Integrating Evidence-based Patient Decision Support in Nursing Curriculum

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies. Demirseren, M., & Gokrem, S. (2004). Circumcision in unqualified hands: A A significant risk of complication [Electronic version]. The Journal of the American Society of Plastic Surgeons, 113(3): 1090 -1092. No Abstract available Healthwise. (2012). Circumcision: Should I keep my son's penis natural? Retrieved 2013-Nov-7 from http://decisionaid.ohri.ca/AZsumm.php?ID=1035 Learman, L. (1999). Neonatal circumcision: A dispassionate analysis [Electronic version]. Clinical Obstetrics and Gynecology, 42(4): 849-859. Abstract: This review provides a dispassionate analysis of the evidence on the benefits and risks of neonatal circumcision. The evidence is considered within a clinically relevant framework in which decision-making relies on three interrelated factors: 1) clinical experience, 2) scientific evidence, and 3) patient preference. The roles of patient preference and clinical experience are outlined; then health benefits, risks, and economic costs of circumcision are explored. The most commonly proposed benefits of circumcision are prevention of penile inflammatory disorders, urinary tract infections, penile cancer, and sexually transmitted diseases. Meanwhile, the short-term risks of circumcision include surgical complications and the infliction of pain and distress on the neonate. A potential long-term consequence of the procedure is sexual dysfunction. In considering the cost-effectiveness of circumcision, the following areas are taken into account: 1) economic data on the direct and indirect cost of the procedure and subsequent care, 2) valid estimates of the probability of events prevented and events cause by the intervention, and 3) an accurate estimate of the circumcision's impact on health status. Evidence of the technical aspects of circumcision, namely, the surgical and anesthetic techniques, are also reviewed. This review provides a dispassionate analysis of the evidence on the benefits and risks of neonatal circumcision. The evidence is considered within a clinically relevant framework in which decision-making relies on three interrelated factors: 1) clinical experience, 2) scientific evidence, and 3) patient preference. The roles of patient preference and clinical experience are outlined; then health benefits, risks, and economic costs of circumcision are explored. The most commonly proposed benefits of circumcision are prevention of penile inflammatory disorders, urinary tract infections, penile cancer, and sexually transmitted diseases. Meanwhile, the short-term risks of circumcision include surgical complications and the infliction of pain and distress on the neonate. A potential long-term consequence of the procedure is sexual dysfunction. In considering the cost-effectiveness of circumcision, the following areas are taken into account: 1) economic data on the direct and indirect cost of the procedure and subsequent care, 2) valid estimates of the probability of events prevented and events cause by the intervention, and 3) an accurate estimate of the circumcision's impact on health status. Evidence of the technical aspects of circumcision, namely, the surgical and anesthetic techniques, are also reviewed. Little, D. C., Cooney, D. R., & Custer. (2002). Pediatric circumcision and release of phimosis Operative Techniques in General Surgery, 4(3), 251-259. Abstract: Neonatal circumcision remains a common, yet controversial surgical procedure. On the one hand, existing scientific evidence demonstrates some potential medical benefits of newborn circumcision. On the other hand, the scientific studies and data to date have not demonstrated a clear risk: benefit ratio resulting in a consensus sufficient to recommend routine neonatal circumcision. Parental wishes should be respected and usually determine what is in the best interest of each individual child. To make an informed choice, parents should be given accurate and unbiased information as well as reassurance about the procedure's safety. It is legitimate for parents and physicians to take into account the cultural, religious, and ethnic traditions of the family in addition to the medical factors. Analgesia is safe and effective in reducing the procedural pain in children and should be used. Circumcision done in the newborn period should be performed only in healthy infants with no obvious genital abnormalities. When properly performed by qualified, well-informed practitioners, circumcision should be a safe procedure with a low risk (<1%) of complications. Neonatal circumcision remains a common, yet controversial surgical procedure. On the one hand, existing scientific evidence demonstrates some potential medical benefits of newborn circumcision. On the other hand, the scientific studies and data to date have not demonstrated a clear risk: benefit ratio resulting in a consensus sufficient to recommend routine neonatal circumcision. Parental wishes should be respected and usually determine what is in the best interest of each individual child. To make an informed choice, parents should be given accurate and unbiased information as well as reassurance about the procedure's safety. It is legitimate for parents and physicians to take into account the cultural, religious, and ethnic traditions of the family in addition to the medical factors. Analgesia is safe and effective in reducing the procedural pain in children and should be used. Circumcision done in the newborn period should be performed only in healthy infants with no obvious genital abnormalities. When properly performed by qualified, well-informed practitioners, circumcision should be a safe procedure with a low risk (<1%) of complications. Integrating Evidence-based Patient Decision Support in Nursing Curriculum D Stacey, et al. Integrating Evidence-based Patient Decision Support in Nursing Curriculum. © 2006 [updated links 2013]. 31 Available from www.ohri.ca/decisionaid. Nelson, C., Dunn, R., Wan, J., & Wei, J. (2005). The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample [Electronic version]. The Journal of Urology, 173(3), 978-981. No abstract available Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women’s Health Care (7 th ed.). New Jersey: Pearson Education. Ottawa decisional support framework. (2005). Retrieved 02/05, 2006 from http://decisionaid.ohri.ca/odsf.html. Rideout, E. (2001). Transforming nursing education through Problem-Based Learning. Mississauga, ON: Jones and Bartlett. Van Howe, R. S. (2004). A cost-utility analysis of neonatal circumcision. Medical Decision Making, 24(6), 584-601. Abstract: A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically. A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically. Integrating Evidence-based Patient Decision Support in Nursing Curriculum D Stacey, et al. Integrating Evidence-based Patient Decision Support in Nursing Curriculum. © 2006 [updated links 2013]. 32 Available from www.ohri.ca/decisionaid. Case Scenario 2.1c: Infant feeding Faculty Resources American Association of Pediatrics (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506, Retrieved February 5, 2006, from the American Association of Pediatrics website: www.aap.org/advocacy/releases/feb05breastfeeding.htm. Chuang, C. K., Lin, S. P., Lee, H. C., Wang, T. J., Shih, Y. S., Huang, F. Y. et al. (2005). Free amino acids in full-term and pre-term human milk and infant formula. Journal of Pediatric Gastroenterology & Nutrition, 40(4), 496-500. Abstract: Objective: Although the nutritional value of human milk has been thoroughly studied, few reports describing its free amino acid (FAA) content have been published. Although infant formulas are designed to approximate the nutrient composition of human milk, the content and concentration of free amino acids are unknown. We compared the FAA concentrations of milk from mothers of preterm and full-term infants with those in several infant formulas. Method: Human milk was obtained during three different stages of lactation (colostral, transitional and mature milk). Sixty-seven samples were collected from 44 healthy mothers of term infants and 23 mothers of premature infants 29 to 36 weeks gestation (mean 33 weeks). Two brands of powdered term formula (TF-A and TF-B) and two brands designed for preterm infants (PTF-A and PTF-B)were also studied. Ion exchange chromatography was used for free amino acid analysis. Results: The mean concentration of total FAA in human milk was significantly higher than any of the infant formulas (8139 μmol/L for pre-term human milk; 3462 μmol/L for full term human milk; TF-A, 720 μmol/L; TF-B, 697 μmol/L; PTF-A, 820 μmol/L; PTF-B, 789 μmol/L) (P <0.01). FAA concentration in term and premature human colostral milk was significantly higher than in human transitional and mature milks (P <0.01). In comparing individual FAAs, there were significant differences in concentrations between term human milk and preterm milk except for phosphoethanolamine, hydroxyproline, asparagine, and α-amino-η-butyric acid. There were significant differences in all FAA concentrations between all human milks and infant formulas (P <0.05), but no significant differences were found among the study formulas. Conclusion: The concentration of FAA is high in human colostral milk and decreases through the transitional and mature milk stages. FAA is higher in all human milks than in infant formulas. Objective: Although the nutritional value of human milk has been thoroughly studied, few reports describing its free amino acid (FAA) content have been published. Although infant formulas are designed to approximate the nutrient composition of human milk, the content and concentration of free amino acids are unknown. We compared the FAA concentrations of milk from mothers of preterm and full-term infants with those in several infant formulas. Method: Human milk was obtained during three different stages of lactation (colostral, transitional and mature milk). Sixty-seven samples were collected from 44 healthy mothers of term infants and 23 mothers of premature infants 29 to 36 weeks gestation (mean 33 weeks). Two brands of powdered term formula (TF-A and TF-B) and two brands designed for preterm infants (PTF-A and PTF-B)were also studied. Ion exchange chromatography was used for free amino acid analysis. Results: The mean concentration of total FAA in human milk was significantly higher than any of the infant formulas (8139 μmol/L for pre-term human milk; 3462 μmol/L for full term human milk; TF-A, 720 μmol/L; TF-B, 697 μmol/L; PTF-A, 820 μmol/L; PTF-B, 789 μmol/L) (P <0.01). FAA concentration in term and premature human colostral milk was significantly higher than in human transitional and mature milks (P <0.01). In comparing individual FAAs, there were significant differences in concentrations between term human milk and preterm milk except for phosphoethanolamine, hydroxyproline, asparagine, and α-amino-η-butyric acid. There were significant differences in all FAA concentrations between all human milks and infant formulas (P <0.05), but no significant differences were found among the study formulas. Conclusion: The concentration of FAA is high in human colostral milk and decreases through the transitional and mature milk stages. FAA is higher in all human milks than in infant formulas. Fulhan, J., Collier, S., & Duggan, C. (2003). Update on pediatric nutrition: breastfeeding, infant nutrition, and growth. Current Opinion in Pediatrics, 15(3), 323-332. Abstract: Recent studies continue to point out the critical nature of a patient's nutritional status in helping to determine important health outcomes in pediatrics. We review recent data concerning the composition of breast milk and its adequacy to support infant growth in the first six months of life, as well as trials that support breastfeeding as an important method to delay or reduce the incidence of atopic diseases such as eczema, allergies, and asthma. Studies have also been published that show how physician education and training about breastfeeding can be optimized. Studies showing how nutritional status is measured (using standard anthropometric techniques as well as more modern measures of basal metabolic rate) are highlighted, as well as the role of micronutrient supplementation of patients with the human immunodeficiency virus infection and diarrheal diseases. Recent studies continue to point out the critical nature of a patient's nutritional status in helping to determine important health outcomes in pediatrics. We review recent data concerning the composition of breast milk and its adequacy to support infant growth in the first six months of life, as well as trials that support breastfeeding as an important method to delay or reduce the incidence of atopic diseases such as eczema, allergies, and asthma. Studies have also been published that show how physician education and training about breastfeeding can be optimized. Studies showing how nutritional status is measured (using standard anthropometric techniques as well as more modern measures of basal metabolic rate) are highlighted, as well as the role of micronutrient supplementation of patients with the human immunodeficiency virus infection and diarrheal diseases. Healthwise Knowledgebase. (2013). Breast-Feeding: Should I Breast-Feed My Baby? http://decisionaid.ohri.ca/AZsumm.php?ID=1149 Informed Choice (2005). Breastfeeding or Bottlefeeding? (Leaflet). Midwives Information and Resource Service. Retrieved February 5, 2006, from the Informed Choice website: http://www.infochoice.org/ . Osborn, D. A., & Sinn, J. (2004). Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database of Systematic Reviews, 3, CD003741. Abstract: BACKGROUND: Allergies and food reactions in infants and children are common and may be associated with foods including adapted cow's milk formulas. Soy based formulas have been used to treat infants with allergy or food intolerance. However, it is unclear whether they can be advocated for the prevention of allergy and food intolerance in infants without clinical BACKGROUND: Allergies and food reactions in infants and children are common and may be associated with foods including adapted cow's milk formulas. Soy based formulas have been used to treat infants with allergy or food intolerance. However, it is unclear whether they can be advocated for the prevention of allergy and food intolerance in infants without clinical Integrating Evidence-based Patient Decision Support in Nursing Curriculum D Stacey, et al. Integrating Evidence-based Patient Decision Support in Nursing Curriculum. © 2006 [updated links 2013]. 33 Available from www.ohri.ca/decisionaid. evidence of allergy or food intolerance. OBJECTIVES: In infants without clinical evidence of allergy or food intolerance, to determine whether feeding them an adapted soy formula compared to human milk, cow's milk formula or a hydrolysed protein formula prevents allergy or food intolerance. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used including searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2003), MEDLINE (1966 January 2004), EMBASE (1980 January 2004), CINAHL (1982 December 2003) and previous reviews including cross references. SELECTION CRITERIA: Randomised and quasi-randomised trials that compare the use of an adapted soy formula to human milk, an adapted cow's milk or a hydrolysed protein formula for infant feeding in the first 6 months. Only trials with > 80% follow up of participants and reported in group of assignment were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Eligibility of studies for inclusion, methodological quality and data extraction were assessed independently by each reviewer. Primary outcomes included clinical allergy, specific allergies and food intolerance. Meta-analysis was conducted using a fixed effects model where no heterogeneity of treatment effect existed, and a random effects model when heterogeneity was found. MAIN RESULTS: Five eligible studies were found, all enrolling infants at high risk of allergy on the basis of a family history of allergy in a first degree relative. All studies compared use of a soy to a cow's milk formula. Two studies also included a group fed a formula containing hydrolysed protein. No eligible study enrolled infants fed human milk. No study examined the effect of early, short term soy formula feeding. Three studies were of good methodology and did not have unbalanced allergy-preventing co-interventions in the treatment groups. Comparing soy to cow's milk formula, one study with unclear allocation concealment and 19.5% losses to follow up reported a reduction in cumulative incidence of childhood allergy, asthma and allergic rhinitis. No other study reported a significant benefit for any allergy or food intolerance. Analysis found no significant difference in allergy cumulative incidence in infancy (one study: RR 1.02, 95% CI 0.69, 1.49) or childhood (3 studies: typical RR 0.73, 95% CI 0.37, 1.44) and no significant difference in cumulative incidence or period prevalence of any specific allergy or food intolerance in infancy or childhood. Analysis of studies comparing soy to a hydrolysed formula found a significant increase in infant (one study: RR 1.67, 95% CI 1.03, 2.69) and childhood allergy cumulative incidence (one study: RR 1.55, 95% CI 1.02, 2.35), infant eczema cumulative incidence (2 studies: typical RR 2.34, 95% CI 1.51, 3.62) and childhood food allergy period prevalence (one study: RR 1.81, 95% CI 1.09, 3.02). REVIEWERS' CONCLUSIONS: Feeding with a soy formula should not be recommended for the prevention of allergy or food intolerance in infants at high risk of allergy or food intolerance Registered Nurses Association of Ontario (2005). Breastfeeding Best Practice Guidelines for Nurses. Toronto, Canada: Registered Nurses Association of Ontario. Rideout, E. (2001). Transforming nursing education through Problem-Based Learning. Mississauga, ON: Jones and Bartlett. U.S. Preventive Service Task Force. (2003). Behavioral Interventions to promote Breastfeeding: Recommendations and Rationale. Retrieved Feb 5, 2006, from The Agency for Healthcare Research and Quality website: http://www.guideline.gov/content.aspx?id=13255 Weigert, E. M. L., Giugliani, E. R. J., França, M. C .T., De Oliveira, L. D., Bonilha, A., Do Espírito Santo, L. C., et al. (2005). The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. Jornal de Pediatria, 81(4), 310-316. Abstract: Objective: To investigate the influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. Methods: We searched for unfavorable parameters of breastfeeding (five related to mother/baby positioning and three related to baby's latch on) in 211 mother-baby pairs in the maternity ward and at day 30, at home. We compared the frequencies of these parameters between mothers practicing or not exclusive breastfeeding at days 7 and 30, and between mothers with or without nipple trauma at the hospital. Results: The number of unfavorable parameters in the maternity ward was similar for mother-baby pairs practicing or not exclusive breastfeeding at day 7 and 30. However, at day 30, it was, on average, lower among those under exclusive breastfeeding, regarding positioning (1.7±1.2 vs 2.2±1.1; p = 0.009) as well as latch on (1.0±0.6 vs 1.4±0.6; p < 0.001). The number of unfavorable parameters related to latch on in the maternity ward was similar for women with or without nipple trauma, but women without trauma presented a higher number of unfavorable parameters related to positioning. (2.0±1.4 vs 1.4±1.2; p = 0.04). Conclusions: The frequencies of exclusive breastfeeding in the first month and of nipple trauma were not influenced by the breastfeeding technique in the maternity ward, but there was an association between a better technique at day 30 and the practice of exclusive breastfeeding. New studies may help to elucidate whether an improvement in breastfeeding practices over time helps the maintenance of exclusive breastfeeding or whether the introduction of bottlefeeding determines a negative effect on breastfeeding. Case Scenario 2.2c: Postpartum depression Integrating Evidence-based Patient Decision Support in Nursing Curriculum D Stacey, et al. Integrating Evidence-based Patient Decision Support in Nursing Curriculum. © 2006 [updated links 2013]. 34 Available from www.ohri.ca/decisionaid. As a Public health nurse, you are scheduled to visit Mrs. Jones for a postpartum followup visit 2 weeks after discharge. As you walk up the driveway you notice that the entry way has not been shoveled. After ringing the door bell, you hear Mrs. Jones shout “I will be there in a minute.” Mrs. Jones lets you in after 5 minutes and begins apologizing stating that “the baby was crying again.” Mrs. Jones places the quiet baby into a portable baby seat. You look around to see that the house is dark, with all the window blinds shut and dishes piled up in the sink. You observe that Mrs. Jones looks tired with dark circles under her eyes, in her pajamas and her hair not brushed. You begin your visit by asking Mrs. Jones how the past 2 weeks have been for her and the baby. Mrs. Jones starts crying, as she tells you that she has had very little rest since coming home. Mrs. Jones states that her husband has been working long hours and even when he is at home he tells her that he does not know how to care for the baby and it is better that she do it. “I have little energy to do anything else but take care of the baby. Some days I just cry for hours because I feel like a failure as a mother.” After consoling Mrs. Jones, you begin an assessment of both mom and baby and do an Edinburgh Postpartum Depression Scale with Mrs. Jones. © Menard, Peterson & Stacey, 09-2006 Integrating Evidence-based Patient Decision Support in Nursing Curriculum D Stacey, et al. Integrating Evidence-based Patient Decision Support in Nursing Curriculum. © 2006 [updated links 2013]. 35 Available from www.ohri.ca/decisionaid. Case Scenario 2.2c: Postpartum depression Public Health Chart Information Mother-Infant/Postnatal Assessment Record