subjects and the controls

There were 57 males and 56 females (male:female ratio of 1.01:1). The preschool children (1–5 years) were the most commonly represented age group, accounting for 52 (46.0%) of the children, followed by school-age children (36 [31.9%]), infants (15 [13.3%]), and adolescents (10 [8.8%]). The mean±standard deviation (SD) ages at diagnosis and presentation were 1.35±1.01 years and 4.74±2.13 years, respectively. About two thirds of them, 77 (68.1%), were from a lower socioeconomic class (IV and V) and the mean±SD weight and height of the children were 19.90±3.12 kg and 94.21±16.75 cm, respectively. As shown in Table 1, the subjects and the controls were similar in their baseline sociodemographic characteristics (p>0.05).

Table 1.

Sociodemographic Characteristics of the Subjects and the Controls

Sociodemographic characteristics	Subjects (N=58)	Control (N=55)	Total	p
Male n (%)	31 (53.4)	26 (47.3)	57 (50.4)	0.512^a
Female n (%)	27 (46.6)	29 (52.7)	56 (49.6)	0.512^a
Infants (<1 year)	8 (13.8)	7 (12.7)	15 (13.3)	0.867^a
Preschool (1–5 years)	31 (56.4)	21 (38.2)	52 (46.0)	0.104^a
School age (>5–10 years)	14 (24.1)	22 (40.0)	36 (31.9)	0.070^a
Adolescents (>10 years)	5 (8.6)	5 (9.1)	10 (8.8)	0.930^a
Upper social class (I–II)	16 (27.6)	20 (36.4)	36 (31.9)	0.317^a
Lower social class (III–V)	42 (72.4)	35 (63.6)	77 (68.1)	0.317^a
Mean±SD age at presentation	4.55±3.57	4.96±3.42	4.74±2.13	0.410^b
Mean±SD age at diagnosis	1.47±2.17	1.24±1.12	1.35±1.01	0.230^b
Mean±SD weight	18.86±7.81	21.0±15.45	19.90±3.12	0.351^b
Mean±SD height	95.63±19.93	92.71±26.37	94.21±16.75	0.507^b

χ² test.

Independent t-test.

SD, standard deviation.

Clinical parameters of the subjects and the controls before or at recruitment

As shown in Table 2, the total as well as the average number of significant painful episodes experienced by the subjects and the controls before their recruitment were not statistically different (p=0.665). Also, the number of subjects and the controls with clinical jaundice, hepatomegaly, and splenomegaly at recruitment were statistically similar (p>0.05). The number of previous admissions and transfusion were similar among the two groups of children with SCA.

Table 2.

Baseline Clinical Characteristics of the Subjects and the Controls

Baseline clinical characteristics before or at recruitment	Subjects (N=58)	Control (N=55)	Total	p
Jaundice at recruitment: n (%)	46 (79.3)	44 (80.0)	90 (79.6)	0.927^a
Hepatomegaly at recruitment: n (%)	12 (20.7)	8 (14.5)	20 (17.7)	0.392^a
Splenomegaly at recruitment: n (%)	21 (36.2)	18 (32.7)	39 (34.5)	0.697^a
Previous significant painful episodes
Number (%) of children	41 (70.7)	42 (76.4)	83 (73.5)	0.495^a
Total number of episodes	189	165	354
Mean±SD number of episodes	3.27±3.93	3.00±2.49	3.14±1.27	0.665^b
Previous hospitalization
Number (%) of children	29 (50.0)	32 (58.2)	61 (54.0)	0.383^a
Total number of hospitalizations	123	157	280
Mean±SD number of hospitalizations	2.12±2.67	2.85±2.56	2.48±1.15	0.141^b
Previous transfusion
Number (%) of children	33 (56.9)	29 (52.7)	62 (54.9)	0.656^a
Total number of transfusions	75	68	143
Mean±SD number of transfusions	1.29±0.77	1.23±0.74	1.26±0.55	0.674^b

n refers to number of children.

χ² test.

Independent t-test.

SD, standard deviation.

Clinical parameters of the subjects and the controls at the end of the study

Table 3 shows that fewer subjects than the controls had significant painful episodes (50.0% versus 92.7%), febrile illness (46.6% versus 87.3%) and hospitalization rate (3.4% versus 34.5%) during the study period (p<0.001). However, the rate of transfusion was not statistically different between the two groups (p=0.223). Also, at the end of the study, the number of children with jaundice (p=0.318), hepatomegaly (p=0.502) and splenomegaly (p=0.422) were similar. The total number of painful episodes (37 versus 83), febrile illness (27 versus 89), and admission rates (2 versus 19) were also fewer in the subjects than the controls during the period of study.

Table 3.

Clinical Characteristics of the Subjects and the Controls at the End of the Study

Clinical characteristics at the end of the study	Subjects (N=58)	Control (N=55)	Total	p
Jaundice at the end of the study: n (%)	41 (70.7)	34 (61.8)	75 (66.4)	0.318^a
Hepatomegaly at the end of the study: n (%)	10 (17.2)	7 (12.7)	17 (15.0)	0.502^a
Splenomegaly at the end of the study: n (%)	15 (25.9)	18 (32.7)	33 (29.2)	0.422^a
Painful episodes
Number (%) of children	29 (50.0)	51 (92.7)	80 (70.8)	<0.001^a
Total number of episodes	37	83	120
Mean±SD number of episodes	0.64±0.11	1.51±0.34	1.06±0.11	<0.001^b
Febrile illness
Number (%) of children	27 (46.6)	48 (87.3)	75 (66.4)	<0.001^a
Total episodes of febrile illness	27	89	116
Mean±SD episodes of febrile illness	0.47±0.25	1.62±0.20	1.03±0.21	<0.001^b
Hospitalization rate
Number (%) of children	2 (3.4)	19 (34.5)	21 (18.6)	<0.001^a
Total number of hospitalizations	2	19	21
Mean±SD number of hospitalizations	0.03±0.01	0.35±0.07	0.19±0.03	<0.001^b
Transfusion rate
Number (%) of children	0 (0.0)	3 (5.5)	3 (2.7)	0.223^a
Total number of transfusions	0	3	3

n refers to number of children.

χ² test.

Independent t-test.

SD, standard deviation.

Laboratory parameters of the subjects and the control before and after the study

As shown in Table 4, the baseline mean hematocrit and serum bilirubin of the subjects and the controls was similar (p=0.310 and 0.774, respectively). However, at the end of the 6-month study period, the mean hematocrit of the subjects (26.23%±2.03%) was significantly higher than that of the controls (23.67±1.74% [t=7.18, df=111, p<0.001]). Although the mean serum bilirubin of the subjects (44.38±11.90) was less than that of the control (48.29±9.30) at the end of the study period, the difference was not statistically different (t=1.94, p=0.055).

Table 4.

Laboratory Findings (Hematocrit and Serum Bilirubin) of Subjects and Controls at Recruitment and at the End of the Study

	Hematocrit (%)			Total serum bilirubin (mg/dL)
Period	Cases	Control	p	Cases	Control	p
Recruitment
Range	19–29	19–29		34–74	34–74
Mean±SD	24.43±3.04	24.95±2.31	0.310	50.70±10.54	51.29±11.21	0.774
At the end
Range	19–29	20–28		26.1–72.4	34.5–67.3
Mean±SD	26.23±2.03	23.67±1.74	<0.001	44.38±11.90	48.29±9.30	0.055

SD, standard deviation.

Discussion

This preliminary study focuses on the effects of lime juice (Citrus aurantifolia) on some clinical and laboratory characteristics of children with SCA. Children with SCA who were given lime juice for 6 months experienced fewer significant painful episodes than the controls. This finding gave credence to findings that lime juice is a good food supplement for people with SCA because of its high content of vitamin C and amino acids, particularly phenylalanine.^8
–10 It is also very rich in flavonoid compounds such as rutin and hesperidin, a glycoside of flavonone.¹⁰ Vitamin C is a potent antioxidant with proven antisickling properties.⁴ Phenylalanine has also been demonstrated to inhibit polymerization of deoxygenated hemoglobin S by about 95.9% in one in vitro study.¹⁰ The metabolites of flavonoid compounds are known to improve capillary blood flow and exert profound stabilizing effects on the membranes of the red blood cells, consequently reducing risk of sickling.¹⁰

Although many citrus, including Citrus aurantifolia, are acidic in vitro, when metabolized, they alkalinize the body.⁵ Foods can be considered alkaline or acidic based on the residues they produce in the body, rather than whether they are alkaline or acidic themselves. Limes are metabolized to alkaline residues because of their high alkaline potassium bicarbonate content.⁵ As demonstrated by Iweala et al.,¹¹ only the alkaline extracts of these citrus juices exerted a significant antisickling effect on hemoglobin S blood in vitro. This perhaps explains why lime juice in acidic medium did not exhibit significant antisickling properties.¹⁰

In this study, children with SCA and who took lime juice had less febrile illness and rates of hospitalization during the study period. In Nigeria, like most parts of sub-Saharan Africa, malaria infection is the leading cause of febrile illness, precipitant of bone pain crisis, and reason for hospitalization in children with SCA.^12,13 Hence, efforts at curtailing malaria infection will significantly reduce morbidities in this group of children. A previous study⁶ has shown that lime juice enhances clearance of the malaria parasite when taken with appropriate antimalarial drugs. In that study,⁶ the average time to achieve more than 75% reduction in parasite load was significantly lower in patients on artemisinin combination therapy (ACT) and lime juice than those taking ACT alone. Also, a significantly higher proportion of children taking antimalarial drugs and lime juice achieved complete parasite clearance by 72 hours of therapy, and none developed early treatment failure. The pain in SCA is often triggered by dehydration, acidosis, and fever, which are usually brought about by malaria. Intake of lime juice, in addition to enhancing malaria parasite clearance, also improves hydration and alkalinizes the body.

Since the two groups studied were comparable at baseline, the possible effects of diets on the severity of bone pain crisis would have been ameliorated. Most of the bone pains occurred at home, and only those severe enough to require analgesia were regarded as significant. However, the possible inaccuracy in pain rating by the parents or caregivers was not peculiar to one group, but to both groups of children studied.

Conclusions

In this preliminary clinical trial, regular intake of lime juice has been shown to reduce rate of bone pain crisis, febrile illness, and hospitalization. In Nigeria, like many other countries in the tropics where lime is abundant and cheap, this juice is recommended for children with SCA.

Footnotes

Acknowledgments

The authors are grateful to all those who assisted during the preparation of this article. Also acknowledged with thanks are all the mothers/caregivers and colleagues who were involved in managing and monitoring of these children.

Disclosure Statement

All the authors declare that there are no financial or commercial conflicts of interest.

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