1. Background
A significant number of babies are jaundiced in the first days after birth due to hyperbilirubinemia. According to published statistics, up to 60% of full-term babies develop jaundice during their first week of life, while 80% of premature babies develop jaundice during their first week of life (1). The leading cause is the breakdown of fetal erythrocytes along with the immaturity of the liver in removing excess bilirubin due to the low activity of glucuronyl transferase enzyme (2). Various maternal and neonatal factors have been identified as the triggers for neonatal physiological jaundice, including ethnicity (higher rate in East Asian and American Indian races), geographical characteristics (living in higher altitudes), genetic variants, and familial susceptibility, nutrition (breastfeeding and inadequate feeding volume), mothers' comorbidities (diabetes mellitus), congenital infection, and prematurity (3-5). The optimal management of neonatal jaundice can lead to an excellent prognosis; however, in some cases and due to severe hyperbilirubinemia-related side effects such as kernicterus or underlying G6PD deficiency, the risk of neonatal death can be increased (6). In this regard, various treatments have been proposed for neonatal jaundice. As acceptable medical approaches, phototherapy, intravenous immune globulin (IVIG), and exchange transfusion are used to manage this complication (3, 7). However, these protocols have potential complications. In this regard, retinal damage, DNA-strand breakage, skin blood flow disturbances, hypocalcemia (in phototherapy), anemia, neurotoxicity, and hemolytic disorders (in IVIG and exchange transfusion) can be expected (8, 9). For this reason, many parents and even physicians choose to use other methods, especially herbal medicine. One of these plant compounds that are used abundantly, especially in eastern countries, is Purgative Manna (10). Bilineaster is another compound, a genus of woody plants from the rose family. This plant is a native of the long-northern habitat (temperate regions of Asia, Europe, and North Africa), and its types are concentrated in the southwestern mountains of China and the Himalayas. Experimental and traditional evidence indicate the effectiveness of this drug in treating neonatal jaundice, and the primary mechanism of its effectiveness is its laxative effects (11). However, based on some clinical evidence, the consumption of this substance itself can have significant neonatal risks, such as severe diarrhea and vomiting and even necrotizing enterocolitis, especially in preterm infants (12). The opinion of parents, family, and even the medical staff regarding the effectiveness and effects of this substance on babies with jaundice is equally important. However, the leading advocates of this drug regimen and whether there are specific guidelines for its use remain unclear. Many traditional societies believe that even without the need for the advice and consultation of doctors, this combination is entirely safe. Doctors and pharmacists may allow families to use this substance for babies in some cases. Therefore, it is imperative to identify the main recommenders of this compound and elucidate on what basis they recommend using this substance.
2. Objectives
The present study investigated the role of people in recommending the use of herbal drugs in the treatment of infant jaundice.
3. Methods
The format of the present cross-sectional study was designed and implemented based on interviews with parents of infants suffering from infantile jaundice using herbal drugs admitted to the Children’s Medical Center of Tehran, Iran, in 2019 and 2022. Initially, the parents of 94 babies with neonatal jaundice who were referred to the hospital and used herbal drugs were interviewed at the beginning of hospitalization. In addition to collecting basic and background information related to the patient, data regarding who recommended the drug for the baby were collected. The background information that was assessed included the demographic information (gender, birth weight, age, and weight at the time of using herbal drugs), type of nutrition (formula or breastfeeding), type of delivery, and information related to social status (level of education), economic condition (income level) of the family, and complications. Herbal drugs are natural ingredients from plant parts, such as leaves, roots, or flowers, for treating infantile jaundice. The main recommenders of the use of herbal drugs for the treatment of neonatal jaundice were classified into five groups, which included parents, neighbors, grandparents, doctors, and pharmacists. The purpose of this study was to determine the role of the mentioned people as recommenders of using herbal drugs and investigate the relationship between this treatment recommendation and families' socioeconomic status.
For statistical analysis, results were presented as mean ± standard deviation (SD) for quantitative variables and were summarized by frequency (percentage) for categorical variables. The categorical variables were compared using the chi-Square or Fisher's exact tests. The statistical software SPSS version 23.0 for Windows (IBM, Armonk, New York) was used for the statistical analysis.
3.1. Ethics Code
This study was approved by the Ethics Committee of Tehran University of Medical Science, and the Ethics Code is IR.TUMS.CHMC.REC.1400.175.
4. Results
The baseline characteristics of study subjects are summarized in Table 1. In total, the parents of 94 neonates who had jaundice and used herbal drugs (43 males and 51 females) were interviewed. Regarding the fathers’ education, 35.1% had diplomas, and 64.9% had academic degrees. Regarding monthly income, 46.8% had low monthly incomes (less than 50 million Rials), 33.0% had moderate incomes (50 - 100 million Rials), and 20.2% had proper incomes (higher than 100 million Rials). Also, 33.0% of parents had a history of smoking.
Table 1.Baseline Characteristics of the Study Population a
| Variables | Values |
|---|---|
| Gender of neonate | |
| Male | 43 (45.7) |
| Female | 51 (54.3) |
| Type of feeding | |
| Formula | 35 (37.2) |
| Breast milk | 59 (62.8) |
| Term condition on delivery | |
| Preterm | 59 (62.8) |
| Term | 33 (35.1) |
| Type of delivery | |
| Vaginal | 64 (68.1) |
| Cesarean | 30 (31.9) |
| Mean gestational age (week) | 36.91 ± 1.36 |
| Mean birth weight (g) | 3506.06 ± 290.64 |
| Mean weight at the time of herbal drug use | 3256.06 ± 475.43 |
| Neonate age at the time of herbal drug use | 6.91 ± 6.28 |
| Fathers’ education level | |
| Diploma | 33 (35.1) |
| Higher degree | 61 (64.9) |
| Economic status of the family | |
| Low | 44 (46.8) |
| Moderate | 31 (33.0) |
| High | 19 (20.2) |
| History of smoking | 31 (33.0) |
a Values are presented as mean ± SD or No. (%).
Regarding the role of people in recommending the use of herbal drugs, in 52.1% of cases, the main recommenders were the relatives. In comparison, the parents' role in recommending this compound's consumption was 25.5%. Also, 6.4% of the neighbors of the patient's family were the main recommenders to use herbal drugs for the neonates. Interestingly, 4.3% of doctors and 11.7% of pharmacists were involved in recommending herbal drugs to treat infant jaundice.
In comparing the background characteristics between two groups of parents who had recommended the use of herbal drugs for the neonates and parents who did not recommend the use of this compound (Table 2), we observed no difference in educational levels. However, parents who recommend using herbal drugs for their neonates had significantly lower economic levels (P = 0.046). Also, smoker parents were more likely to recommend this compound to treat infantile jaundice (P = 0.002). Poor feeding and dehydration were the most common complications in these neonates (22.3% and 24.4%, respectively), and necrotizing enterocolitis (NEC), hypernatremia, and vomiting were other less common complications (Table 3).
Table 2.Baseline Information in Parents with and Without Recommendation to use Herbal Drugs
| Characteristics | Parents as Recommender, No. (%) | Parents as Non-recommender, No. (%) | P-Value |
|---|---|---|---|
| Fathers’ education level | 0.202 | ||
| Diploma | 11 (45.8) | 22 (31.4) | |
| Higher degree | 13 (54.2) | 48 (68.6) | |
| Economic status of the family | 0.046 | ||
| Low | 15 (62.5) | 29 (41.4) | |
| Moderate | 3 (12.5) | 28 (40.0) | |
| High | 6 (25.0) | 13 (18.6) | |
| History of smoking | 0.002 | ||
| Smoker | 14 (58.3) | 17 (24.3) | |
| Non-smoker | 10 (41.7) | 53 (75.7) |
Table 3.Frequency of Complications of the Study Population
| Complications | No. (%) |
|---|---|
| Dehydration | 23 (24.4) |
| Poor feeding | 21 (22.3) |
| NEC | 15 (16) |
| Diarrhea | 12 (12.8) |
| Hypernatremia | 8 (8.5) |
| Vomiting | 6 (6.4) |
Abbreviation: NEC, necrotizing enterocolitis.
5. Discussion
Physiological jaundice, in most cases, is a benign phenomenon but may concern parents. Due to insufficient knowledge of parents, especially in underdeveloped countries, dealing with neonatal physiological jaundice is always difficult, and sometimes, it is associated with resorting to unapproved and unsafe treatment methods. Reliance of parents of babies with jaundice on traditional and experimental treatment approaches, which sometimes cause morbidity and even mortality in the baby, originates from several factors, the most important one being high trust and confidence in the experiences of others, especially parents, relatives, and even the neighbors. The people around the parents of the affected baby sometimes do not refrain from giving non-scientific treatment recommendations and suggestions. Trusting the opinions of non-specialists makes parents unwilling to refer to specialists to manage their patients. Another reason for turning to the advice of others in the treatment of neonatal jaundice is the cost-effectiveness of these methods compared to conventional ones and scientific treatment methods. Traditional medicine interventions are less costly than other methods in the treatment of diseases (13). The use of Purgative Manna in the treatment of infantile jaundice is quite common in Iranian society (10). Meanwhile, the majority of users and recommenders of this herbal medicine believe that these substances are completely safe and do not have any side effects. On the contrary, this combination may have life-threatening side effects (14). A series of studies have explored the effects of treatment with herbal medicines in reducing bilirubin levels (15). It is crucial to investigate the potential side effects of these medicines in patients while also closely monitoring the weight gain of babies, considering that dehydration and poor feeding were common complications associated with the use of herbal drugs in our study (12). However, the case can become more complicated when a significant part of the treatment staff, including doctors and pharmacists, become the main recommenders of herbal drugs in the treatment of neonatal jaundice. As in our study, doctors and pharmacists constituted 16% of those recommending the use of this substance to treat infantile jaundice. This shows the incomplete and defective knowledge of the benefits and harms of herbal drugs in the management of neonatal jaundice. Therefore, the treatment staff should be strongly advised to obtain comprehensive scientific information about this therapeutic combination for managing infants with neonatal jaundice.
Another finding of our study was regarding the role of economic and livelihood status in recommending the use of herbal drugs to treat neonatal jaundice. Firstly, the recommended consumption of herbal drugs was significantly higher in families from a lower economic status. Secondly, this recommendation was significantly higher among smoker parents than non-smokers (currently, in our society, smoking is a profile for a lower social level). Obviously, in the opinion of non-experts, dealing with jaundice in babies can have a close relationship with the socioeconomic level of families (16). Of course, we did not find a relationship between the recommendation to use herbal drugs and the education level of parents, which is because all participants in the study had at least a diploma, and under-graduated people were not included in the study. Therefore, radio and other media platforms are essential tools for providing information to parents about the potential side effects of herbal drugs in neonates.
5.1. Conclusions
In conclusion, relatives, parents, grandparents, and even neighbors play a significant role in recommending the use of herbal drugs in the treatment and control of neonatal jaundice. Interestingly, the role of doctors and pharmacists in recommending the use of this compound in the treatment of jaundice cannot be underestimated, as 16% of those recommending the use of this substance in the treatment of jaundice were healthcare professionals. Considering the numerous reports of the potential side effects of this herbal drug in the treatment of neonatal jaundice, it is necessary to improve the level of knowledge and understanding of all people in society at different levels regarding the benefits and harms of this substance.
