Influencing factors of lactational insufficiency at 72 hours postpartum and construction of nomogram model
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摘要:目的
探讨产妇产后72 h乳汁分泌缺乏的影响因素并构建列线图模型。
方法选取住院分娩的345例产妇作为研究对象, 按照7∶3的比例分为建模组242例和验证组103例，并根据产后72 h乳汁分泌情况将建模组产妇分为乳汁分泌缺乏组69例和乳汁分泌正常组173例。收集产妇的临床资料，采用多因素Logistic回归模型分析产妇产后72 h乳汁分泌缺乏的影响因素; 采用R3.6.3软件构建预测产妇产后72 h乳汁分泌缺乏的列线图模型; 分别绘制受试者工作特征(ROC)曲线和校准曲线，评估列线图模型预测产妇产后72 h乳汁分泌缺乏的区分度和一致性。
结果建模组产妇年龄、孕次、分娩方式、乳头类型等与验证组比较，差异无统计学意义(P>0.05)。乳汁分泌缺乏组初产、剖宫产、分娩至开奶时间>1 h、婴儿24 h吮吸乳房次数≤6次、未进行乳房按摩产妇占比高于乳汁分泌正常组，差异有统计学意义(P＜0.05); 多因素Logistic回归模型分析结果显示，产次、分娩方式、分娩至开奶时间、婴儿24 h吮吸乳房次数均为产妇产后72 h乳汁分泌缺乏的影响因素(OR=3.488、2.381、2.442、2.223, P＜0.05)。ROC曲线显示，该列线图模型在建模组、验证组中预测产妇产后72 h乳汁分泌缺乏的曲线下面积分别为0.844(95%CI: 0.792~0.897)、0.863(95%CI: 0.791~0.935), 校准曲线斜率均接近1，且Hosmer-Lemeshow拟合优度检验结果显示该模型拟合良好(χ2=7.002、4.560, P=0.429、0.714)。
结论产次、分娩方式、分娩至开奶时间、婴儿24 h吮吸乳房次数为产妇产后72 h乳汁分泌缺乏的影响因素，据此构建的列线图预测模型具有较好的区分度和一致性。
Abstract:ObjectiveTo investigate the influencing factors of lactational insufficiency in 72 hours postpartum and to construct a nomogram model.
MethodsA total of 345 puerperae who were hospitalized for delivery were selected as research subjects. According to a ratio of 7 to 3, they were divided into modeling group (242 cases) and validation group (103 cases). Based on the lactation situation at 72 hours postpartum, the modeling group was further divided into lactational insufficiency group (69 cases) and normal lactation group (173 cases). The clinical data of the puerperae were collected. Multivariate Logistic regression model was used to analyze the influencing factors of lactational insufficiency at 72 hours postpartum. R 3.6.3 software was used to construct a nomogram model for predicting lactational insufficiency at 72 hours postpartum. The receiver operating characteristic (ROC) curve and calibration curve were plotted to evaluate the discrimination and consistency of the nomogram model in predicting lactational insufficiency at 72 hours postpartum.
ResultsThere were no significant differences in age, parity, delivery mode, nipple type, and other factors between the modeling group and the validation group (P>0.05). The proportions of primipara, cesarean section, time from delivery to milk expression >1 hour, the number of breastfeeding ≤6 times in 24 hours, and absence of breast massage in the lactational insufficiency group were higher than those in the normal lactation group (P < 0.05). Multivariate Logistic regression model analysis showed that parity, delivery mode, time from delivery to milk expression, and the number of breastfeeding in 24 hours were influencing factors of lactational insufficiency at 72 hours postpartum (OR=3.488, 2.381, 2.442, 2.223, P < 0.05). The ROC curve showed that the area under the curve of the nomogram model in the modeling group and the validation group was 0.844 (95%CI, 0.792 to 0.897) and 0.863 (95%CI, 0.791 to 0.935), respectively. The slope of calibration curve was close to 1, and the Hosmer-Lemeshow goodness-of-fit test showed that the model fitted well (χ2=7.002, 4.560, P=0.429, 0.714).
ConclusionParity, delivery mode, time from delivery to milk expression, and the number of breastfeeding in 24 hours are influencing factors of lactational insufficiency at 72 hours postpartum. The nomogram prediction model constructed based on these factors has good discrimination and consistency.
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Keywords:
- puerpera /
- lactational insufficiency /
- influencing factors /
- nomogram model /
- breastfeeding
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表 1 建模组与验证组基线资料比较(x±s)[n(%)]
指标 分类 建模组(n=242) 验证组(n=103) t/χ2 P 年龄/岁 28.01±5.51 27.45±5.42 0.868 0.386 孕前体质量指数/(kg/m2) 22.51±3.24 22.13±3.26 0.995 0.320 孕次 1次 145(59.92) 57(55.34) 0.624 0.430 ≥2次 97(40.08) 46(44.66) 产次 初产 140(57.85) 51(49.51) 2.032 0.154 经产 102(42.15) 52(50.49) 分娩方式 阴道分娩 164(67.77) 63(61.17) 1.400 0.237 剖宫产 78(32.23) 40(38.83) 分娩至开奶时间 ≤1 h 159(65.70) 74(71.84) 1.243 0.265 >1 h 83(34.30) 29(28.16) 婴儿24 h吮吸乳房次数 ≤6次 74(30.58) 37(35.92) 0.945 0.331 >6次 168(69.42) 66(64.08) 乳头类型 突出 182(75.21) 71(68.93) 1.455 0.228 凹陷/扁平 60(24.79) 32(31.07) 乳房按摩 有 128(52.89) 48(46.60) 1.144 0.285 无 114(47.11) 55(53.40) 乳房胀痛程度 无/轻度 137(56.61) 63(61.17) 0.687 0.709 中度 71(29.34) 28(27.18) 重度 34(14.05) 12(11.65) 
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表 2 乳汁分泌正常组和乳汁分泌缺乏组基线资料比较(x±s)[n(%)]
指标 分类 乳汁分泌正常组(n=173) 乳汁分泌缺乏组(n=69) t/χ2 P 年龄/岁 28.36±5.62 27.14±5.25 1.553 0.122 孕前体质量指数/(kg/m2) 22.27±3.18 23.10±3.39 1.799 0.073 孕次 1次 98(56.65) 47(68.12) 2.701 0.100 ≥2次 75(43.35) 22(31.88) 产次 初产 88(50.87) 52(75.36) 12.138 ＜0.001 经产 85(49.13) 17(24.64) 分娩方式 阴道分娩 127(73.41) 37(53.62) 8.842 0.003 剖宫产 46(26.59) 32(46.38) 分娩至开奶时间 ≤1 h 125(72.25) 34(49.28) 11.558 0.001 >1 h 48(27.75) 35(50.72) 婴儿24 h吮吸乳房次数 ≤6次 41(23.70) 33(47.83) 13.526 ＜0.001 >6次 132(76.30) 36(52.17) 乳头类型 突出 134(77.46) 48(69.57) 1.647 0.199 凹陷/扁平 39(22.54) 21(30.43) 乳房按摩 有 100(57.80) 28(40.58) 5.873 0.015 无 73(42.20) 41(59.42) 乳房胀痛程度 无/轻度 99(57.22) 38(55.07) 1.965 0.374 中度 53(30.64) 18(26.09) 重度 21(12.14) 13(18.84)
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表 3 产妇产后72 h乳汁分泌缺乏的多因素Logistic回归分析
变量 β SE Wald χ2 P OR 95%CI 产次 1.249 0.352 12.564 ＜0.001 3.488 1.748~6.958 分娩方式 0.867 0.348 6.207 0.013 2.381 1.203~4.711 分娩至开奶时间 0.893 0.338 6.972 0.008 2.442 1.259~4.737 婴儿24 h吮吸乳房次数 0.799 0.333 5.756 0.016 2.223 1.157~4.269 乳房按摩 0.385 0.327 1.384 0.239 1.469 0.774~2.789 常量 -2.840 0.401 50.091 ＜0.001 0.058 —
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