Breastfeeding Persistence at 6 Months: Trends and Disparities from 2008 to 2015

Is Public Interest Associated with Real-World Management of Ankyloglossia?

OBJECTIVES

Assess the relationship between public interest in ankyloglossia as determined by internet search volume and real-world medical claims data.

STUDY DESIGN

Retrospective Cohort Study.

SETTING

This retrospective cohort study was conducted using claims data from the Merative™ Marketscan® Research Databases. The internet search data was collected from Google Trends.

METHODS

Annual Google Trends data were compiled using search terms associated with "ankyloglossia" and "frenotomy" for the years 2011 to 2021. We obtained incidence of ankyloglossia diagnoses and frenotomy procedures in children under 12 months from Marketscan relative to all infants enrolled. We compared associations between search and incidence data among US states and over time.

RESULTS

Google search correlated with ankyloglossia incidence (r = 0.4104, P = .0031) and with frenotomy incidence (r = 0.4062, P = .0034) per state. Ankyloglossia diagnoses increased with Google search index (coefficient = 0.336, 95% confidence interval [CI] 0.284, 0.388) and year (coefficient = 0.028, 95% CI 0.025, 0.031). Similarly, frenotomy procedures increased with Google search index (coefficient = 0.371, 95% CI 0.313, 0.429) and year (coefficient = 0.027, 95% CI 0.024, 0.030).

CONCLUSIONS

Associations between online ankyloglossia search trends and both diagnosis and treatment rates, persist across US regions and timeframes. Internet search trends are pivotal in shaping pediatric health care decisions, driving clinical consensus, and disseminating evidence-based information.

Preeclampsia Onset, Days to Delivery, and Autism Spectrum Disorders in Offspring: Clinical Birth Cohort Study

BACKGROUND

Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring.

OBJECTIVE

This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery.

METHODS

This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery.

RESULTS

Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset.

CONCLUSIONS

Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

Maternal obesity and diabetes during pregnancy and early autism screening score at well-child visits in standard clinical practice

LAY ABSTRACT

Early intervention and treatment can help reduce disability in children diagnosed with autism spectrum disorder. Screening for autism spectrum disorder in young children identifies those at increased likelihood of diagnosis who may need further support. Previous research has reported that exposure to maternal obesity and diabetes during pregnancy is associated with higher likelihood of autism spectrum disorder diagnosis in children. However, little is known about whether these maternal conditions are associated with how very young children score on autism spectrum disorder screening tools. This study examined associations between exposure to maternal obesity and diabetes during pregnancy and offspring scores on the Quantitative Checklist for Autism in Toddlers, an autism spectrum disorder screening questionnaire administered between 18-24 months at well-child visits. A higher score on the Quantitative Checklist for Autism in Toddlers suggests a higher likelihood of autism spectrum disorder; children with scores 3 or greater are referred to developmental pediatricians for evaluation. Our study found that children of mothers with obesity or diabetes during pregnancy had higher scores than children whose mothers did not have these conditions. Associations with maternal obesity and gestational diabetes diagnosed at or before 26 weeks of pregnancy were also present in children who did not have later autism spectrum disorder diagnoses, suggesting that exposure to these conditions during early pregnancy may be associated with a broad range of social and behavioral abilities. Identifying associations between maternal health conditions and early Quantitative Checklist for Autism in Toddlers screening scores could influence future screening and provision of support for children of mothers with these conditions.

Breastfeeding Disparities During the COVID-19 Pandemic: Race/Ethnicity, Age, Education, and Insurance Payor

BACKGROUND

There are well-documented disparities in rates of continued breastfeeding. Existing research regarding breastfeeding during COVID-19 has raised concerns that the pandemic may have exacerbated these disparities.

RESEARCH AIMS

The aim of this research was first to quantify disparities in any breastfeeding associated with the maternal factors of race/ethnicity, age, insurance payor, and zip code rates of education in North Carolina. Second, we aimed to investigate any changes in these disparities before and during the COVID-19 pandemic.

METHOD

This was an observational study, with a retrospective, longitudinal design. Participants included infants who were born in one of eight medical centers across North Carolina from either September 1, 2019 to October 31, 2019 (pre-COVID: n = 1,104) or from April 1, 2020 to May 31, 2020, (during COVID: n = 1,157), and whose caregivers reported whether they were breastfeeding at either a 3-month or 6-month postnatal follow-up (N = 2,261). Mixed effects logistic models, including random effects of zip code, assessed predictors associated with probability of breastfeeding cessation at 3- and 6-month child well-check.

RESULTS

Overall, younger maternal age, being non-Hispanic Black, not having commercial insurance, and residing in a zip code with lower rates of higher education, were all independently associated with earlier breastfeeding cessation across both cohorts. Disparities did not significantly change during the COVID-19 pandemic.

CONCLUSION

We did not find support for the hypothesis that the COVID-19 pandemic might have exacerbated breastfeeding disparities. Nevertheless, there is a continued need to eliminate existing disparities.

The most common medications dispensed to lactating persons: An electronic health record-based approach

PURPOSE

Using a novel, electronic health record (EHR)-based approach, to estimate the prevalence of prescription medication use at 2, 4, and 6 months postpartum among lactating individuals.

METHODS

We utilized automated EHR data from a US health system that records infant feeding information at well-child visits. We linked mothers who received prenatal care to their infants born May 2018-June 2019, and we required infants to have ≥1 well-child visit between 31 and 90 days of life (i.e., 2-month well-child visit with a ±1 month window). Mothers were classified as lactating at the 2-month well-child visit if their infant received breast milk at the 2-month well-child visit. For subsequent well-child visits at 4 and 6 months, mothers were considered lactating if their infant was still receiving breast milk.

RESULTS

We identified 6013 mothers meeting inclusion criteria, and 4158 (69.2%) were classified as lactating at the 2-month well-child visit. Among those classified as lactating, the most common medication classes dispensed around the 2-month well-child visit were oral progestin contraceptives (19.1%), selective serotonin reuptake inhibitors (8.8%), first generation cephalosporins (4.3%), thyroid hormones (3.5%), nonsteroidal anti-inflammatory agents (3.4%), penicillinase-resistant penicillins (3.1%), topical corticosteroids (2.9%), and oral imidazole-related antifungals (2.0%). The most common medication classes were similar around the 4 and 6-month well-child visits although prevalence estimates were often lower.

CONCLUSIONS

Progestin-only contraceptives, antidepressants, and antibiotics were the most dispensed medications among lactating mothers. With routine collection of breastfeeding information, mother-infant linked EHR data may overcome limitations in previous studies of medication utilization during lactation. These data should be considered for studies of medication safety during lactation given the need for human safety data.

Breastfeeding Duration and Timing of Bottle Supplementation: Associations with Body Mass Index from Childhood to Young-Adulthood

Evidence for the association between breastfeeding (BF) duration and later body mass index (BMI) is inconsistent. We explored how BF duration and BF type (exclusive or partial) related to BMI from childhood to young adulthood in a Chilean cohort. Infants were recruited at 6 months between 1994 and 1996 in Santiago, Chile (n = 821). Mothers reported date of first bottle and last BF; anthropometry was measured at 1, 5, 10, 16, and 23 years. We tested whether: (1) type of BF at 6 months (none, partial, exclusive) and (2) duration of exclusive BF (<1 month, 1 to <3 months, 3 to <6 months, and ≥6 months) related to BMI. At 6 months, 35% received both breastmilk and formula ("partial BF") and 38% were exclusively breastfed. We found some evidence of an association between longer BF and lower BMI z-scores at young ages but observed null effects for later BMI. Specifically, BF for 3 to <6 months compared to <1 month related to lower BMI z-scores at 1 and 5 years (both p < 0.05). Our results are in partial accordance with others who have not found a protective effect of longer BF for lower BMI.

A Comparison of Audio-Only and Audio-Visual Tele-Lactation Consultation Services: A Mixed Methods Approach

BACKGROUND

The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life; however, a lack of access to breastfeeding resources influences breastfeeding initiation and continuation. Tele-lactation services may reduce some of these barriers to access.

RESEARCH AIMS

To identify facilitators and barriers of two modes of tele-health service utilization and to compare the differences between two modes of providing tele-lactation services on breastfeeding knowledge, breastfeeding intention, perceived social support, and 3-month breastfeeding continuation behavior.

METHODS

We conducted a mixed method, longitudinal pilot study utilizing prospective convenience sampling and random assignment of postpartum women recruited from two medical centers in Little Rock, Arkansas. Participants (N = 43) were randomized into telephone-only (n = 23) or audio-visual (n = 20) intervention groups. Participants completed a self-administered pre- and post-intervention survey, as well as a semi-structured qualitative phone interview at 4-6 weeks post-discharge.

RESULTS

No significant difference in demographic characteristics across groups was found. At 3 months after discharge, both groups reported continued breastfeeding (telephone-only: n = 17, 81%; audio-visual: n = 18, 90%) with no significant difference between the two groups (p = .663). Additionally, no group differences were found for breastfeeding knowledge or perceived social support. Overall, participants reported positive experiences with tele-lactation, emphasizing the convenience, accessibility, education, and support provided.

CONCLUSION

We found that both telephone-only and audio-visual delivery of tele-lactation services were equally effective. Both methods of tele-lactation services should be considered by health care providers to encourage and sustain breastfeeding behavior in mothers.

Maternal obesity, diabetes, preeclampsia, and asthma during pregnancy and likelihood of autism spectrum disorder with gastrointestinal disturbances in offspring

LAY ABSTRACT

Autism spectrum disorder is heterogeneous and often accompanied by co-occurring conditions. Previous studies have shown that maternal health conditions during pregnancy including obesity, diabetes, preeclampsia, and asthma were associated with increased likelihood of autism. However, little has been done examining the likelihood associated with autism with co-occurring conditions. This study assessed these maternal health conditions in relationship to autism and gastrointestinal disturbances, a common co-occurring condition in children diagnosed with autism. Data included 308,536 mother-child pairs from one integrated health care system with comprehensive electronic medical records. Among the study cohort, 5,131 (1.7%) children had a diagnosis of autism by age 5. Gastrointestinal disturbances were present in 35.4% of children diagnosed with autism and 25.1% of children without autism diagnoses. Our results showed that each of the four maternal health conditions during pregnancy was associated with increased likelihood of gastrointestinal disturbances, autism without gastrointestinal disturbances, and autism with gastrointestinal disturbances. For all four maternal health conditions, the association was greatest for likelihood of autism with gastrointestinal disturbances. Given that children diagnosed with autism are more likely to have gastrointestinal disturbances and over 80% of gastrointestinal disturbances in this cohort were diagnosed prior to autism diagnosis, this study suggests that there may be common biological pathways between autism and gastrointestinal disturbances impacted by these maternal exposures. Future studies are warranted to assess associations between different exposures and autism with other co-occurring conditions to increase our understanding of autism heterogeneity.

Changes in Breastfeeding Exclusivity and Satisfaction During the COVID-19 Pandemic

BACKGROUND

Because of its many benefits, exclusive breastfeeding for 6 months is a common public health goal. However, only 44% of infants aged 0-6 months are exclusively breastfed worldwide and, in the United States, only 26% of infants are exclusively breastfed for 6 months. The restrictions imposed during the COVID-19 pandemic may have reduced these rates even further.

RESEARCH AIM

To examine the differences in breastfeeding exclusivity and satisfaction before and during the COVID-19 pandemic.

METHODS

A cross-sectional, two-group survey design was used. Parents (N = 110) of infants born April 1 to December 31, 2019 (pre-pandemic; n = 69), or April 1 to December 31, 2020 (during the pandemic; n = 41), who received lactation support services from an urban academic breastfeeding clinic were surveyed.

RESULTS

Respondents who gave birth in 2020 (pandemic year) were no less likely to exclusively breastfeed for the first 6 months of their infant's life compared to respondents who gave birth in 2019 (pre-pandemic year). After multivariable logistic regression, the odds of high breastfeeding satisfaction were 73% lower in respondents with infants born in 2020 than in respondents with infants born in 2019 (OR = 0.27, 95% CI [0.08, 0.89]). The strongest contributor to high breastfeeding satisfaction was a prenatal breastfeeding visit with an International Board Certified Lactation Consultant.

CONCLUSIONS

Future research is needed to identify the specific pandemic-related factors that led to the difference in breastfeeding satisfaction between the two groups and to confirm the impact of prenatal International Board Certified Lactation Consultant visits on breastfeeding satisfaction.

Low Job Control and Racial Disparities in Breastfeeding

BACKGROUND

Low job control may predict shorter breastfeeding (BF) among working mothers and may contribute to racial disparities in BF.

METHODS

We used demographic, employment, and health data for n = 631 observations from the Panel Study of Income Dynamics. Job control scores came from a job-exposure matrix.Using path analysis, we assessed whether job control predicted BF and mediated Black-White BF differences. We controlled for education, working hours, marital status, and low birthweight.

RESULTS

Lower job control predicted decreased odds of BF for at least 6 months (odds ratio, 0.61; 95% confidence interval, 0.31-0.90; reference, no BF). Low job control explained 31% of the Black-White difference for both shorter-term and longer-term BF.

CONCLUSIONS

Low job contributes to shorter BF and to BF disparities by race. Intervening to enhance job control could improve BF.

Relationship Between Maternal COVID-19 Infection and In-Hospital Exclusive Breastfeeding for Term Newborns

Objective

To evaluate the relationship between maternal COVID-19 infection and the odds of in-hospital exclusive breastfeeding for term newborns.

Design

Retrospective descriptive quantitative.

Setting

A large, urban hospital with more than 6,000 births annually.

Sample

Term newborns born between March 1, 2020, and March 31, 2021 (N = 6,151).

Methods

We retrospectively extracted data from electronic health records to evaluate the relationship of maternal COVID-19 infection with the odds of in-hospital exclusive breastfeeding using univariate analysis and logistic regression models. The covariates included insurance type, race/ethnicity, glucose gel administration, length of stay, newborn gestational age, newborn birth weight, and maternal COVID-19 infection.

Results

Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding (p = .138) after adjustment for covariates in the logistic regression model. However, when newborns who received pasteurized donor human milk supplementation were excluded from the logistic regression model, maternal COVID-19 infection significantly decreased the odds of in-hospital exclusive breastfeeding (p = .043).

Conclusion

Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding when newborns received donor human milk supplementation. Access to donor human milk for supplementation for term newborns may protect the odds of in-hospital exclusive breastfeeding.

Smoking and Race Associated with Decreased Breastfeeding Initiation and Duration Among a Low Income Population

Objectives: To assess associations between smoking behaviors during pregnancy and postpartum and breastfeeding initiation and duration, among DC Women, Infants, and Children (WIC) recipients, the majority of whom are non-White, controlling for sociodemographic factors, low birth weight (LBW), and delivery in a Baby-Friendly hospital (BFH). Materials and Methods: A series of ordinary least squares and logistic regressions estimated the association between smoking during pregnancy and postpartum on breastfeeding initiation and duration, respectively. A multilevel modeling approach accounted for WIC site effects. Results: Overall, 8.8% of DC WIC recipients smoked during pregnancy. Smoking during pregnancy and postpartum was negatively associated with breastfeeding initiation (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI]: 0.36, 0.61) and duration (adjusted coefficient [B] = -37.96, 95% CI: -62.92, -13.00) in adjusted models, respectively. Maternal age, race, marital status, LBW, and delivery in a BFH were also significantly associated with initiation, while age, race, and marital status were significantly associated with duration. Likewise, the number of cigarettes smoked per day was negatively associated with initiation (aOR = 0.79, 95% CI: 0.72, 0.87) and duration (B = -8.98, 95% CI: -15.55, -2.41) in adjusted models. Conclusions: Both smoking and number of cigarettes smoked during pregnancy and postpartum are significant factors associated with less breastfeeding in the DC WIC population. Furthermore, smoking cessation during pregnancy shows initial promise to increase breastfeeding initiation. Future research is needed to better understand the role of smoking, relapse, and cessation interventions on breastfeeding rates among low-income, predominantly minority populations.

Factors related to inhibition of lactation by pharmacological means at birth in a Spanish referral hospital (2011-2017)

OBJECTIVE

To describe the maternal, neonatal and pregnancy characteristics related to inhibition of lactation (IL) with cabergoline.

METHOD

We assessed 20,965 occasions of breastfeeding initiation, according to data collected from obstetric records at the Hospital Clinic of Barcelona (Spain) between January 2011 and December 2017.

RESULTS

IL decreased over the study period from 8.78% to 6.18% (odds ratio [OR]: 0.93 per year; 95% confidence interval [95%CI]: 0.90-0.95). Women with a lower educational level (OR: 2.5; 95%CI: 2.0-3.0), mothers living in more depressed areas (OR: 1.08 per 10 extra points over 100; 95%CI: 1.04-1.12), smokers (OR: 2.2; 95%CI: 1.9-2.6), and those with more children (OR: 1.2 for each sibling; 95%CI: 1.1-1.3), preterm birth (OR: 1.8; 95%CI: 1.4-2.3), multiple births (OR: 1.6; 95%CI: 1.2-2.1) and a higher risk pregnancy (OR: 1.3 per risk point; 95%CI: 1.2-1.4) showed a higher prevalence of IL. Compared to women born in Spain, IL was less likely in all other women with the exception of Chinese women (OR: 7.0; 95%CI: 5.7-8.6). These disparities remained during the study period.

CONCLUSIONS

Factors related to lower socioeconomic status and poor health were more likely to be associated with IL. The overall use of cabergoline decreased during the study period while inequalities persisted. Taking these inequalities into account is the first step to addressing them.

Work, race and breastfeeding outcomes for mothers in the United States

Background

In the United States, mothers’ employment status and occupation are related to breastfeeding. However, it is unclear whether not working leads to longer breastfeeding duration even when compared to professional/managerial jobs, which tend to accommodate breastfeeding better than service/manual labor jobs. Furthermore, occupation and breastfeeding are racially patterned, and it is possible that race could moderate the relationships between mother’s work and breastfeeding.

Methods

Using data from the Panel Study of Income Dynamics, we modeled breastfeeding duration based on mother’s employment/occupation (not working, professional/managerial work, or service/labor work) during the first 6 months postpartum, as well as mother’s race (White, Black or other) and other potential confounders. We used zero-inflated negative binomial regression models and tested an interaction between employment/occupation type and race. Predictive margins were used to compare breastfeeding duration among subgroups.

Results

Mothers working in service/labor occupations had the shortest breastfeeding duration of the three employment/occupation groups, and there was no significant difference in duration between not working and professional/managerial occupation. White mothers had longer breastfeeding duration than Black mothers on average. When we included an interaction between employment/occupation and race, we found that among White mothers, non-working mothers breastfed the longest, while mothers in service/labor work breastfed for the shortest duration, but among Black mothers, mothers in professional/managerial work breastfed for longer than mothers in the other two work categories.

Discussion

Race moderated the relationship between employment status/occupation type and breastfeeding such that, for White mothers, not working was the most advantageous circumstance for breastfeeding, in line with traditional work-family conflict theory. In contrast, for Black mothers, professional/managerial work was the most advantageous circumstance. These findings support the idea of the Market-Family Matrix, which allows that different work scenarios may be more or less advantageous for parenting behaviors like breastfeeding, depending on mothers’ circumstances.

Breastfeeding but not Exclusively: Exploration of Chinese American Mothers' Infant Feeding Practices

BACKGROUND

Previous qualitative researchers have shown that Chinese American mothers experienced high rates of suboptimal breastfeeding, especially early introduction of other foods before the recommended 6-month period of exclusive breastfeeding.

RESEARCH AIMS

(1) To explore attitudes that Chinese American mothers have about the meaning and practice of exclusive breastfeeding; (2) to evaluate the extent of family pressure and support to maintain exclusive breastfeeding; and (3) to examine the influence of breastfeeding self-efficacy and the intention to continue exclusive breastfeeding.

METHOD

Guided by the theory of planned behavior, this descriptive cross-sectional prospective online survey was conducted with Chinese American breastfeeding mothers (N = 401). Participants' attitudes, subjective norms, and perceived behavioral control for exclusive breastfeeding behaviors were measured.

RESULTS

The M (SD) age of participants was 29.14 (SD = 6.90). Just over 50% reported receiving family support for exclusive breastfeeding. While participants had positive attitudes about exclusive breastfeeding and the value of colostrum, 64% (n = 257) had already introduced foods other than mother's own milk before their infant was 6-months old. Participants also expressed concern that their infants did not receive enough nutrition from exclusive mother's milk. Participants with more than one child had significantly greater intention to continue exclusive breastfeeding compared to participants with only one child. Perception of approval by others for exclusive breastfeeding and breastfeeding self-efficacy were significantly related to behavioral intention to continue exclusive breastfeeding.

CONCLUSION

Suboptimal infant feeding is a problem for Chinese American women and may also be a problem for mothers in other ethnic groups. We found a lack of adherence with standard recommendations for sustaining 6-months of exclusive breastfeeding.

BMI growth trajectory from ages 2 to 6 years and its association with maternal obesity, diabetes during pregnancy, gestational weight gain, and breastfeeding

OBJECTIVE

To identify latent BMI growth trajectories from ages 2 to 6 years and examine their independent associations with maternal prepregnancy obesity or overweight, pre-existing type 1 (T1D) or type 2 diabetes (T2D) or gestational diabetes (GDM) with or without requiring antidiabetic medications during pregnancy, excessive gestational weight gain (EGWG), and breastfeeding ≤ 6 months.

RESEARCH DESIGN AND METHOD

Data included 71 892 children born at Kaiser Permanente Southern California hospitals in 2007 to 2011 with complete information on maternal risk factors. Group-based trajectory modelling was used to identify latent BMI trajectory groups. Logistic regression was used to assess independent associations adjusted for covariates.

RESULTS

Three distinct BMI trajectory groups were identified: Group 1 (59% of the cohort) had stable low BMI, Group 2 (35% of the cohort) had stable median BMI, and Group 3 (6% of the cohort) had high and increasing BMI over time. Relative to Groups 1 and 2 combined, the adjusted odds ratio (OR) (95% CI) of being in Group 3 associated with maternal exposures were 5.6 (5.1-6.2) for prepregnancy obesity, 2.4 (2.2-2.7) for prepregnancy overweight, 2.1 (1.2-3.7) for T1D, 1.6 (1.4-1.8) for T2D, 1.4 (1.3-1.6) for GDM requiring medication treatment, 1.1 (1.0-1.3) for GDM not requiring medication, 1.3 (1.2-1.4) for EGWG, and 1.2 (1.2-1.3) for breastfeeding ≤ 6 months.

CONCLUSION

Child's high and increasing BMI trajectory was strongly associated with maternal prepregnancy obesity and overweight, modestly associated with maternal T1D, T2D, and GDM requiring medication treatment and EGWG, and slightly associated with breastfeeding ≤ 6 months. GDM not requiring medication treatment during pregnancy had little association.

The use of natural language processing to identify vaccine-related anaphylaxis at five health care systems in the Vaccine Safety Datalink

PURPOSE

The objective was to develop a natural language processing (NLP) algorithm to identify vaccine-related anaphylaxis from plain-text clinical notes, and to implement the algorithm at five health care systems in the Vaccine Safety Datalink.

METHODS

The NLP algorithm was developed using an internal NLP tool and training dataset of 311 potential anaphylaxis cases from Kaiser Permanente Southern California (KPSC). We applied the algorithm to the notes of another 731 potential cases (423 from KPSC; 308 from other sites) with relevant codes (ICD-9-CM diagnosis codes for anaphylaxis, vaccine adverse reactions, and allergic reactions; Healthcare Common Procedure Coding System codes for epinephrine administration). NLP results were compared against a reference standard of chart reviewed and adjudicated cases. The algorithm was then separately applied to the notes of 6 427 359 KPSC vaccination visits (9 402 194 vaccine doses) without relevant codes.

RESULTS

At KPSC, NLP identified 12 of 16 true vaccine-related cases and achieved a sensitivity of 75.0%, specificity of 98.5%, positive predictive value (PPV) of 66.7%, and negative predictive value of 99.0% when applied to notes of patients with relevant diagnosis codes. NLP did not identify the five true cases at other sites. When NLP was applied to the notes of KPSC patients without relevant codes, it captured eight additional true cases confirmed by chart review and adjudication.

CONCLUSIONS

The current study demonstrated the potential to apply rule-based NLP algorithms to clinical notes to identify anaphylaxis cases. Increasing the size of training data, including clinical notes from all participating study sites in the training data, and preprocessing the clinical notes to handle special characters could improve the performance of the NLP algorithms. We recommend adding an NLP process followed by manual chart review in future vaccine safety studies to improve sensitivity and efficiency.