2.1 Methods

A pilot interventional study on children with SCD was conducted at King Fahd Medical Research Center (KFMRC), King Abdulaziz University, Jeddah. The demographics and anthropological data of enrolled patients are presented in Tables 1 and 2 respectively. Criteria for sample selection were also based on practicality, availability of patients, procurement of clinical data and patient’s consent. Since we were conducting the study on children, the sample size of our patients mainly depended upon acceptance of patient’s guardians for participation. A control or placebo group could not be included in the study owing to non-compliance. Therefore, the patients’ pre supplementation values were considered as their controls.

2.2 Ethical consideration

The study was approved by the institutional ethical committee of King Abdulaziz University (no.2/36/8390). Written consents were obtained from parents/guardians of the patients.

2.3 Inclusion criteria

Male and female children with SCD in a steady state, 5–16 years of age, approximately matched with weights were included in the study. Steady state was defined as steady hemoglobin and hematocrit levels for more than 3–4 weeks. There was no bias due to composite physical traits of different ethnicities contributing to the patient’s phenotype.

2.4 Exclusion criteria

Patients less than 5 years of age and above 16 years of age, having undergone any blood transfusions within the last ten weeks prior to getting enrolled for the study; presence of other chronic diseases; or diagnoses other than VOC, or prior treatment with HU, in the previous 10 weeks, were excluded.

2.5 Supplementation

Children were given oral omega-3 mango flavored syrup (BRAINWISE from SPB Laboratories, HP, India) according to their body weights. Children of body weight 11–24 kg were given 2 teaspoons oral omega-3 syrup every day and those having body weights 25 kg and above were supplemented with 3 teaspoons every day. Each teaspoon contained 190 mg of DHA, and EPA 250 mg. No other dietary recommendations were prescribed along with the supplement administered.

The use of HU may affect the frequency and severity of vaso-occlusive crisis. Therefore only those patients who were not taking hydroxyurea were enrolled for our study.

2.6 Clinical data and hematological parameters

Standard clinical parameters were assessed and recorded by the clinician at the hospital during their check-up, along the course of the study. Breathing problems include breathlessness due to chest infections and shortness of breath; abdominal pain—refers to stomach cramps and severe stomach pain at times; renal complications include renal papillary necrosis and renal medullary carcinoma; splenomegaly refers to spleen enlargement; bed wetting problems refer to the incontinence issues faced; eye problems include conjunctivitis, and itchy eyes; and dental problems include dental caries.

Five ml blood was collected before and after supplementation. A complete blood count was done using a Sysmex KX-21 automated cell counter (Sysmex Corporation, Kobe Hyogo, Japan).

2.7 Fatty acid analysis

Blood collected (3 ml) in non-EDTA tubes, was allowed to stand for half an hour and then centrifuged at 3000 rpm for 15 min. to obtain serum fraction as supernatant. Methyl esters were prepared using anhydrous methanolic HCl and the resultant esters extracted in hexane (Ichihara and Fukubayashi, 2010; Ren et al., 2013) and dried using nitrogen gas. The methyl esters were then re-suspended in 50 μl of chloroform and 1 μl sample injected and analyzed by gas chromatography performed on an Agilent 6890 gas chromatograph using a Omegawax®, column (30 m × 0.25 mm I.D., 0.25 µm). Helium was the carrier gas set at a flow rate of 1.0 ml/min. A flame ionization detector was used with a column oven temperature initially held at 140 °C for 1 min, programmed at 5 °C rise/minute up to 200 °C. After a 3.0 min hold, temperature was increased to 215 °C with a 5 °C /min heating ramp for 5 min. This temperature was finally increased to 240 ⁰C with a 10 °C/min for 10.5 min. Injector and detector temperature were kept at 220 °C and 200 °C respectively. Injection was done in a split mode of (20:1) and the run time was 35 min. Peak identification was done by retention time matched to standards. The data was presented as percent of the total fatty acids, and compared with appropriate standards (Masood et al., 2005).

2.8 Psychological parameters

Assessment of Intensity of pain -The pain indices were checked using the Wong Baker faces pain scale. (Chambers et al., 1999; von Baeyer, 2006; Wong et al., 2001; Wong and Baker, 1988). Pain was measured on a scale of 1–10; where ‘0′ denotes - no pain, 1–3 denotes low pain, 4–6 denotes moderate pain, and 7–10 denotes extreme pain. Frequency of pain was measured by the number of episodes in the past six months in different ranges (range 1 with one pain episode; range 2 with 2–5 pain episodes and range 3 with 6–10 episodes).

2.9 Statistical analysis

Mean values of the variables along with their standard deviations were analyzed using the statistical software SPSS16 for a paired t-test. P value of <0.05 was considered as statistically significant.

3.1 Clinical picture

At the inception of the study, all patients experienced the same complications, crisis and other clinical features (Table 3). Data on their hospitalizations could not be collected due to insufficient procurement procedure. No adverse reaction was observed by the children whatsoever, except for gastric upset in three children at the beginning of the study, which subsided in 2–3 days. Also, no bleeding events were observed throughout the supplementation period.

During the six months of omega-3 supplementation, patients reported lesser complications, tolerable pain, fewer infections, and fewer visits to the hospitals. Moreover, management for the fewer complications like head ache, body ache, slight fever, cold etc. could be done by the parents of patients at home by giving medications for a very short duration. No hospital admissions were required. A general positive influence of omega-3 supplementation on the clinical symptoms of the patients was visibly noticed.

3.2 Hematological parameters

Most of the children enrolled were severely anemic (Hb < 8) with only a few being moderately anemic (Hb 8.0–10.9). Supplementation caused an increase in hemoglobin concentration significantly with a p value of 0.045 as seen in Table 4. The concentration of MCHC was increased significantly from 32.390 ± 1.500 to nearer the normal range 33.690 ± 2.19 with a p value of 0.02. Red cell distribution width (RDW) decreased significantly with a ‘p ‘value of 0.000. Other parameters like hematocrit (HCT), red blood cells (RBC), platelet count, mean corpuscular hemoglobin (MCH), mean corpuscular volume (MCV), and white blood cells (WBC) did not alter significantly.

3.3 Omega-3 fatty acids

No appreciable reduction of saturated fatty acids was observed as seen in Table 5. Nonetheless, there was a subsequent decrease in the omega-6 to omega-3 fatty acid ratio. There was an increase in the omega-3 fatty acids EPA and DHA after supplementation, but it was not significant. A decrease in the omega-6 fatty acid arachidonic acid (AA) was significant with a p value of 0.03. But the reduction in total sum of omega-6 concentrations, was not significant. The only omega-6 fatty acid which increased was gamma linolenic acid (GLA) which is an anti-inflammatory fatty acid and is known to possess immense health benefits.

3.4 Psychological parameters

All children enrolled in our project experienced immense pain when assessed on a scale of 1–10 as well as the faces pain scale at the commencement of the study (Fig. 1). It was observed that the pain was accompanied with negativity and a feeling of hopelessness. The number of crises experienced was in the higher range at the start of the study. Post supplementation, most of the children were in the no pain range with the number of pain episodes also decreased (Fig. 2). None of the patients required hospitalization during the few pain crises experienced during the entire supplementation period.

Close

Fig. 1

Pain levels in children with sickle cell disease supplemented with omega-3 fatty acids.

Export to PPT

Close

Fig. 2

Pain episodes in children with sickle cell disease supplemented with omega-3 fatty acids.

Export to PPT

4.1 Limitations of the study

One of the biological variables that modulates the severity of this disease is the concentration of HbF in blood, which was not analyzed in our study.

4.2 Future follow up studies

The increases in active vitamin D by omega-3 fatty acids when supplemented along with vitamin D to patients with cardiovascular problems, could possibly be responsible for the subsequent cardio protective effects observed (Lee et al., 2015; Manson et al., 2012). Also the role of vitamin D in selectively targeting cancer cells by its interaction with Cu(II) ions (Rizvi et al., 2015) and bio-synthesized silver nanoparticles (Azmi et al., 2021) are worth mentioning. These studies could give insights in planning future researches.

It would be interesting to note the differences if any, are observed, in the blood as well as clinical picture of SCD patients of varying genotypes. More structured follow up studies with a control group, different dosage, larger sample size, and different time periods of supplementation of omega-3 fatty acids are warranted, for consolidating the results obtained.

CRediT authorship contribution statement

Shahida Khan: Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Data curation, Investigation, Formal analysis, Validation, Writing – original draft, Writing – review & editing. Ghazi Damanhouri: Conceptualization, Methodology, Project administration, Resources, Supervision, Investigation, Formal analysis, Validation, Writing – review & editing. Tahir Jameel Ahmed: Methodology, Project administration, Resources, Investigation, Formal analysis, Validation, Writing – review & editing. Saeed Halawani: Resources, Investigation, Formal analysis, Validation, Writing – review & editing. Ashraf Ali: Data curation, Investigation, Formal analysis, Validation, Writing – review & editing. Ahmad Makki: Data curation, Investigation, Formal analysis, Validation, Writing – review & editing. Sarah Khan: Methodology, Data curation, Investigation, Formal analysis, Validation, Writing – review & editing.