Financial toxicity in allogeneic haematopoietic stem cell transplant patients from a social determinants of health perspective

PURPOSE

Financial toxicity (FT) refers to the subjective perception of financial distress resulting from objective economic strain due to illness, exerting a detrimental influence on health outcomes. This study aimed to describe FT among allogeneic haematopoietic stem cell transplant (allo-HSCT) recipients within a public health framework, employing a social determinants of health approach.

METHODS

A multi-centre cross-sectional study involving adult allo-HSCT patients was conducted across three public hospitals in Madrid. FT was assessed using a validated COST scale (range 0-44; lower scores indicating higher FT). Patient-administered paper/online questionnaires were utilized to collect data on sociodemographic, socioeconomic, clinical, and healthcare access variables. Descriptive, non-parametric univariate statistical analysis and multiple linear regression models were performed.

RESULTS

Sixty-six patients, with a mean age: 52.5 years (SD: 11.5), 50% women, 28.7% displaced to Madrid for HSCT, and 71.4% lacking financial support were included. The median FT score was 20 points (IQR 12-27.25). Independent factors associated with higher FT included being females (Coef = -3.26; p = 0.079), perceived income loss after HSCT (Coef = -6.81; p < 0.001) and a monthly household income of ≤1000 € compared to 1001-2500€ (Coef = 8.29; p = 0.005) or >2500 € (Coef = 15.75; p < 0.001).

CONCLUSIONS

Despite the limited sample size, our findings underscore the presence of financial toxicity among allo-HSCT patients, shaped by social determinants of health. Recognizing and addressing FT within the HSCT process is essential to mitigate social inequalities in health.

Donor Lung Preservation at 10°C: Clinical and Logistical Impact

INTRODUCTION

Cold static donor lung preservation at 10°C appears to be a promising method to safely extend the cold ischemic time (CIT) and improve lung transplant (LTx) logistics.

METHODS

LTx from November 2021 to February 2023 were included in this single institution, prospective, non-randomized study comparing prolonged preservation at 10°C versus standard preservation on ice. The inclusion criteria for 10°C preservation were suitable grafts for LTx without any donor retrieval concerns.

PRIMARY ENDPOINT

primary graft dysfunction (PGD) grade-3 at 72-h. Secondary endpoints: clinical outcomes, cytokine profile and logistical impact.

RESULTS

Thirty-three out of fifty-seven cases were preserved at 10°C. Donor and recipient characteristics were similar across the groups. Total preservation times (h:min) were longer (p<0.001) in the 10°C group [1st lung: median 12:09 (IQR 9:23-13:29); 2nd: 14:24 (12:00-16:20)] vs. standard group [1st lung: median 5:47 (IQR 5:18-6:40); 2nd: 7:15 (6:33-7:40)]. PGD grade-3 at 72-h was 9.4% in 10°C group vs. 12.5% in standard group (p=0.440). Length of mechanical ventilation (MV), ICU and hospital stays were similar in both groups. Thirty and ninety-day mortality rates were 0% in 10°C group (vs. 4.2% in standard group). IL-8 concentration was significantly higher 6-h post-LTx in the standard group (p=0.025) and IL-10 concentration was increased 72-h post-LTx in the 10°C group (p=0.045).

CONCLUSIONS

Preservation at 10°C may represent a safe and feasible strategy to intentionally prolong the CIT. In our center, extending the CIT at 10°C may allow for semi-elective LTx and improve logistics with similar outcomes compared to the current standard preservation on ice.

Outcomes after lung transplantation from selected donors older than 70 years in a single centre: time to close the debate?

OBJECTIVES

The aim of this study was to compare the outcomes of lung transplantations using grafts from donors aged over 70 years against those performed using younger donors.

METHODS

This retrospective single-centre analysis includes lung transplants conducted at our institution from January 2014 to June 2022. Lung recipients were classified into 2 groups based on donor age (group A <70 years; group B ≥70 years). Variables regarding demographics, peri and postoperative outcomes and survival were included. The statistical analysis approach included univariable analysis, propensity score matching to address imbalances in donor variables (smoking status), recipient characteristics (sex, age, diagnosis and lung allocation score) and calendar period and survival analysis.

RESULTS

A total of 353 lung transplants were performed in this period, 47 (13.3%) using grafts from donors aged over 70 years. Donors in group B were more frequently women (70.2% vs 51.6%, P = 0.017), with less smoking history (22% vs 43%, P = 0.002) and longer mechanical ventilation time (3 vs 2 days, P = 0.025). Recipients in group B had a higher lung allocation score (37.5 vs 35, P = 0.035). Postoperative variables were comparable between both groups, except for pulmonary function tests. Group B demonstrated lower forced expiratory volume 1 s levels (2070 vs 2580 ml, P = 0.001). The propensity score matching showed a lower chance of chronic lung allograft dysfunction by 12% for group B. One-, three- and five-year survival was equal between the groups.

CONCLUSIONS

The use of selected expanded-criteria donors aged over 70 years did not result in increased postoperative morbidity, early mortality or survival in this study.

Hysteroscopic versus histopathological agreement in the diagnosis of chronic endometritis: results from a retrospective observational study

PURPOSE

To evaluate the agreement rate between hysteroscopy and pathological examination in case of chronic endometritis.

METHODS

A retrospective observational study carried out at Gynecology and Obstetrics Department, Puerta de Hierro Hospital, Autónoma University of Madrid, Spain, from January 2021 to June 2022 was performed by obtaining data from 115 medical records of women who underwent office hysteroscopies that was compared with the findings of final histological examination of endometrial biopsy. Cohen's kappa index was used to evaluate this agreement rate. In addition, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were obtained.

RESULTS

The agreement between hysteroscopic findings and histological examination showed a modest result with a Cohen's kappa index of 34%. In addition, we obtained a specificity of 70% and a sensitivity of 64%. The positive and negative predictive value were 60.8% and 73.4%, respectively. An excellent agreement rate (100%) between histological and hysteroscopic results was observed in presence of hyperemia and micropolyps.

CONCLUSION

Although the sample size is not as large as that of other studies published so far, the first glance of our experience is that hysteroscopic signs are not yet sufficient to make an accurate diagnosis of chronic endometritis, thus requiring a histopathological confirmation to make it.

Association of the presence of a COVID-19 infection at the time of birth and the rates of exclusive breastfeeding upon discharge in BFHI hospitals: a multicenter, prospective cohort study

BACKGROUND

Very few studies have assessed the association between COVID-19 infection and the rates of exclusive breastfeeding (EBF) upon discharge following the first waves of the pandemic and after initiation of vaccination. The primary objective of this study is to compare the rates of EBF since birth upon discharge in mothers diagnosed with COVID-19 infection at the time of the delivery versus a group of non-infected mothers in maternity hospitals with Baby Friendly Hospital Initiative (BFHI) accreditation. The secondary objectives include determining the rates of any breastfeeding at three and six months of life in both groups, as well as determining the possible factors associated with EBF rates observed upon discharge.

METHODS

An observational, Spanish multi-center hospital, prospective cohort study conducted from 1 to 2021 to 31 March 2022 and with follow-up during the first six months of life. Follow-up was performed via telephone contact with calls performed at three and six months. A multivariate logistic regression analysis model was used to identify the factors related to a lower probability of EBF upon discharge.

RESULTS

308 mother-infant pairs participated in the study, 111 in the cohort of women with COVID infection and 197 in the comparison group. EBF upon discharge was 62.7% in the COVID group vs. 81.2% in the comparison group (p = 0.002); at three months; 52.4% vs. 57.0% (p = 0.33) were performing EBF, with the rates of EBF at six months being 43.0% vs. 39.3% (p = 0.45), respectively. Exposure to COVID-19 at delivery (AOR 5.28; 95% CI 2.01, 13.86), not practicing BF previously (AOR 36.3; 95% CI 7.02, 187.74), birth via Cesarean section (AOR 5.06; 95% CI 1.62, 15.79) and low birth weight of the newborn (AOR 1.01; 95% CI 1.01, 1.01) were associated with a greater risk of not performing EBF upon discharge.

CONCLUSIONS

Mothers with a mild or asymptomatic COVID-19 infection at the time of the delivery were less likely to have exclusively breastfed during their hospital stay than other mothers in these BFHI-accredited hospitals. However, there were no differences in breastfeeding rates between the groups at three and six months postpartum.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures

Objective

The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality.

Materials and Methods

This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality.

Results

We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]).

Conclusion

Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

Interrupted Versus Continuous Suture for Bronchial Anastomosis in Lung Transplantation: Does It Matter?

OBJECTIVES

Bronchial anastomotic complications remain a major concern in lung transplantation. We aim to compare two different techniques, continuous versus interrupted suture by analyzing airway complications requiring intervention.

METHODS

Lung transplantations between January-2015 and December-2020 were included. Airway complications requiring intervention were classified following the 2018 ISHLT consensus and analyzed comparing three groups of patients according to surgical technique: Group A, both anastomosis performed with continuous suture; Group B, both with interrupted; and Group C, interrupted suture for one side and continuous suture for the contralateral side.

RESULTS

A total of 461 anastomoses were performed in 245 patients. The incidence of airway complications requiring intervention was 5.7% (95%CI 2.8; 8.6) per patient (14/245) and 3.7% (95%CI 2.0; 5.4) per anastomosis (17/461). Complications that required intervention were present in 5 out of 164 (3.1%) anastomosis with interrupted technique, and in 12/240 (5%) with continuous suture. No significant differences were found between techniques (p = 0.184). No statistical differences were found among Group A, B or C in terms of incidence of anastomotic complications, demographics, transplant outcomes or overall survival (log-rank p = 0.513). In a multivariable analysis, right laterality was significantly associated to complications requiring intervention (OR 3.7[CI 95%:1.1-12.3], p = 0.030). Endoscopic treatment was successful in 12 patients (85.7%). Retransplantation was necessary in two patients.

CONCLUSION

In summary, although it seems that anastomotic complications requiring intervention occur more frequently with continuous suture, there are no statistical differences compared to interrupted suture. Endoscopic treatment offers good outcomes in most of the airway complications after lung transplantation.

A prospective study among neonates born to mothers with active or past Graves disease

OBJECTIVE

The aim of this prospective study was to describe demographic and clinical characteristics of neonates born to mothers with active or past Graves disease and to assess compliance since implementation of a new protocol in our center.

METHODS

We prospectively followed up neonates born to mothers with active or past Graves disease in a tertiary hospital in Spain between August 2019 and September 2021 according to our protocol. We reviewed maternal and neonatal history of these neonates, and we followed up newborns at risk of neonatal hyperthyroidism.

RESULTS

Among 5808 births, 33 neonates were born to mothers with active or past Graves disease (0.57%). Six mothers (18.2%) had positive levels of thyroid-stimulating hormone receptor antibodies during pregnancy and five mothers (15.1%) between weeks 20 and 24 of pregnancy. Two of them had received definitive therapy for Graves disease before pregnancy. Two neonates (7.1%) were at high risk of neonatal hyperthyroidism and were followed-up until two months, without hyperthyroidism signs or abnormal thyroid hormone levels. Compliance of protocol during pregnancy was 84.9% and 75.8% at birth.

CONCLUSIONS

Prevalence of Graves disease among pregnant women was 0.57%, with no cases of neonatal hyperthyroidism. Compliance of protocol was adequate during pregnancy (84.9%) and acceptable at birth (75.8%).

Peripheral blood eosinophilia as a marker of acute cellular rejection in lung transplant recipients

Previous studies in solid organ transplantation have shown a relationship between circulating eosinophil (EOS) counts and the presence of acute cellular rejection (ACR). However, the relationship between this potential biomarker and ACR in lung transplant (LTx) patients remains unclear.

OBJECTIVE

To assess the association between EOS and the presence of acute cellular rejection in lung transplant recipients.

MATERIALS AND METHODS

Retrospective study of 583 transbronchial biopsies (TBB) performed in 256 lung transplant patients between 2012 and 2018. We analyzed age, sex, underlying pathology, date of transplant, indications for TBB, presence and degree of ACR, and the simultaneous absolute and relative EOS.

RESULTS

ACR were observed in 170 of 583 TBB (29.2%). EOS in patients with ACR were higher than in patients without ACR (203.6 ± 248/mm³ vs 103.1 ± 153/mm³; p < 0.001). High levels of both absolute and relative EOS were associated with the presence of ACR regardless of the underlying disease (odds ratio [OR] 1.003; 95% confidence interval [CI], 1.002-1.004; OR 1.226; 95% CI, 1.120-1.342) and time after transplant (OR 1.003; 95% CI, 1.002-1.004 and OR 1.239; 95% CI, 1.132-1.356). Moreover, both absolute and relative EOS were strongly associated with moderate and severe grades of ACR (OR 3.55; 95% CI, 3.00-4.10 and OR 3.56; 95% CI, 3.00-4.12).

CONCLUSIONS

EOS are elevated in ACR, especially in moderate or severe ACR. Increased vigilance for ACR is therefore advisable in lung transplant recipients with elevated EOS.

Baby Friendly Hospital Initiative Breastfeeding Outcomes in Mothers with COVID-19 Infection During the First Weeks of the Pandemic in Spain

BACKGROUND

Adherence to the Ten Steps of the Baby-Friendly Hospital Initiative has been shown to have a protective role for the initiation and maintenance of breastfeeding.

RESEARCH AIMS

(1) To determine the breastfeeding rate during the first 6 months of life in children of mothers diagnosed with COVID-19 infection at the time of birth; and (2) to assess the possible influence of being born in a center with Baby-Friendly Hospital Initiative accreditation.

METHODS

This was a two-group comparative longitudinal observational study of infants born to mothers with COVID-19 at the time of birth, between March 13-May 31, 2020 (the first wave of the pandemic) in Spain. Fourteen Spanish hospitals participated, five (35.7%) were Baby-Friendly Hospital Initiative accredited. Type of feeding was assessed prospectively at discharge, 1, 3, and 6 months of age. A total of 248 newborns were included in the study.

RESULTS

A total of 117 (47.3%) newborns were born in Baby-Friendly Hospital Initiative (BFHI) accredited centers. These centers applied skin-to-skin contact with greater probability (OR = 1.9; 95% CI [1.18, 3.29]) and separated the newborns from their mothers less frequently (OR = 0.46; 95% CI [0.26, 0.81]) than non-accredited centers. No differences were observed in relation to the presence of a companion at the time of birth. At discharge, 49.1% (n = 57) of newborns born in BFHI-accredited centers received exclusive breastfeeding versus 35.3% (n = 46) in non-accredited centers (p = .03). No differences were observed in breastfeeding rates throughout follow-up.

CONCLUSIONS

The exclusive breastfeeding rate at discharge in children of mothers with COVID-19 infection at birth was higher in Baby-Friendly Hospital Initiative accredited centers, which most frequently applied skin-to-skin contact at birth as well as rooming-in.

Assessment of exposure-response relationship for bevacizumab in patients with metastatic colorectal cancer

Limited literature is available for bevacizumab exposure-response relationship and there is not a concentration threshold associated with an optimal disease control. This prospective observational study in patients with metastatic colorectal cancer (mCRC) aims to evaluate, in a real-life setting, the relationship between bevacizumab through concentrations at steady state (C_{trough, SS}) and disease control. C_{trough, SS} were drawn, coinciding with the radiological evaluation of the response (progression or clinical benefit). Generalized estimating equations (GEE) analysis was performed. To test the association between C_{trough, SS} in each patient with overall survival (OS) or progression-free survival (PFS), Cox proportional hazard models were developed. Data included 50 bevacizumab C_{trough, SS} from 27 patients. The GEE model did not suggest any positive association between bevacizumab C_{trough, SS} and clinical benefit (OR 0.99, 95% CI: 0.98-1.02, p = 0.863). The Cox regression showed association between higher median C_{trough, SS} with better OS (HR 0.86, 95% CI: 0.73-1.01, p = 0.060), but not with PFS. We cannot confirm a relationship between bevacizumab C_{trough, SS} and clinical benefit but this is the first real-world study trying to show a relationship between bevacizumab C_{trough, SS} and disease control in mCRC. It was conducted in a small sample size which reduces the level of evidence. Further controlled randomized studies with a sufficient number of patients are required.

Impact of Recommended Maternal Vaccination Programs on the Clinical Presentation of SARS-CoV-2 Infection: A Prospective Observational Study

The COVID-19 pandemic has raised questions about the possible cross immunity resulting from common vaccination programs and SARS-CoV-2 infection. Therefore, the Spanish Obstetric Emergency group performed a multicenter prospective study on the vaccination status of Influenza and Tdap (diphtheria, tetanus and pertussis vaccine boost administered in adulthood) in consecutive cases of SARS-CoV-2 infection in a pregnancy cohort, in order to assess its possible association with the clinical presentation and severity of symptoms of SARS-CoV-2 infection, as well as to determine the factors that may affect vaccination adherence. A total of 1150 SARS-CoV-2 positive pregnant women from 78 Spanish hospitals were analyzed: 183 had not received either vaccine, 23 had been vaccinated for Influenza only, 529 for Tdap only and 415 received both vaccines. No association was observed between the vaccination status and the clinical presentation of SARS-CoV-2 infection and/or the severity of symptoms. However, a lower adherence to the administration of both vaccines was observed in the Latin-American subgroup. Based on the results above, we reinforce the importance of maternal vaccination programs in the actual pandemic. Health education campaigns should be specially targeted to groups less likely to participate in these programs, as well as for a future SARS-CoV-2 vaccination campaign.

A survey of procedural pain assessment and non-pharmacologic analgesic interventions in neonates in Spanish public maternity units

OBJECTIVE

To qualify and quantify clinical practices related to pain assessment and non-pharmacologic analgesia (NPA) in newborns in Spanish public maternity hospitals STUDY DESIGN: We surveyed providers online regarding their use of pain assessment scales, NPA interventions in neonates undergoing procedures, as well parents' presence or absence during interventions.

RESULTS

The number of painful procedures and the subjective grading of pain from the responding physicians were similar in all hospitals. Only 12.5% of hospitals used pain scales. No NPA was employed in 37.7% of procedures, with less NPA used in the lower complexity hospitals for venous extraction (p < 0.001) and gastric lavage (p = 0.001). Respondents reported parents' absence during 56.1% of procedures.

CONCLUSIONS

Available pain assessment scales and NPA interventions to mitigate pain are being underused. The presence of the parents during painful interventions is low despite the evidence that this may help to reduce newborns' perception of pain.

Multicentre Spanish study found no incidences of viral transmission in infants born to mothers with COVID-19

AIM

Our aim was to describe the clinical features of mothers infected with COVID-19 and examine any potential vertical mother to newborn transmission. We also assessed how effective the discharge recommendations were in preventing transmission during the first month of life.

METHODS

This multicentre descriptive study involved 16 Spanish hospitals. We reviewed the medical records of 42 pregnant women diagnosed with COVID-19 from March 13, 2020, to March 29, 2020, when they were in their third trimester of pregnancy. They and their newborn infants were monitored until the infant was 1 month old.

RESULTS

Over half (52.4%) of the women had a vaginal delivery. The initial clinical symptoms were coughing (66.6%) and fever (59.5%), and one mother died due to thrombo-embolic events. We admitted 37 newborn infants to the neonatal unit (88%), and 28 were then admitted to intermediate care for organisational virus-related reasons. No infants died, and no vertical transmission was detected during hospitalisation or follow-up. Only six were exclusively breastfed at discharge.

CONCLUSION

There was no evidence of COVID-19 transmission in any of the infants born to COVID-19 mothers, and the post-discharge advice seemed effective. The measures to avoid transmission appeared to reduce exclusive breastfeeding at discharge.

[CD64 index as a marker of infection in patients with postoperative fever]

OBJECTIVE

To evaluate the utility of the granulocyte CD64 index as a marker of infection in patients with postoperative fever.

METHODS

Prospective observational study of a cohort of patients with postoperative fever (2nd-21st day after the intervention) collected during 14 months. Obtaining blood samples during the first 24 hours after the febrile peak to determine the CD64 index (ratio of fluorescence intensity, measured, in the granulocytes of the patient with respect to healthy controls), procalcitonin and C-reactive protein (CRP).

RESULTS

During the study period, 50 patients were included, 28 patients (56%) with infection and 22 patients (44%) without evidence of infection. The PCR, procalcitonin and the CD64 index showed significantly higher values in the group of patients who suffered infection. The CD64 index showed a sensitivity of 88.9%, with a specificity of 65.2%. The positive predictive value (PPV) was 75% and the negative predictive value (NPV) was 83.3%, with an area under the curve (AUC) of 0.805 (95% CI 0.68-0.93). Procalcitonin presented a sensitivity of 53.9% and specificity of 86.4%, with NPV and PPV of 82.4% and 61.3% respectively, with AUC of 0.752 (95% CI 0.61-0.89). Regarding the PCR, it showed a sensitivity of 100%, with specificity of 4.4% with an area under the curve of 0.676 (95% CI 0.52-0.83).

CONCLUSIONS

The quantification of the CD64 index in patients who develop fever in the early postoperative period is useful to distinguish post-surgical inflammatory phenomena from episodes of established infection.

Cessation of breastfeeding in association with oxytocin administration and type of birth. A prospective cohort study

BACKGROUND

Some studies have suggested an association between synthetic oxytocin administration and type of birth with the initiation and consolidation of breastfeeding.

AIM

This study aimed to test whether oxytocin administration and type of birth are associated with cessation of exclusive breastfeeding at different periods. A second objective was to investigate whether the administered oxytocin dose is associated with cessation of exclusive breastfeeding.

METHODS

We conducted a prospective cohort study (n=529) in a tertiary hospital. Only full-term singleton pregnancies were included. Four groups were established based on the type of birth (vaginal or cesarean) and the intrapartum administration of oxytocin. Follow-up was performed to evaluate the consolidation of exclusive breastfeeding at 1, 3 and 6months.

FINDINGS

During follow-up, the proportion of exclusive breastfeeding decreased in all groups. After adjusting for confounding variables, the group with cesarean birth without oxytocin (planned cesarean birth) had the highest risk of cessation of exclusive breastfeeding (odds ratio [95% confidence interval], 2.51 [1.53-4.12]). No association was found between the oxytocin dose administered during birth and puerperium period and the cessation of exclusive breastfeeding.

CONCLUSION

Planned cesarean birth without oxytocin is associated with the cessation of exclusive breastfeeding at 1, 3 and 6months of life. It would be desirable to limit elective cesarean births to essentials as well as to give maximum support to encourage breastfeeding in this group of women. The dose of oxytocin given during birth and puerperium period is not associated with cessation of exclusive breastfeeding.

A Comparison of Factors Associated with Cessation of Exclusive Breastfeeding at 3 and 6 Months

AIM

To analyze the association of labor and sociodemographic factors with cessation of exclusive breastfeeding (EBF) at 3 and 6 months of life.

MATERIALS AND METHODS

A prospective cohort study (n = 529) was performed in a tertiary hospital with the Baby-Friendly Hospital Initiative (BFHI) award. Labor and sociodemographic factors were investigated. Single-term newborns were included. After 3 and 6 months, telephone calls were made to determine the type of lactation. Univariate analysis was performed with the chi-square test or Fisher's exact test. Multivariable logistic regression models were developed to determine risk factors associated with cessation of breastfeeding at 3 and 6 months.

RESULTS

At 3 months, 523 participants (98.9%) were contacted, of whom 64.4% maintained EBF. Factors associated with cessation were pacifier use (odds ratio [OR] 3.49; 95% confidence interval [95% CI] 2.24-5.43), cesarean delivery (OR 4.49; 95% CI 2.96-6.83), no college degree (OR 2.01; 95% CI 1.35-3.01), and not attending breastfeeding support groups (OR 1.96; 95% CI 1.22-3.12). At 6 months, 512 participants (96.8%) were contacted, of whom 31.4% maintained EBF. Factors associated with cessation were reintegration into the workplace (OR 4.49; 95% CI 2.96-6.83), pacifier use (OR 3.49; 95% CI 2.24-5.43), and primiparity (OR 1.61; 95% CI 1.05-2.46).

CONCLUSIONS

Several risk factors are associated with the premature cessation of EBF. There is a need to define strategies to correct modifiable factors and to promote protective factors with the aim of improving the success rate of EBF to reach the recommendations of the World Health Organization.