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lowing the vaccine administration, lipid nanoparticles con-
taining the vaccine mRNA are carried to mammary glands via
hematogenous and/or lymphatic routes.
5,6
Furthermore, we
speculate that vaccine mRNA released into mammary cell cy-
tosol can be recruited into developing EVs that are later se-
creted in EBM.
The limitations of this study include the relatively small
sample size and the lack of functional studies demonstrating
whether detected vaccine mRNA is translationally active. Also,
we did not test the possible cumulative vaccine mRNA expo-
sure after frequent breastfeeding in infants. We believe it is safe
to breastfeed after maternal COVID-19 vaccination. However,
caution is warranted about breastfeeding children youngerthan
6 months in the first 48 hours after maternal vaccination un-
til more safety studies are conducted. In addition, the poten-
tial interference of COVID-19 vaccine mRNA with the im-
mune response to multiple routine vaccines given to infants
during the first 6 months of age needs to be considered. It is
critical that lactating individuals be included in future vacci-
nation trials to better evaluate the effect of mRNA vaccines on
lactation outcomes.
Nazeeh Hanna, MD
Ari Heffes-Doon, MD
Xinhua Lin, PhD
Claudia Manzano De Mejia, MD
Bishoy Botros, BS
Ellen Gurzenda, BS
Amrita Nayak, MD
Author Affiliations: Division of Neonatology, Department of Pediatrics, NYU
Langone Hospital–Long Island, NYU Long Island School of Medicine, Mineola,
New York (Hanna, Heffes-Doon, Nayak);Women and Children’s Research
Laboratory, NYU LongIsland School of Medicine, Mineola, New York (Lin,
Manzano De Mejia, Botros, Gurzenda).
Accepted for Publication: July 25, 2022.
Published Online: September 26, 2022. doi:10.1001/jamapediatrics.2022.3581
Correction: This article was corrected on September 30, 2022, to fix the year of
the study period and other minor typographical errors in the eMethods in the
Supplement.
Corresponding Author: Nazeeh Hanna, MD, Division of Neonatology,
Department of Pediatrics, NYU Langone Hospital–Long Island, NYU Long Island
School of Medicine, 259 First St, Mineola, NY 11501 (nazeehhanna@gmail.com).
Author Contributions: Dr Hanna had full access to all of the data in the study
and takes responsibility for the integrity of the data and the accuracy of the data
analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Hanna, Heffes-Doon, Lin, Nayak.
Critical revision of the manuscript for important intellectual content:All authors.
Statistical analysis: Hanna, Lin.
Obtained funding: Hanna.
Administrative, technical, or material support: Hanna, Lin, Manzano De Mejia,
Botros, Gurzenda, Nayak.
Supervision: Hanna.
Conflict of Interest Disclosures: Dr Hanna reported grants from the National
Institute of Child Health and Human Development, National Institute of
Environmental Health Sciences, American Lung Association, March of Dimes,
New York State Department of Health, and Robert Wood Johnson Foundation.
No other disclosures were reported.
Funding/Support: All financial and material support for this work was provided
by the Department of Pediatrics, NYU Langone Hospital–Long Island, New York
University Long Island School of Medicine.
Role of the Funder/Sponsor:The supporting organization had a role in the
design and conduct of the study; collection, management, analysis, and
interpretation of the data; preparation, review, or approvalof the manuscript;
and decision to submit the manuscript for publication.
Additional Contributions: We acknowledge the participants who volunteered
for this study.We are thankful to Christie Clauss, PharmD (Department of
Pharmacy, NYU Langone Hospital–LongIsland), for voluntarily providing
unused vaccines for this study and for her critical revision of the manuscript. We
are also thankful to the following individuals for their voluntary help in
recruitment: Regina Cafferty,RN (Department of Pediatrics, NYU Langone
Hospital–Long Island), and Elisabeth Sulger, MD, and Hollisa Rosa, MD
(Department of Obstetrics and Gynecology, NYU Langone Hospital–Long
Island). None of these individuals received compensation for their contribution.
1. Van Spall HGC. Exclusion of pregnant and lactating women from COVID-19
vaccine trials: a missed opportunity.Eur Heart J. 2021;42(28):2724-2726. doi:
10.1093/eurheartj/ehab103
2. US Food and Drug Administration. Coronavirus (COVID-19) update: FDA
authorizes Moderna and Pfizer-BioNTechCOVID-19 vaccines for children down
to 6 months of age. Released June 17, 2022. https://www.fda.gov/news-events/
press-announcements/coronavirus-covid-19-update-fda-authorizes-moderna-
and-pfizer-biontech-covid-19-vaccines-children
3. Centers for Disease Control and Prevention. COVID-19vaccines while
pregnant or breastfeeding. Accessed March 8, 2021. https://www.cdc.gov/
coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.
4. European Medicines Agency. Assessment report: COVID-19 vaccine
Moderna. Published March 11, 2021. http://www.ema.europa.eu/en/documents/
assessment-report/spikevax-previously-covid-19-vaccine-moderna-epar-public-
assessment-report_en.pdf.
5. Pardi N, Tuyishime S,Muramatsu H, et al. Expression kinetic s of
nucleoside-modified mRNA delivered in lipid nanoparticles to mice by various
routes. J Control Release. 2015;217:345-351.doi:10.1016/j.jconrel.2015.08.007
6. Bansal S, Perincheri S, Fleming T, et al. Cutting edge: circulating exosomes
with COVID spike protein are induced by BNT162b2 (Pfizer-BioNTech)
vaccination prior to development of antibodies: a novel mechanism for immune
activation by mRNA vaccines. J Immunol. 2021;207(10):2405-2410. doi:10.
4049/jimmunol.2100637
COMMENT & RESPONSE
Trends in Autism Spectrum Disorder Among Children
and Adolescents in the US From 2016 to 2020
To the Editor Several studies have reported trends in autism
spectrum disorder (ASD) in recent years, with a particular in-
terest in exploring the potential effects of the COVID-19
pandemic.
1-3
The study by Li et al
1
estimated the prevalence
of ASD among children and adolescents in the US from 2019
to 2020 based on data from the National Health Interview Sur-
vey (NHIS). They reported that the prevalence of ASD de-
creased from 2.76% in 2016 to 2.29% in 2017 and increased
from 2.29% in 2017 to 3.49% in 2020. However, according to
another recent study
2
based on data from the National Sur-
vey of Children’s Health (NSCH), the prevalence of current ASD
diagnoses was stable from 2016 (2.5%) to 2020 (2.7%). Cau-
tion should be taken in the interpretation of the findings from
Li et al
1
for the following reasons.
First, although data from NHIS could be used to estimate
ASD prevalence in the US, the NSCH has a sample size of chil-
dren and adolescents aged 3 to 17 years in 2019 and 2020 4 to
9 times larger than that of NHIS (29 433 and 42 777 from NSCH
vs 7648 and 4870 from NHIS, respectively).
1,2
This difference
is further highlighted by the narrower 95% CIs of weighted
prevalence based on the data from NSCH than that from NHIS.
For instance, the prevalence of ASD in 2020 was 2.7% (95% CI,
Letters
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2.4-3.1) according to NSCH and 3.49% (95% CI, 2.82-4.12) ac-
cording to NHIS.
The higher prevalence of ASD in 2020 in NHIS vs NSCH
could be partially explained by the measurement of ASD. The
estimated prevalence of ASD from NHIS in this
1
and another
prior study
4
is based solely on ever having received a diagno-
sis of ASD, whereas a current diagnosis of ASD was used in the
study
2
citing NSCH data. It is not unexpected that the preva-
lence ASD appears higher among individuals who have ever
been diagnosed with ASD compared with those with a cur-
rent ASD diagnosis. A similar finding
5
has been suggested in
the estimated prevalence of ASD in 2016. However, this dif-
ference would not result in an increasing trend from NHIS and
stable pattern from NSCH over the same period. Giventhat cur-
rent ASD diagnosis was also recorded by NHIS, it is expected
that the authors could check the trends of current ASD diag-
nosis by using data from NHIS to investigatethe reason for the
different patterns.
Chenxi Li, MD
Wen-Qiang He, PhD, BMed, MMSc
Author Affiliations: Melbourne School of Population & Global Health,
University of Melbourne, Melbourne, Victoria, Australia (Li); Children’s Hospital
at Westmead Clinical School, University of Sydney, Sydney, New South Wales,
Australia (He).
Corresponding Author: Wen-Qiang He, PhD, BMed, MMSc, Children’sHospital
at Westmead Clinical School, University of Sydney, Level 2, Charles Perkins
Centre D17,John Hopkins Drive, Camperdown NSW, 2006, Australia (wen-
qiang.he@sydney.edu.au).
Published Online: October 24, 2022. doi:10.1001/jamapediatrics.2022.4109
Conflict of Interest Disclosures: None reported.
1. Li Q, Li Y,Liu B, e t al. Prevalenceof autism spectrum disorder among children
and adolescents in the United States from 2019 to 2020. JAMA Pediatr. 2022;
176(9):943-945. doi:10.1001/jamapediatrics.2022.1846
2. Lebrun-Harris LA, Ghandour RM, Kogan MD, WarrenMD. Five-year trends in
US children’s health and well-being, 2016-2020. JAMA Pediatr. 2022;176(7):
e220056. doi:10.1001/jamapediatrics.2022.0056
3. Solmi M, Song M, Yon DK, et al. Incidence, prevalence,and global burden of
autism spectrum disorder from 1990 to 2019 across 204 countries. Mol Psychiatry.
Published online June 29, 2022. doi:10.1038/s41380-022-01630-7
4. Xu G, Strathearn L, Liu B, Bao W. Prevalenceof autism spectrum disorder
among US children and adolescents, 2014-2016.JAMA. 2018;319(1):81-82. doi:
10.1001/jama.2017.17812
5. Kogan MD, Vladutiu CJ,Schieve LA, et al. The prevalence of parent-reported
autism spectrum disorder among US children. Pediatrics. 2018;142(6):e20174161.
doi:10.1542/peds.2017-4161
In Reply We appreciate the interest in our Research Letter
1
regarding the prevalence of autism spectrum disorder (ASD)
among children and adolescents in the US. Based on data
from the National Health Interview Survey (NHIS), we esti-
mated the prevalence of ASD among US children and ado-
lescents in 2019 to 2020 and examined trends in prevalence
from 2014 to 2020.
We welcome the comments from Li and He discussing
the difference between prevalence of ASD in 2020 based on
NHIS and the National Survey of Children’s Health (NSCH)
and suggesting that current ASD diagnosis be used to
recheck the prevalence trend. We added this to our analysis
of NHIS data to determine the prevalence of current ASD
diagnoses beginning in 2016. The prevalence of current ASD
diagnosis among US children and adolescents aged 3 to 17
years was 2.47% (95% CI, 1.94-3.00) in 2016, 1.99% (95% CI,
1.64-2.34) in 2017, 2.09 (95% CI, 1.65-2.54) in 2018, 2.54%
(95% CI, 2.11-2.97) in 2019, and 3.34% (95% CI, 2.70-3.99) in
2020 (Ptrend = .32). The prevalence of lifetime ASD diagno-
sis was 2.76% (95% CI, 2.20-3.31) in 2016, 2.29% (95% CI,
1.91-2.68) in 2017, 2.44% (95% CI, 1.91-2.98) in 2018, 2.79%
(95% CI, 2.34-3.24) in 2019, and 3.49% (95% CI, 2.82-4.15)
in 2020 (Ptrend = .35) (Figure). We did not find a significant
increase in prevalence of lifetime ASD diagnoses from 2016
to 2020 by year. The results were consistent with our previ-
ous analysis.
1
We concur with Li and He that caution should be taken in
the interpretation of our findings. There are some differences
in the results from different databases, and it is not appropri-
ate to single out a few years but is important to compare the
results of successive years with the overall trend.Notably, the
prevalence of lifetime ASD diagnoses in 2019 was 2.79% (95%
CI, 2.34-3.24), less than the prevalence of current ASD diag-
nosis in 2019 (3.1%; 95% CI, 2.7-3.6) and from 2016 to 2019
(2.9%) in NSCH, and the 95% CI of weightedprevalence in 2019
NHIS was very similar to the 95% CI in 2019 NSCH (2.34-3.24
vs 2.7-3.6, respectively).
1,2
To date, there is no cure for ASD.
3,4
However, the symp-
toms of ASD can decrease over time with appropriate treat-
ment and, in a small number of individuals, be minimized to
the extent that they lose their ASD diagnosis.
3
Therefore, the
number of people with current ASD diagnoses is most likely
to be reduced by way of reduction in symptoms following in-
tervention. Although rehabilitation intervention is typically
carried out after diagnosis, most patients still need close at-
tention and assistance and are not expected to fully recover.
3,5
Therefore, we believe that data on lifetime diagnoses better
reflect reality and help raise awareness of ASD.
Qian Li, MM
Yanmei Li, MM
Wenhan Yang, MD, PhD
Figure. Prevalence of Autism Spectrum Disorder (ASD) in Children
and Adolescents Aged 3 to 17 Years in the US,2016-2020
5
4
3
2
1
0
Weighted prevalence of ASD, %
Year
Current ASD diagnosis
Lifetime ASD diagnosis
2016 2017 2018 2019 2020
Letters
jamapediatrics.com (Reprinted) JAMA Pediatrics December 2022 Volume 176, Number 12 1271
© 2022 American Medical Association. All rights reserved.
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Author Affiliations: Department of Child and Adolescent Health, School of
Public Health, Guangdong Pharmaceutical University,Guangzhou, Guangdong
Province, China.
Corresponding Author: Wenhan Yang,MD, PhD, Department of Child and
Adolescent Health, School of Public Health, Guangdong Pharmaceutical
University,No. 283 Jianghai Rd, Guangzhou City, Guangdong Province,
Guangzhou 510006, China (wenhan-yang@gdpu.edu.cn).
Published Online: October 24, 2022. doi:10.1001/jamapediatrics.2022.4112
Conflict of Interest Disclosures: None reported.
1. Li Q, Li Y,Liu B, e t al. Prevalenceof autism spectrum disorder among children
and adolescents in the United States from 2019 to 2020. JAMA Pediatr. 2022;
176(9):943-945. doi:10.1001/jamapediatrics.2022.1846
2. Bitsko RH, Claussen AH, Lichstein J, et al. Mental health surveillance among
children—United States, 2013-2019.MMWR Suppl. 2022;71(2):1-42. doi:10.
15585/mmwr.su7102a1
3. Xu G, Strathearn L, Liu B, et al. Prevalence and treatment patterns of autism
spectrum disorder in the United States, 2016. JAMA Pediatr. 2019;173(2):153-159.
doi:10.1001/jamapediatrics.2018.4208
4. Lyall K, Croen L, Daniels J,et al. The changing epidemiology of autism
spectrum disorders. Annu Rev Public Health. 2017;38:81-102.doi:10.1146/
annurev-publhealth-031816-044318
5. Lord C, Elsabbagh M, Baird G, Veenstra-Vanderweele J.Autism spectrum
disorder. Lancet. 2018;392(10146):508-520. doi:10.1016/
S0140-6736(18)31129-2
Neurodiversity and Early Autism
To the Editor We appreciated the recent Viewpoint
1
discussing
neurodiversity and early intervention(EI) for autism. We share
the authors’ concerns about systematic discrimination in the
education and employment of individuals with diverse
abilities
2
and agree that society needs to accommodate both
strengths and weaknesses. Having studied the loss of the au-
tism spectrum disorder diagnosis,
3
we agree that the loss of
the diagnosis should not be a priority in EI for autistic chil-
dren; rather, EI should focus on supporting them in lan-
guage, social communication, adaptive behavior, and rela-
tionships. We endorse the long-term goals proposed by
McCauley et al
4
of autonomy, daily living skills, relation-
ships, and employment or other activities outside the home
in forms that are consistent with the individual’s abilities and
interests.
We were particularly interested in the report by Dawson
et al
1
that parents are increasingly expressing reservations
about EI for autistic children and the lack of appreciation for
neurodiversity in these programs. We work with a wide cross
section of parents of autistic children, adolescents, and young
adults, often delivering the initial autism diagnosis, and we
rarely hear concerns expressed over EI and the lack of neuro-
diversity. In our experience, parents have pressing concerns
about language and communication, relationships with sib-
lings and peers, and behavior and adaptive skills; longer-
term concerns typically center on the child’seduc ation and em-
ployment and prospects for autonomy and having a family. In
addition to child-centered concerns, families are worried about
access to support for their children, including decreasing ac-
cess to and increasing costs of EI, coordinating EI with work
schedules, the costs of copays and transportation, and child-
care for siblings. Many of the families we see, including single-
parent families and those who are racially and ethnically mi-
noritized, are socioeconomically disadvantaged. Such families
are often multiply marginalized, and we hear,espec ially from
families with children with multiple diagnoses, that their pri-
mary concern is support for their children, including EI, within
a climate of structural racism.
We are keenly aware that EI professionals face increasing
economic pressure to decrease services. Inefficient or lim-
ited reimbursement, staff shortages, increasing caseloads, and
pandemic-related personnel shortages have all interferedw ith
in-person EI. We hope that all autism stakeholders and advo-
cates will continue to work together to maintain and increase
access to early intervention.
Inge-Marie Eigsti, PhD
Teresa Girolamo, PhD
Deborah Fein, PhD
Author Affiliations: Department of Psychological Sciences, University of
Connecticut, Storrs.
Corresponding Author: Inge-Marie Eigsti, PhD, Department of Psychological
Sciences, University of Connecticut, 406 Babbidge Rd, Storrs, CT 06269
(inge-marie.eigsti@uconn.edu).
Published Online: October 31, 2022. doi:10.1001/jamapediatrics.2022.4141
Conflict of Interest Disclosures: Dr Girolamo reported grants from the
National Institute on Deafness and Other Communication Disorders. No other
disclosures were reported.
1. Dawson G, Franz L, Brandsen S. At a crossroads—reconsideringthe goals of
autism early behavioral intervention from a neurodiversity perspective. JAMA
Pediatr. 2022;176(9):839-840. doi:10.1001/jamapediatrics.2022.2299
2. Eigsti IM, Fein DA, Larson C. Editorial perspective: another look at “optimal
outcome” in ASD. J Child Psychol Psychiatry. Published online June 30,2022.
doi:10.1111/jcpp.13658
3. Fein D, Barton M, Eigsti IM, et al. Optimal outcome in individuals with a
history of autism. J Child Psychol Psychiatry. 2013;54(2):195-205. doi:10.1111/
jcpp.12037
4. McCauley JB, Pickles A, Huerta M, Lord C. Defining positive outcomes in
more and less cognitively able autistic adults. Autism Res. 2020;13(9):1548-1560.
doi:10.1002/aur.2359
Tothe Editor As autistic physicians, we agree with the position
of Dawson et al
1
: the neurodiversity movement regards
autistic individuals to be both neurodivergent (diverging
from the neurotypical majority) and disabled by environ-
ments not designed for autistic flourishing.
1
Neurodiversity-
informed therapeutic interventions therefore emphasize
modification of external factors to better fit the autistic
person.
1
Therapeutic attempts to alter factors within the
person must be done with utmost care to maintain the per-
son’s autistic identity while helping support integration in
the neurotypical world.
1
Applied behavioral analysis (ABA) is a common interven-
tion for autistic children. It seeks to modify socially significant
behaviors in a measurable way.
2
Operant conditioning theory
is central to ABA, which views human behavior as intentional
and contingent on interactions with the environment.
2,3
ABA
is delivered by board-certified behavior analysts, who use tech-
niques such as modeling, shaping, reinforcement, and pun-
ishment to increase skills and so-called socially desired be-
haviors and reduce behaviors that are considered socially
undesirable.
2,3
ABA is foundational to other widespread be-
havioral interventions for autism, including positive behav-
ior support.
4,5
Letters
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