Newborn – AFA 2014

1 When examining a newborn, systematically look for subtle congenital anomalies (e.g., ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes.

History:

  • Pregnancy
    • planned/not, prenatal care, Prev OB Hx,
    • results of routine tests (ABO blood type, Rh antibody, Hemoglobin, TSH [if done],
    • Urinalysis and urine culture, GBS swab result
    • Chlamydia and Gonorrhea screen) maternal infection screen,
    • prenatal genetic screening, gestational DM
  • Labour – length of labour, duration of ROM, presence of meconium
  • Delivery – mode of delivery, Apgars, need for resuscitation
  • History of congenital abnormalities, stillbirths, genetic/syndromic conditions
  • Mother and father’s medical and genetic history – e.g., maternal lupus, pre-eclampsia

Physical Exam:

General Appearance:
  • Body position at rest – posture often reflects the position the fetus was in in utero
  • Body Movement – check symmetry
  • Nutritional state – subcutaneous fat in anterior thigh, gluteal region; amount of Wharton’s jelly in umbilical cord
  • Colour – pale, ruddy, jaundiced
  • Respiratory effort – increased RR, nasal flaring, accessory muscle use, indrawing, grunting

Causes of Hyperbilirubinemia in Newborns
  1. Unconjugated hyperbilirubinemia
    • Physiologic hyperbilirubinemia (most common cause)
    • Breastfeeding (dehydration) and breastmilk (inhibitory enzyme) jaundice
    • Increased production of bilirubin: hemolysis (immune or nonimmune), sequestered blood (subdural hematoma, cephalhematoma, hemangioma, ecchymosis), polycythemia, sepsis
    • Decreased hepatic uptake or conjugation: hypothyroidism, Gilbert syndrome, Crigler-Najjar syndrome (types I and II), transient familial neonatal hyperbilirubinemia (Lucey-Driscoll syndrome)
  2. Conjugated hyperbilirubinemia
    1. Hepatobiliary disorders: neonatal idiopathic hepatitis, infections (TORCH, echovirus, syphilis, systemic infections), prolonged parenteral nutrition, severe hemolytic disease, metabolic disorders (galactosemia, glycogen storage diseases)
    2. Ductal disturbances in bilirubin excretion: biliary atresia, choledochal cyst, bile plug syndrome

Differential Diagnosis of Cyanosis in Infants
  1. Pulmonary disorders: Respiratory distress syndrome, Aspiration syndromes: blood, meconium, amniotic fluid, Infections: pneumonia, Pneumothorax, pleural effusion, Diaphragmatic hernia, Persistent pulmonary hypertension of the newborn, Choanal atresia
  2. Pierre Robin syndrome*: Pierre Robin syndrome includes micrognathia, glossoptosis, and cleft of the soft palate; the primary defect is early mandibular hypoplasia.
  3. Abdominal distension: elevation of diaphragm
  4. Cardiac disorders: Fallot’s tetrology, Transposition of the great arteries, Tricuspid atresia, Pulmonary atresia with intact ventricular septum, Truncus arteriosus, Ebstein’s anomaly, Double-outlet right ventricle, Single ventricle with pulmonary stenosis, Total anomalous pulmonary venous drainage, Coarctation of the aorta†, Interrupted aortic arch†, Hypoplastic left heart syndrome†
    • Coarctation of the aorta, interrupted aortic arch, and hypoplastic left heart syndrome cause systemic hypoperfusion with mild or no cyanosis.
  5. Others
    • Central nervous system disorders: neuromuscular infections, asphyxia, seizures, hemorrhage, apnea
    • Hematologic disorders: polycythemia
    • Metabolic and endocrine disorders: hypoglycemia, hypocalcemia, hypermagnesemia
    • Hypothermia

Measurements:

  • Head circumference: avg. 35 cm at 40 weeks, may change over first few days because of moulding, edema
  • Length: avg. 51 cm at 40 weeks
  • Weight: avg. 3.6 kg for males, 3.5 kg for females at 40 weeks
  • Vital signs (axillary temp 36.1 to 37ºC (97.0 to 98.6ºF) in an open crib; RR 40-60/minute, count over full minute; HR 120-160 bpm)

Head Circumference and Fontanelle Size in Newborns*
  • The size of the head and the anterior and posterior fontanelles should be compared with appropriate standards.
  • Head size varies with age, sex, and ethnicity and has a general correlation with body size.
  • Macrocephaly: as an isolated anomaly, is often familial, with autosomal dominant inheritance; may be a manifestation of other anomalies, including hydrocephalus and skeletal disorders such as achondroplasia
  • Microcephaly: can be familial, with autosomal dominant or recessive inheritance; may be associated with infections (viruses such as cytomegalovirus) and syndromes such as trisomy 13 and 18, Cornelia de Lange’s, Rubinstein-Taybi, Prader-Willi, and fetal alcohol
  • Large fontanelles: may be associated with hypothyroidism, trisomy 13, 18, and 21 syndromes, and bone disorders such as cleidocranial dysostosis or hypophosphatasia

SGA (BW <10%)
  1. Symmetric:
    • Features: onset early in gestation; brain size corresponding with body size; glycogen and fat content corresponding with body size (hence, lower risk of hypoglycemia)
    • Etiology: environmental factors such as smoking or drugs (heroin, methadone, ethanol, phenytoin [Dilantin]); genetic factors such as small maternal size or chromosomal disorder (trisomy 13, 18, and 21 syndromes, Turner’s syndrome); intrauterine infections such as TORCH, bacterial (tuberculosis), or spirochetic (syphilis); metabolic disorders such as phenylketonuria
  2. Asymmetric
    • Features: onset late in gestation; no effect or minimal effect on fetal brain growth; reduced glycogen and fat content relative to body size (hence, increased risk of hypoglycemia); increased risk of perinatal asphyxia and polycythemia (hyperviscosity)
    • Etiology: uteroplacental insufficiency with chronic fetal hypoxia
LGA (BW >90%)
  • Features: increased incidence of perinatal asphyxia and birth injuries; respiratory distress syndrome; hypoglycemia
  • Etiology: maternal diabetes (increased likelihood of large birth size, respiratory distress syndrome, and hypoglycemia)

Organ system:

Skin
  • Possible underlying disorder beneath abnormal pigmentation, macular stains, congenital nevi, or hemangiomas
  • Benign conditions include milia  (keratin / sebaceous material – often on nose and cheeks); transient neonatal pustular melanosis (superficial pustules on top of hyperpigmented macules, mostly in African-American neonates); erythema toxicum neonatorum (white pustules on erythematous base); Sucking blister, Mongolian spots (congenital bluish-grey or brown pigmented macules, indefinite borders, especially in African-American or Asian babies); nevus simplex (i.e., macular stain, angel kiss, or stork bite); nevus flammeus (i.e., port wine stain, may or may not be benign)

Head – check shape and size; presence of abnormal hair; unusual lesions or protuberances; lacerations, abrasions or contusions; scalp defects
  • Fontanelles – normal is soft and flat with infant sitting.
    • Tense or bulging fontanelles – suspect increased ICP (e.g. bacterial meningitis, subdural hematoma)
  • Sutures – often have moulding with transit through birth canal, but asymmetric skull that persists for longer than 2-3 days after birth or a persistent palpable ridge along the suture line may suggest craniosynostosis;
    • consider increased ICP due to hydrocephalus with widely split sutures with full fontanelle
  • Bleeding: caput succedaneum, cephalohematoma, subgaleal hemorrhages (blood between aponeurosis of scalp and periosteum, extend across suture lines, feel fluctuant and firm, can get ++bleeding, can be life-threatening)

Common Forms of Head Trauma in Newborns

Caput succedaneum

  • Commonly observed after prolonged labor
  • Secondary to accumulation of blood or serum above the periosteum
  • Clinical features: poorly demarcated soft tissue swelling that crosses suture lines; accompanying pitting edema and overlying petechiae, ecchymoses and purpura at the presenting part of the head
  • Treatment: none needed because condition usually resolves within days

Cephalhematoma

  • Less common than caput succedaneum but may occur after prolonged labor and instrumentation
  • Secondary to rupture of blood vessels that traverse skull to periosteum
  • Clinical features: well-demarcated, often fluctuant swelling that does not cross suture lines; no overlying skin discoloration; possibly, skull fractures; sometimes, elevated ridge of organizing tissue
  • Complications: intracranial hemorrhage with resultant shock; hyperbilirubinemia
  • Treatment: none recommended for uncomplicated lesions, which usually reabsorb in 2 weeks to 3 months;
    • for suspected or detected fracture, radiographs again at 4 to 6 weeks to ensure closure of linear fractures and to exclude formation of leptomeningeal cysts, which can be detected by radiography (if there is doubt, cranial computed tomographic scanning can be helpful);
    • for depressed skull fractures, immediate neurosurgical consultation

face Face – check symmetry
    • Facial nerve palsies with inability to close eye, nasolabial fold flattening, inability to move lips on the affected side
      • increased risk if have forceps delivery or prolonged labour and delivery in mother with prominent sacral promontory)
      • should resolve within days to weeks;
      • have difficulty effecting a seal around the nipple and consequently exhibit drooling of milk; ensure baby can feed prior to discharge; persistent facial palsy may be due to central lesion
    • Asymmetric Crying Facies due to inadequate depressor anguli oris muscle, causes mouth asymmetry when crying; may be associated with cardiovascular anomalies

 Eyes
  • Spacing (hypertelorism [wide interpupillary distance] associated with numerous syndromes
  • Symmetry: epicanthal folds, globe size, ptosis, extra-ocular movements
  • Palpebral fissures: may be widened or narrow; could be normal variant or part of syndrome; upward slanting from inner canthus seen in Down syndrome
  • Sclera: normally white, clear; may be light blue in premature infants; consider osteogenesis imperfecta if dark blue
  • Conjunctiva: check for hemorrhage, inflammation, purulent discharge
  • Cornea: consider glaucoma if enlarged (>12 mm), photophobia, increased tearing, corneal haze
  • Pupils: check shape, reactivity to light
  • Iris: check for defects (e.g. coloboma), which may be part of syndrome
  • Red reflex: abnormalities may be caused by cataracts, retinoblastoma, or persistent fetal vasculature

 Conjunctivitis in Newborns
  1. Chemical conjunctivitis
    • Usually occurs within 24 hours of instillation of eye prophylaxis after birth
    • Clinical features: mild lid edema with sterile discharge from eyes
    • Treatment: none needed because condition usually resolves within 48 hours after birth
  2. Gonorrheal conjunctivitis
    • Usually occurs within 24 to 48 hours after birth
    • Clinical features: profound lid edema, chemosis, intensely purulent exudates, corneal ulceration
    • Treatment:
      • ceftriaxone (Rocephin), 25 to 50 mg per kg IV or IM (not to exceed 125 mg) given once, or
      • cefotaxime (Claforan), 100 mg per kg IV or IM given once;
      • until discharge is eliminated, frequent eye irrigations with saline;
      • gonorrheal treatment for the mother and her sexual partner(s)
  3. Chlamydial conjunctivitis
    • Usually occurs within 7 to 14 days after birth
    • Clinical features: watery discharge that later becomes copious and purulent; if untreated, may result in corneal scarring and pannus formation
    • Treatment: orally administered erythromycin, 50 mg per kg per day in four divided doses for 2 weeks
  4. HSV conjunctivitis
    • Usually occurs within 2 weeks after birth
    • Eyes involved in 5% to 20% of HSV-infected infants
    • Clinical features: infants may present with keratitis, cataracts, chorioretinitis, or optic neuritis; imperative to rule out disseminated herpes
    • Treatment: both topical and systemic antiviral agents, because HSV-infected neonates do not present with isolated conjunctivitis;
      • systemic therapy—acyclovir (Zovirax), 60 mg per kg per day in three divided doses for 14 days if disease is limited to skin, eyes, and mouth;
      • topical therapy—1% trifluridine (Viroptic) or 3% vidarabine (Vira-A);
      • referral to subspecialist

 Ears: check position, size, and appearance
  • Positionhelix should be along horizontal line from outer canthus of eye and perpendicular to vertical axis of head
  • Malformations – check for sinuses, preauricular skin tags or pits, or dysplastic features; may indicate anomalies of inner ear and associated hearing loss; may be part of syndrome, esp. renal.
  • Hearing – may need to repeat

U/S should be performed in newborns with isolated ear anomalies, such as preauricular pits or cup ears, only when they are associated with one or more of the following characteristics: other malformations or dysmorphic features, teratogenic exposures, a family history of deafness, or a maternal history of gestational diabetes.


Nose: check shape (abnormal if extremely thin or broad or depressed nasal bridge) and patency (rule out septal deviation, choanal atresia)
Mouth:
  • check size and shape; small jaw may be associated with Robin sequence;
  • check for cleft lip and palate;
  • check tongue for tongue tie; assess gingival, palate, uvula; natal teeth may be associated with syndrome

Neck: check for masses, decreased mobility (torticollis), redundant skin (may be associated with syndrome, e.g. Turner), and clavicles
  • 1 = Preauricular area (parotid gland): congenital lesions- cystic hygroma, hemangioma, venous malformation; inflammatory condition-lymphadenitis secondary to infection in upper face and/or anterior scalpneck
  • 2 = Postauricular area: congenital lesions- branchial cleft I cyst (cystic, inflamed, or both); inflammatory condition-lymphadenitis secondary to inflammation of posterior scalp
  • 3 = Submental area: congenital lesions-thyroglossal duct cyst, cystic hygroma, dermoid cyst, venous malformation; inflammatory condition-lymphadenitis secondary to inflammation in perioral area, anteriour oral area, or nasal cavity
  • 4 = Submandibular area: congenital lesions- cystic hygroma, hamangioma, ranula; inflammatory condition-lymphadenitis of submandibular gland secondary to inflammation in cheek and/or mid-oral cavity; in cystic fibrosis, enlartement of submandibular gland without inflammation
  • 5 = Jugulodiagastric area (tonsil node; normal structures include transverse process of C2 and styloid process): congenital lesions- bronchial cleft I or II, hemangioma, cystic hygrom; inflammatory condition- lymphadenitis secondary to oropharyngeal inflammation
  • 6 = Area of neck midline (normal structures include hyoid, thyrouid isthmus, and thyroid cartilage): congenital lesions-thyroglossal duct cyst, dermoid cyst; inflammatory condition-lymphadenitis
  • 7 = Area at anterior border of sternocleidomastoid muscle (normal structures include hyoid, thyroid cartilage, and carotid bulb): congenital lesions-branchial cleft I, II, or III (IV is rare), laryngocele, hemangioma, lymphangioma, hematoma (fibroma of sternocleidomastoid muscle)
  • 8 = Spinal accessorry: inflammatory condition-lymphadenitis secondary to nasopharyngeal inflammation
  • 9 = Paratracheal area: thyroid mass, parathyroid mass, esophageal diverticulum, metastatic lesion
  • 10 = Supraclavicular area (normal structures include fat pad, pneumatocele from apical lobe related to defect in Gibson fascia[prominent mass with Valsalva’s maneuver]): congenital lesion-cystic hygroma; neoplastic lesion-lipoma.
  • 11 = Suprasternal area: thyroid mass, lipoma, dermoid cyst, thymis mass, mediastinal mass

Cardio: auscultate, palpate chest and pulses
  • Murmur: worrisome murmur: Grade III or higher, harsh quality, pansystolic, loudest LUSB, abnormal S2, decreased femoral pulses, other abnormalities; patent ductus murmur – continuous, harsh; some murmurs develop in few days, so auscultation needs to be repeated prior to discharge and in outpatient visit
  • Pulses: decreased femoral in coarctation; increased pulse pressure in PDA
Resp: check size, symmetry, structure of chest, chest wall movement, and resp effort
Breast: check size and nipple position (>25% of chest circumference = wide-spaced, may occur in genetic syndromes, like Turner syndrome)

Abdomen:
  • check size, overall appearance, normally slightly protuberant;
  • look for distension (e.g. with organomegaly, bowel obstruction, or ascites) or scaphoid appearance (e.g. with diaphragmatic hernia), and
  • abdo wall defects (umbilical hernia, omphalocele, or gastroschisis).
  • Palpate while infants’ legs are flexed, check liver edge (normal 1-3 cm below R. costal margin), palpate for spleen (not usually palpable) and kidneys;
  • check for masses; inspect umbilical cord for signs of infection, number of vessels (single umbilical artery associated with higher number of chromosomal and congenital abnormalities)
Differential Diagnosis of Abdominal Masses in Newborns
  • Renal masses: hydronephrosis (ureteropelvic junction obstruction, posterior urethral valves, vesicoureteric reflux), cystic disease of the kidneys (multicystic dysplastic kidneys, polycystic kidneys), renal vein thrombosis, tumors (Wilms’ tumor, mesoblastic nephroma)
  • Gastrointestinal masses: duplication cyst, complicated meconium ileus (intraperitoneal meconium cyst), mesenteric or omental cyst, hypertrophic pyloric stenosis
  • Nonrenal retroperitoneal masses: adrenal hemorrhage, tumors (neuroblastoma, teratoma, rhabdomyosarcoma, sacrococcygeal teratoma)
  • Genital masses: hydrometrocolpos, ovarian mass (simple cyst, torsion, teratoma)
  • Hepatobiliary masses: infections (viruses, bacteria), lysosomal storage diseases (glycogen storage diseases), congestive heart failure, tumors (hepatoblastoma), choledochal cyst, hemolytic anemias
  • Splenomegaly: infections (viruses, spirochetes), congenital hemolytic anemias (hereditary spherocytosis, thalassemia, hemoglobinopathies), storage disorders (Gaucher’s disease, Niemann-Pick disease), mucopolysaccharide disorders (Hurler’s syndrome)
Omphalocele
  • Clinical features: defect covered by amnion, with cord attachment to apex of defect; prematurity and intrauterine growth retardation less common than in gastroschisis
  • Herniation through defect: any abdominal organ, but usually the large or small intestine, liver, stomach, gall bladder, urinary bladder, pancreas, spleen, or internal genitalia
  • Associated anomalies in 67% of affected newborns: trisomy 13, 18, or 21 syndrome, congenital heart disease (15% to 25%), gastrointestinal anomalies (midgut volvulus, Meckel’s diverticulum, intestinal atresia and duplication, imperforate anus, colonic agenesis), and neurologic and renal anomalies (20%)
Gastroschisis
  • Clinical features: no sac covering the defect; defect in abdominal wall positioned to right of umbilicus; cord attachment to abdominal wall to left of defect; prematurity and intrauterine growth retardation more common than in omphalocele
  • Herniation through defect: usually limited to small intestine and ascending colon, with thickened and matted appearance of intestine
  • Associated anomalies: primarily intestinal atresia

Genitalia: confirm sex.
  • Female: check labia, clitoris, meatus, and vaginal opening; labia minora and clitoris more prominent in preterm infants
  • Male: check testes (descent), penis, scrotum, position of urethral opening
  • Ambiguous genitalia: may indicate sexual differentiation problem or congenital adrenal hyperplasia (can get salt-wasting crisis)
  • Anus: check location, patency; imperforate anus may be part of syndrome (e.g. VACTERAL association)

Bilateral undescended testes, a micropenis, or a bifid scrotum should prompt investigation for ambiguous genitalia.

Newborns with a hypospadias should not be circumcised because the foreskin may be needed for repair.

Inguinal hernia

  • Incidence: term newborns, 0.5% to 1%; premature newborns, 5% to 10%
  • Clinical features: soft, nontender, reducible bulge in the inguinal canal, off the midline, especially at times of increased intra-abdominal pressure, with possible extension into scrotum; when incarcerated, tenderness and tenseness of hernia, with discoloration of overlying skin
  • Complications: incarceration and strangulation
  • Treatment: elective surgical repair as soon as possible after diagnosis

Hydrocele

  • Clinical features: painless, tense, fluctuant scrotal mass that transilluminates; upper border usually movable away from inguinal canal; possibly, testis not palpable
  • Treatment: none usually needed, because hydroceles generally decrease in size and resolve over the first year of life; if not resolved by the age of 1 to 2 years, consideration of elective surgical repair; for communicating hydrocele (i.e., one that fluctuates in size), same treatment as for inguinal hernia

Hands and feet:
  • check digits (fused or extra digits may be normal variant or part of syndrome),
  • palmar crease (single crease more metatarsus adductuscommon in Down syndrome),
  • movement of all 4 limbs (may have brachial plexus injury or palsies, like Erb’s palsy, which is damage to C5 and C6 nerve roots)

Metatarsus adductus is identified by the C curve of the lateral border of the foot

  • associated with a fixed intrauterine position and may be associated with developmental hip dysplasia.
Brachial Plexus Injury in Newborns*
Erb-Duchenne palsy
  • Incidence: most common brachial nerve injury involving spinal nerve roots C5–7
  • Clinical features: arm adducted and internally rotated, with elbow extension, pronation of arm, flexion of wrist, and intact grasp reflex; “waiter’s tip” position if spinal nerve root C7 is involved
Klumpke’s palsy
  • Incidence: rare (<1% of brachial plexus injuries); involves spinal nerve roots C8-T1
  • Clinical features: hand paralyzed, with no voluntary movements of wrist and an absence of grasp reflex
Paralysis of entire arm
  • Incidence: more common than Klumpke’s paralysis
  • Clinical features: entire arm paralyzed and flaccid, with absence of all reflexes

Hips: Barlow and Otolani
  • check for developmental dysplasia (risk factors: female, breech position, family hx), needs to be repeated at outpatient follow-up visits
  • Girls born in the breech position should receive imaging to evaluate for hip dysplasia.
  • Imaging should be considered in newborns with a family history of developmental hip dysplasia and in newborn boys born in the breech position.

Spine:

visualize and palpate, check for neural tube defect (NTD), soft tissue masses (lipomas, mylomeningoceles), sacral cleft or dimple (more worrisome if deep, big > 0.5 cm, above gluteal crease, skin changes associated with NTD). May have underlying spinal cord abnormality if have tuft of hair, discolouration, or hemangioma over sacrococcygeal region

A sacral dimple is simple if it is less than 0.5 cm in diameter, located within 2.5 cm of the anal verge, and not associated with cutaneous markers (discoloration or hypertrichosis). In the absence of these criteria, ultrasonography should be performed before three months of age to evaluate for spinal dysraphism.


Neuro: check alertness, spontaneous motor movement, strength, tone, primitive reflexes
Neurologic Impairment in Newborns
  • Causes: ischemia (intrapartum or postnatal), cerebral birth trauma (including intracranial hemorrhages), congenital malformations, sepsis or meningitis, prenatal infections, neuromuscular disorders, maternal medications, metabolic disorders, degenerative diseases
  • Clinical features of neurologic impairment in newborns: hypotonia (less frequently, hypertonia), weakness (decreased strength), asymmetry of muscle tone and/or movement, alterations in level of consciousness, seizures, single or multiple cranial nerve involvement, fasciculations

2 In a newborn, where a concern has been raised by a caregiver (parent, nurse),

a) Think about sepsis as a ddx, and
b) Look for signs of sepsis, as the presentation can be subtle (i.e. not the same as in adults, non-specific, feeding difficulties, respiratory changes, irritability)
c) Make a provisional diagnosis of sepsis.

Sepsis Risk Factors:

  • GBS+ – Check if maternal intrapartum antibiotics received (at least 2 doses for GBS+)
  • Intrapartum fever ≥38ºC (100.4ºF)
  • Membrane rupture ≥18 hours
  • Delivery at <37 weeks gestation
  • Chorioamnionitis
  • 5 minute Apgar <6
  • Fetal distress during labour

Exam for sepsis: may have subtle, non-specific signs: temperature instability, respiratory distress, anorexia, vomiting, jaundice, hepatomegaly, lethargy, cyanosis, irritability, apnea, abdo distension, diarrhea


3 Resuscitate newborns according to current guidelines.

nrp


4 Maintain neonatal resuscitation skills if appropriate for your practice.


5 When a parent elects to bottle feed, support their decision in a non-judgemental manner.

Encourage breast feeding for newborn, but don’t criticize a parent’s decision to bottle feed.


6 In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (e.g., hips abnormality, heart murmur, hearing).

Ensure newborn able to feed, void, stool; advise parents to seek immediate advice with physician if baby lethargic or febrile; seek prompt help if other signs of sepsis. Should have follow-up within first week for 1st newborn visit, esp. to check weight, feeding pattern, voiding/stooling, address parental concerns


7 When discharging a newborn from hospital,
a) Advise parent(s) of warning signs of serious or impending illness, and
b) Develop a plan with them to access appropriate care should a concern arise.


References:
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Posted in 67 Newborn, 99 Priority Topics, FM 99 priority topics, OB

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