NURS 3402 Evidence Based Nursing Research

Introduction 

The assignment is the outcome of aim to learn evidence based practice for implementation in future profession as children’s nurse.  Evidence based practice is the approach to make quality health care decisions based on best possible evidence. It will help deliver effective neonatal care for a clinical issue based on relevant research available combined with clinical expertise. Such practice in children nursing when integrated with patient values allows effective care. It will enhance the paediatric health outcomes (LoBiondo-Wood and Haber, 2017). Evidence-based practice is important in child health nursing as it allows for informed decision making and wise utilisation of health care resources.. It is useful to develop the attitude of inquiry and critical thinking skills. The assignment deals with the research question “What is the current evidence for providing nutrition in children with Crohn’s disease?”The rationale for choosing this research question is increasing burden of the disease and lack of suitable care pathway. Crohn’s disease is the lifelong gastrointestinal disorder commonly presented in children and in adulthood.  It is an emerging global disease and in Australia, the prevalence of this disease tends to be one of highest in world. In children it is as twice as likely to develop this disease.   This disease is of chronic nature and the symptoms such as inflammation of colon and flares are unpredictable in each child. Hence, it is also known as inflammatory bowel disease. The condition may affect all the parts of the digestive system without treatment. However, literature evidence shows efficacy of certain dietary recommendations in children as this disease greatly affects the nutrition and growth parameters (Vasseur et al. 2010; Wright et al. 2015). To address this research question literature review is conducted using electronic database with appropriate search strategy.  Based on literature review relevant articles will be selected for discussion. Further, the implications for practice using this evidence, will be discussed in brief.  

Search strategy

Search strategy is the organised structure to search the database using the set of terms that combines the concept of research question to extract relevant articles (Moher et al. 2015). The main aim of the search strategy is to identify the high quality research papers related to the research question.

The list of databases used for the research is the CINHAL, Medline, an Cochrane library. CINAHL stands for the Cumulative Index of Nursing and Allied Health Literature. According to Wright et al. (2015) CINHAL and CINHAL plus is the most in-depth nursing database for research. One can extract full text papers for 768 journals, and indexing for more than five thousand journals in the field of allied health and nursing along with citations that are otherwise are not available. Medline or Medical Literature Analysis and Retrieval System Online is the database with collection of the bibliographic information for articles in the field of life science and biomedical information. Academic journals are available for wide variety of areas such as nursing, medicine, pharmacy, veterinary, health care and dentistry. This database has more than 5600 publications and more than 26 million records. Both CINHAL and Medline are user-friendly and allows to conduct the database search in systematic manner using the Boolean operators and combine Mesh terms. One can filter the articles using the desired criteria   of inclusion and exclusion for extracting articles of specific journals, date, population, location, and language.  It is highly advantageous for small selections. For this research purpose, CINHAL is highly preferred due to personal inclination towards it. Cochrane library is used as it contains the collection of databases of systematic reviews and meta- analysis in different health care specialities.  It is the good source of evidence based medicine as it contains the results of the

 The inclusion and exclusion criteria were set accordingly to address the research question. Articles included are those published in English language and between 2010-2018. There is no specific criterion set for country and setting so as to collect sufficient evidence related to research question. It was ensured that the population on which the research conducted is children (paediatrics). Discussion, narratives reviews, qualitative studies and clinical guidelines are excluded along with articles published in language other than English. The research methodology included is systematic reviews, RCTs, observational studies such as case control and cohort studies.

The search terms used for the database search are- “nutrition”, “children”, “crohn’s disease”, “paediatric crohn’s disease”, “nutritional management”, “nutritional therapy”, “nutritional support”, and “children crohn’s disease”. After the pilot search, these terms were amalgamated with the Boolean operators.  In CINHAL database advance search mode was used while restricting it to the electronic resources and English language.  This refinement allowed narrowing down the search. Without refinement of date and language the number of articles initially retrieved is 533 and is arduous to review each of them.

The key words used for the search using the Boolean operator “AND” and “OR” are depicted in the table below-

On using the Boolean operators the search was narrowed to 80-90 hits. On using different sets of keywords with AND operator as well as other filters such as date, language, population, full text the search was reduced to 34 articles. Out of these articles only 8 were selected for literature review presentation. The rest were excluded as the research was still in progress and no conclusive data was available in 8 studies. 15 articles focused on corticosteroids along with nutritional therapy and 11 articles focused on use medical management in addition to nutrition including thiopurines. Further, analysis of only 6 out of 8 articles was conducted for discussion in literature review as they were highly relevant to address research question.  Two of the articles were excluded as because there was greater focus on anti-TNF combined with nutritional therapy focusing solely on nutrition enhancement during paediatric crohn’s disease and other articles how crohn’s diseases lead to growth failure. The remaining 6 articles were highly relevant as the main focus was on the evidence related to nutrition and reduction of symptoms of crohn’s disease in children.

Aim of the study

The study aimed to find out the effect of Enteral nutrition in children with Cronch’s disease. Enteral nutrition replaces the normal diet with a completely liquid diet for a definite period of time.

What was the study about?

The study elaborated the role of Exclusive Enteral Nutrition (EEN) in the management of CD. It aims to find out the mechanisms by which the various intervention methods act. However, there has been a speculation that compared to other CD therapies EEN is not that effective, which has been investigated through the article.

What was planned to be done?

The results obtained from the randomised control trial were to be compared for arriving at significant results.

How was it done?

An eight week course of EEN was started in children diagnose with IBD.  They were compared with a control group were the children were subjected to higher corticosteroids.  

What was found?

It was found though earlier studies that children with Cronch disease had vitamin D deficiency. The report showed that children with deficiency of vitamin D had higher corticosteroid level compared to the ones with normal vitamin D level. It was found after diagnosis that the mean serum vitamin D concentration was high in the group treated with EEN.

Implications for practice

There were large-scale implications in the implementation of EEN. The huge differences in the methods of application of EEN and the marked difference in results obtained made the clinical practitioners sceptical regarding the usefulness of the method.

Aim of the study

The study aims to find out the specific carbohydrate diet (SCD) which further complicates the symptoms of Crohn disease. This is because the nutritional therapy has been found to be effective in successfully carrying out the EEN.  Hence, the goal is to decrease intestinal inflammation by restoring the balance of bacteria within the bowels. This is relevant evidence to address the research question as the focus is on nutrition. Hence, this article was selected. 

What was the study about?

The study was aimed at finding out the specific carbohydrate diet and the manner in which it could restore or aggravate the Crohn’s disease within an individual, as many lactose rich diets were found to induce gastritis within the children. The study evaluates the possibilities of low complex carbohydrate therapies in the form of SCD for the treatment of paediatric Crohn disease.

What was planned to be done?

The medical records of patients with Crohn disease put on the specific carbohydrate diet was to be reviewed.

How was it done?

In this context, seven children with Crohn disease receiving the SCD and no immunosuppressive medications were evaluated. The duration of the diet therapy was ranged from 5 to 30 months. The symptoms for improvement of individual patients were followed up after an interval of 3 months.

What was found?

It was found that for each patient some of the laboratory indices including serum albumin,   C – reactive protein, hematocrit and stool calprotectin significantly improved during the following clinical visits. Hence, it could be possible therapeutic option for paediatric crohn isease.

Implications for practice

Further studies were required to fully evaluate the safety and the efficacy of the SCD, as small sample size  challenged the efficacy of the results.

Aim of the study

The study aimed at finding out the effect of six week EEN in children with active stage of the Crohn disease. The article also takes into consideration intestinal microflora function. Though, the mode of action of EEN in suppressing mucosal inflammation was not fully understood. The modulation of intestinal microflora by the therapy could be one possible explanation.

What was the study about?

The study was about finding out the plausible aetiology by which the gut microflora can enhance the chances of the contraction of CD within the children.  Corticiosteiods have been seen to control the effects of CD within a child. However, the use of the corticosteroids was questioned, as it had stunting effect on the growth of a child.

What was planned to be done?

In the current study faecal samples from 18 children were collected who had active CD. The short chain fatty acid was used as marker of gut microflora function.

How was it done?

The children were studies before and after the EEN treatment. Here, the results from 12 teenagers were used for comparison standards.

What was found?

It was found that 11 of the children responded positively to EEN treatment and showed decrease in the level of pro-inflammatory acetic acid along with increased concentrations of butyric acid which has anti-inflammatory effects.

Implications for practice

There is an unclear result which signifies the importance of the EEN in controlling the progression of Crohn disease.  The inflammatory responses have pointed towards the unequitable distribution of gut mircobiota, which are responsible for the development of inflammation bowel disease.  However, the process has been ineffective in children with perianal disease which is again caused by an inflammation caused due to increased population of hut microbiota. Therefore, further clinical research needs to support the data gathered through the present experiment.

Fourth article (Lambert et al. 2012)

Aim of the study

The study aimed to find the group outcomes for upto 24 months  following EEN in a group of children  with CD.

What was the study about?

The study aims to find the long term outcomes of EEN in paediatric CD as less details were available regarding the efficacy of the methods.

What was planned to be done?

Children treated with EED as initial therapy over a five years course were identified for the experiment purpose. Outcomes were compared with a group of children treated with corticosteroids.

How was it done?

Details of the disease activity, growth and drug requirements over long periods of time were followed up.

What was found?

It was found that children treated with EEN over corticosteroids had shown lower paediatric activity crohn’s disease index (PCDAI) scores and required low cumulative doses of steroids.  It was found that the group treated with EEN had lower incidents of relapse.

Implications for practice

There were limitations related to retrospective design which could interfere with the quality of the results. Hence, it opens the gateway for future research into comparison of long term and short term trials as small sample sizes could lead to confounding biases.

Fifth article (Shaikhkhalil and Crandall 2018)

Aim of the study

To evaluate the effectiveness of enteral nutrition that is liquid diet in children with crohn’s disease and its advantages.  

What was the study about?

 The study was outcome of increasing incidence of crohn’s’ disease in children and it high risk of complications related to nutrition and growth parameters. Diet is considered an important hallmark of lifestyle, for which the study tends to examine the efficacy of  liquid nutrition product given through tube feeding

What was planned to be done?

The plan was to identify the effectiveness of enteral nutrition, its advantages and barriers and solutions for its underuse in US.

How was it done?

 The aims of the study were fulfilled by conducting systematic review using several databases to analyse range of studies.  The results were evaluated for its reliability and validity.

What was found?

Enteral nutrition is highly effective in diminishing the side effects of corticosteroids while improving the growth factors and marinating remission. When compared with traditional medications, Enteral nutrition is more effective in mucosal healing. Despite these benefits it is largely underutilised in US.  The variation in protocol for administration route, cost, insurance coverage and poor awareness of this method are potential barriers.

Implications for practice

There are several limitations for use among providers however; the use may be increased by addressing the real and perceived barriers.  On further assessing the strength of evidence, parents may be advocated for Enteral nutrition in clinical setting and raise awareness among physicians.  Assistance in communicating with insurance companies may be enhanced.  Render greater support and give counselling to families using enteral nutrition therapy.

Sixth article (Gavin et al. 2018)

Aim of the study

The study aimed to find the potential of Maintenance enteral nutrition as a supplement for preventing the growth delay and poor nutritional status in poor nutritional status.

What was the study about?

The study as all about children diagnosed with Crohn’s disease and assessment of impact of nutrition supplementation.

What was planned to be done?

 The cohort study planned to collect data from large unselected paediatric population that will include collection of anthropometric data as well as results of using the Maintenance enteral nutrition.  It was planned to recruit the heterogeneous group of population and represent real-life, cohort of patients

How was it done?

The patients newly diagnosed with crohn’s disease was recruited (102, age 13 years) who have completed exclusive enteral nutrition (EEN) as induction therapy as well as Maintenance enteral nutrition (MEN). The data collection includes taking the outcomes of Anthropometry, and treatments for 12 months. The participants were evaluated by subjecting them to two different groups one is “EEN: Steroid primary treatment group” and the other is “MEN: ND (normal diet) treatment group”.

What was found?

Maintenance enteral nutrition when taken after induction therapy increased -BMI Z-score over 12 months and it was not found to associated with prolonged time to relapse if compared with consumption of normal diet and steroids. EEN and steroids were equally efficacious and have comparable rates of relapse. They equally induced clinical remission.

Implications for practice

There is a need of prospective study to further assess the utility of Maintenance enteral nutrition. Results should have been subjected for statistical analysis and identify significance.  This area calls for prospective, long-term paediatric studies in future to determine the efficacy of prolonged nutritional support through MEN and assess long term growth benefits for use in practice.  

Comparison of articles and rationale for selection

 The article by Day et al. (2015) is chosen as it focused on EEN and  remission in children with active crohn’s disease and is the cause of preferring this article as it will address the research question. It will help in understating how to replace the normal diet of children. In similar other article by Suskind et al. (2014) there was focus on carbohydrate based diet to subside the intestinal inflammation. On the other hand the Tjellström et al. (2012), explained the mechanism by which EEN exhibit the anti-inflammatory effect while overcoming the side effects of corticosteroids and negative effects of it in growth. This was however not covered by Day et al. (2015) and Suskind et al. (2014). These studies also failed to explain the long term consequences EEN in a group of children with CD.  The above studies mainly focused on the short term trial of the EEN and on small sample sizes.  However, Lambert et al. (2012) addressed this gap by taking into consideration big sample size and focused on long term effects of EEN. The above studies failed to focus on the barriers in implementing the EEN. However, Shaikhkhalil and Crandall (2018) indentified both barriers and solutions to effective implementation of EEN.  Further, the rationale for choosing the article by Gavin et al. (2018) is the focus on preventing the growth delay in children with CD through Maintenance enteral nutrition. Moreover it presented comparative results with Steroid primary treatment group and normal diet.  It was found that these articles better addressed the research questions than the Lee et al. (2015), which gave inconclusive data on the CD treatment in children with anti TNF therapy. Therefore, it was not considered for review. Similarly, Vasseur, focused on young boys with CD and prevention of inflammation. Therefore, it was excluded from review for not answering research question. 

Conclusion

It can be concluded from the literature that crohn’s disease greatly impairs the nutritional and growth parameters in children. There is growing body of evidence regarding the high effectiveness of exclusive enteral nutrition therapy in decreasing disease symptoms. Only six articles were selected for literature review owing to high relevance.  Exclusive enteral nutrition has been considered more beneficial when compared with effectiveness of steroids, specific carbohydrate diet, normal diet and others. It can be recommended as first line therapy as it allows high rate of remission, improve growth parameters. It improves the condition caused by malnutrition due to crohn’s disease.  There are fewer side effects like nausea and vomiting.   It helps with mucosal healing, and promotes good bone health. There is no detailed mechanism of action available, however, it is found to interact with inflamed gut. The evidence from last 8 years shows greater disease control with Exclusive enteral nutrition, improvement in growth patterns and prevent growth failure. If this therapy is followed by maintenance enteral nutrition, there is less relapse with high increase in improvement in BMI Z-score. The benefits of this therapy implies to be promoted for greater use in nursing care. However, there are several barriers to effective implementation of this nutritional support as first line therapy.  It mainly includes cost, lack of insurance coverage, poor awareness among physician about effectiveness of Exclusive enteral nutrition therapy and its low side effects. There is still a greater preference for use of corticosteroids. Thus, it implies for increasing counselling programs to educate parents and families to consider this therapy as well as recommend physicians for using this therapy instead of corticosteroids.  There is a need of greter assessment of this therapy with prospective study using participants from different locations. There is need of active partnerships with insurance companies and other health care providers to overcome barriers to this therapy.

Implications for practice

 As a child nurse one may advocate the parents and the families about the exclusive enteral nutrition and support them through counselling.  Child nurse can educate them about the various benefits of such nutrition like improvement in growth rate and decrease in remission.   The children’s nurse will disseminate this information and promote such nutritional therapy in collaboration with physicians, social workers, and insurance companies.

 The further information that is required to know if there is further development in this field is to better understand the short and long term outcomes of this nutrition support.  There is a need of understanding how can the EEN protocols be individualised and optimised and reduce the side effects.

This area was not well known before research. It can be said that evidence based practice helps to keep up with rapidly growing and changing health care information. It will help paediatric nursing significantly. It is useful to change my practice based on updated information related to paediatric crohn’s disease and efficacy of nutritional support.  Nurses will able to refine strategies for care delivery for crohn’s disease and nutritional management.

 The process of searching helps to update the recent information on a given clinical issue. This research on nutritional evidence on the Crohn’s disease in children helped to develop insights into effectiveness of the enteral nutrition. A nurse can assess the perceptions of the family members and relatives about the enteral nutrition and address any concerns. It implies for paediatric nurses to help organisations to set guidelines related to provision of enteral nutrition therapy.  Using this information searching process a nurse can partner with physicians and pharmacy if the strength of the evidence is high to translate the evidence into practice. It will implement the safe child care during crohn’s disease.  Paediatric nurse can effectively plan the practice using the latest evidence for sustainable improvement. Paediatric care practice in future hence, will delivery  high quality care for children with crohn’s disease using suitable evidence.

References

Day, A.S. and Lopez, R.N., 2015. Exclusive enteral nutrition in children with Crohn’s disease. World Journal of Gastroenterology: WJG, 21(22), p.6809.

Gavin, J., Ashton, J.J., Heather, N., Marino, L.V. and Beattie, R.M., 2018. Nutritional support in paediatric Crohn’s disease: outcome at 12 months. Acta Paediatrica, 107(1), pp.156-162.

Lambert, B., Lemberg, D.A., Leach, S.T. and Day, A.S., 2012. Longer-term outcomes of nutritional management of Crohn’s disease in children. Digestive diseases and sciences, 57(8), pp.2171-2177.

Lee, D., Baldassano, R.N., Otley, A.R., Albenberg, L., Griffiths, A.M., Compher, C., Chen, E.Z., Li, H., Gilroy, E., Nessel, L. and Grant, A., 2015. Comparative effectiveness of nutritional and biological therapy in North American children with active Crohn’s disease. Inflammatory bowel diseases, 21(8), pp.1786-1793.

LoBiondo-Wood, G. and Haber, J., 2017. Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences.

Shaikhkhalil, A.K. and Crandall, W., 2018. Enteral Nutrition for Pediatric Crohn’s Disease: An Underutilized Therapy. Nutrition in Clinical Practice.

Suskind, D.L., Wahbeh, G., Gregory, N., Vendettuoli, H. and Christie, D., 2014. Nutritional therapy in pediatric Crohn disease: the specific carbohydrate diet. Journal of pediatric gastroenterology and nutrition, 58(1), pp.87-91.

Tjellström, B., Högberg, L., Stenhammar, L., Magnusson, K.E., Midtvedt, T., Norin, E. and Sundqvist, T., 2012. Effect of exclusive enteral nutrition on gut microflora function in children with Crohn’s disease. Scandinavian journal of gastroenterology, 47(12), pp.1454-1459.

Vasseur, F., Gower-Rousseau, C., Vernier-Massouille, G., Dupas, J.L., Merle, V., Merlin, B., Lerebours, E., Savoye, G., Salomez, J.L., Cortot, A. and Colombel, J.F., 2010. Nutritional status and growth in pediatric Crohn’s disease: a population-based study. The American journal of gastroenterology, 105(8), p.1893.

Wright, E.K., Kamm, M.A., Teo, S.M., Inouye, M., Wagner, J. and Kirkwood, C.D., 2015. Recent advances in characterizing the gastrointestinal microbiome in Crohn’s disease: a systematic review. Inflammatory bowel diseases, 21(6), pp.1219-1228.

Wright, K., Golder, S. and Lewis-Light, K., 2015. What value is the CINAHL database when searching for systematic reviews of qualitative studies?. Systematic reviews, 4(1), p.104.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.