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CONTRIBUTORS
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ix
Beena D. Kamath-Rayne, MD, MPH
Associate Professor of Pediatrics
Department of Pediatrics
University of Cincinnati College of Medicine;
Associate Professor of Pediatrics
Perinatal Institute
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Megan Kirkley, MD, MPH
Assistant Professor
Department of Pediatrics
University of Colorado School of Medicine
Aurora, Colorado;
Neonatologist
Department of Pediatrics
Denver Health Medical Center
Denver, Colorado
Betsy Knappen, MSN, APRN
Neonatal Nurse Practitioner
Division of Neonatology
Children’s Mercy Hospital
Kansas City, Missouri
Lawrence C. Ku, MD
Assistant Professor
Department of Pediatrics
Duke University
Durham, North Carolina
Robert M. Lawrence, MD, FAAP
Clinical Professor of Pediatrics
Department of Pediatrics
University of Florida
San Diego, California
Ruth A. Lawrence, MD, DD (Hon), FAAP, FABM
Distinguished Alumna Professor of Pediatrics and
Obstetrics/Gynecology
Division of Neonatology
Department of Pediatrics;
Director
Breastfeeding and Human Lactation Study Center;
Director
Finger Lakes Children’s Environmental Health Center
University of Rochester
Rochester, New York
Harold N. Lovvorn III, MD
Associate Professor
Pediatric Surgery
Vanderbilt University
Nashville, Tennessee
Carolyn Lund, RN, MS, FAAN
Neonatal Clinical Nurse Specialist
Newborn Intensive Care Unit
UCSF Benioff Children’s Hospital—Oakland
Oakland, California;
Associate Clinical Professor
Department of Family Health Care Nursing
University of California
San Francisco, California
Anne L. Matthews, RN, PhD, FACMG
Professor
Genetics & Genome Sciences
Case Western Reserve University;
Director
Genetic Counseling Training Program
Genetics & Genome Sciences
Case Western Reserve University
Cleveland, Ohio
Jane E. McGowan, MD
Professor Emeritus, Pediatrics
Retired Associate Chair for Research
Drexel University School of Medicine
Philadelphia, Pennsylvania
Christopher McKinney, MD
Assistant Professor
Pediatrics
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Susan Niermeyer, MD, MPH, FAAP
Professor of Pediatrics
University of Colorado School of Medicine
Aurora, Colorado

CONTRIBUTORSx
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Michael Nyp, DO, MBA
Associate Professor
Pediatrics
Children’s Mercy—Kansas City;
Associate Professor
Pediatrics
University of Missouri—Kansas City;
Assistant Medical Director of the Donald W. Thibeault
Neonatal Laboratory
Pediatrics
Children’s Mercy—Kansas City
Kansas City, Missouri;
Clinical Assistant Professor
Pediatrics
University of Kansas Medical Center
Kansas City, Kansas
Steven L. Olsen, MD
Neonatologist
Division of Pediatrics
Children’s Mercy Hospital
Kansas City, Missouri
Alexandra Oschman, PharmD, BCPPS
Clinical Pharmacy Specialist
Children’s Mercy Hospital
Kansas City, Missouri
Annette S. Pacetti, BSN, MSN, NNP-BC
Neonatal Nurse Practitioner
Division of Neonatology
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Nashville, Tennessee
Eugenia K. Pallotto, MD, MSCE
Medical Director
Intensive Care Nursery;
Medical Director, Neonatal ECMO;
Professor of Pediatrics Pediatrics/Neonatology
Children’s Mercy Kansas City;
UMKC School of Medicine
Kansas City, Missouri
Alfonso F. Pantoja, MD
Neonatologist
Division of Neonatology
Saint Joseph Hospital;
Neonatologist
Colorado Permanente Medical Group
Denver, Colorado
Webra Price-Douglas, PhD, NNP-BC, IBCLC
Coordinator
Maryland Regional Neonatal Transport Program
Johns Hopkins & University of Maryland Medical
Centers
Baltimore, Maryland
Daphne Reavey, ARNP, MSN, PhD
Neonatal Nurse Practitioner
Division of Neonatology
Children’s Mercy Hospital;
Coordinator: Neonatal Nurse Practitioner Program
Department of Nursing
University of Missouri—Kansas City
Kansas City, Missouri
Nathaniel H. Robin, MD, FACMG
Professor of Genetics
Pediatrics and Otolaryngology
University of Alabama at Birmingham
Birmingham, Alabama
Mario Augusto Rojas, MD, MPH
Medical Director
Neonatal Intensive Care
Department of Pediatrics
Division of Neonatology
Valley Children’s Hospital
Madera, California
Paul J. Rozance, MD
Professor of Pediatrics
University of Colorado School of Medicine
Aurora, Colorado
Mohan Pammi, MD, PhD, MRCPCH
Associate Professor
Department of Pediatrics
Baylor College of Medicine
Houston, Texas
Tamara Rush, MSN, RN, C-NPT, EMT
Nurse Manager
Brenner Children’s Hospital-Wake Forest Baptist Health
Winston-Salem, North Carolina

CONTRIBUTORS
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xi
Danielle E. Soranno, MD
Assistant Professor of Pediatrics
Bioengineering and Medicine
University of Colorado
Aurora, Colorado
John D. Strain, MD, FACR, CAQ
Pediatric Radiology, Neuroradiology
Professor of Radiology
Department of Radiology
University of Colorado School of Medicine;
Chairman, Department of Radiology
Children’s Hospital Colorado
Anschutz Medical Campus
Aurora, Colorado
Julie R. Swaney, MDiv
Director
Department of Spiritual Care Services
University of Colorado Hospital
Aurora, Colorado
Tara Swanson, MD
Director
Fetal Cardiology Program
Heart Center
Children’s Mercy Hospital
Associate Professor
University of Missouri—Kansas City
Kansas City, Missouri
David T. Tanaka, MD
Professor of Pediatrics
Neonatologist
Duke University Medical Center
Durham, North Carolina
Elizabeth H. Thilo, MD
Associate Professor of Pediatrics
Section of Neonatology
University of Colorado School of Medicine;
Neonatologist
Division of Pediatrics
Children’s Hospital Colorado
Aurora, Colorado
Kristin Voos, MD
Director of Family Integrated Care Neonatal Intensive
Care Unit
Associate Professor
Pediatrics, Division of Neonatology
Director of Neonatal-Perinatal Medicine Fellowship
Program
Rainbow Babies and Children’s Hospital
University Hospitals Cleveland Medical Center
Cleveland, Ohio
Beth Boulden Warren, MD, MS
Center for Cancer and Blood Disorders
Children’s Hospital Colorado
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Jason P. Weinman, MD
Associate Professor
Department of Radiology
Children’s Hospital of Colorado;
Associate Professor
Department of Radiology
University of Colorado School of Medicine
Aurora, Colorado
Leonard E. Weisman, MD
Professor of Pediatrics
Baylor College of Medicine;
Neonatology Attending
Pediatrics
Texas Children’s Hospital
Houston, Texas
Rosanne Woloschuk, RD
Clinical Dietitian
The Kidney Center
Children’s Hospital Colorado
Aurora, Colorado
Jennifer Woo, PhD, CNM/WHNP-BC
Assistant Professor
College of Nursing
Texas Woman’s University
Denton, Texas
Kelly Tracy, MS, RD, LD, CNSC
Nutrition Program Coordinator;
Senior Clinical Nutrition Specialist
Department of Nutrition
Children’s Mercy Hospital
Kansas City, Missouri

REVIEWERS
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Sandra Sundquist Beauman, MSN, RNC-NIC, CNS
Manager
Clinical Trials Operations
Department of Pediatrics
University of New Mexico Health Sciences Center
Albuquerque, New Mexico
Stephanie M. Blake, DNP, RN, NNP-BC
Neonatal Nurse Practitioner
Division of Neonatology/Department of Pediatrics
Duke University Medical Center
Durham, North Carolina
Karen D’Apolito, PhD, APRN, NNP-BC, FAAN
Neonatal Nurse Practitioner Program
School of Nursing
Vanderbilt University School of Nursing
Nashville, Tennessee
Joyce Foresman-Capuzzi, MSN, APRN, CCNS, CEN, CPN,
CTRN, CPEN, CCRN, TCRN, AFN-BC, SANE-A, EMT-P, FAEN
Clinical Nurse Educator
Nursing
Lankenau Medical Center
Wynnewood, Pennsylvania
Dolores Greenwood, MSN, RNC-NIC
Education Manager
Stephen & Alexandra Cohen Newborn and Infant
Critical Care Unit
Children’s Hospital Los Angeles
Los Angeles, California
Carie Linder, MSN, APRN, NNP
Neonatal Nurse Practitioner
Neonatal Intensive Care Unit
Integris Baptist Medical Center
Oklahoma City, Oklahoma
Christina Mahoney, RN, BSN, CCRN
RN Staff Nurse II, Charge RN
NICU
Boston Children’s Hospital
Boston, Massachusetts
Diane McClure, DNP, CPNP, CCRN, APHN-BC, CCAP, CEIM
Neonatal Advanced Practice Nurse-Caritas Coach
Maternal Child Health
St. Joseph’s Healthcare System
Paterson, New Jersey
Sarah Mears, MSN, BC-NNP
Neonatal Nurse Practitioner
Intensive Care Nursery
Duke University Medical Center
Durham, North Carolina
Andrea C. Morris, DNP, RNC-NIC, CCRN, CNS
Neonatal Clinical Nurse Specialist
Newborn Intensive Care Unit
Citrus Valley Medical Center-NICU
West Covina, California
Mindy Morris, DNP, NNP-BC, CNS
Consultant
Neonatal
Huntington Beach, California
Tonya Oliver, MSN, RN, NNP-BC
Neonatal Nurse Practitioner
Neonatal
Wake Forest Baptist Health, Duke University
Winston-Salem, North Carolina
Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI
Clinical Nurse Specialist
Pain/Pediatric Intensive Care Unit/Evidence-based
Practice and Research
Children’s Hospital of Pittsburgh of University of
Pittsburgh Medical Center
Pittsburgh, Pennsylvania
xii

REVIEWERS
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xiii
Sandra Priest, RN, MSN, NNP-BC
Assistant Professor
Neonatal Nurse Practitioner Program, School of
Nursing
University Texas Medical Branch
Galveston, Texas
Patricia Scheans, DNP, NNP-BC
NNP, Clinical Support for Neonatal Care
Women’s and Children’s
Legacy Health
Portland, Oregon
Timothy Matthew Snow, BSN, MSN
Neonatal Nurse Practitioner
Wake Forest Baptist Health-Brenner Children’s Hospital
Winston-Salem, North Carolina

PREFACE
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he concept of the team approach is important in neonatal intensive care. Each health
T
the duties of his or her own role but must also
understand the roles of other involved professionals. Nurses, physicians, other health care providers,
and parents must work together in a coordinated
and efficient manner to achieve optimal results for
patients in the neonatal intensive care unit (NICU).
the field of neonatal intensive care, we believe it is
necessary that this book contain input from major
fields of health care—nursing and medicine. Both
nurses and physicians have edited and co-authored
every chapter.
have been reviewed, revised, and updated for the
ninth edition. Unit One presents evidence-based
practice and the need to scientifically evaluate neonatal therapies, emphasizing randomized controlled
trials as the ideal approach. Units Two to Five are
the clinical sections, which have been fully updated
for this edition. The chapters within these sections
include highlighted clinical directions for quick
care professional must not only perform
Because this team approach is so important in
The book is divided into six units, all of which
reference, Parent Teaching boxes to aid in discharge
instructions, Critical Findings boxes to prioritize
assessment data, and medication tables.
The combination of physiology and pathophysiology and separate emphasis on clinical application
in this text is designed for neonatal intensive care
nurses, nursing students, medical students, and
pediatric, surgical, and family practice housestaff.
This text is comprehensive enough for nurses and
physicians, yet basic enough to be useful to families
and all ancillary personnel.
Unit Six presents the psychosocial aspects of
neonatal care. The medical, psychological, and social
aspects of providing care for the ill neonate and
family are discussed in this section. This section in
particular will benefit social workers and clergy,
who often deal with family members of neonates
in the NICU.
In this handbook we present physiologic principles and practical applications and point out areas
as yet unresolved. Material that is clinically
applicable is set in bold type so that it can be
easily identified.
xiv

INTRODUCTION
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n 1974 as the Perinatal Outreach Educator at
the Children’s Hospital in Denver, Colorado,
I
I took a folder to Gerry Merenstein, MD, at
Fitzsimmons Army Medical Center to discuss his
lectures for the first outreach education program in
La Junta, Colorado. When we finished, he removed
from his desk drawer a 1-inch-thick compilation
of the neonatal data, graphs, nomograms, and diagrams he had created for the medical housestaff
during his fellowship. Giving the document to me,
he asked that I review it and let him know what I
thought. Several weeks later, I told him it was good
except there was no nursing care or input, which is
essential in every NICU. So Gerry asked, “Want
to write a book?”—and the idea for the Handbook
was born!
With this ninth edition in 2020, we celebrate
35 years of publication of the Handbook of Neonatal
Intensive Care. Gerry and I co-edited this book for
21 years until his death in December 2007. To fulfill
my promise that Gerry’s name would always be on
the book, the seventh and all subsequent editions
are now known as Merenstein & Gardner’s Handbook
of Neonatal Intensive Care. Instead of editing this
edition alone or with another physician, I decided
to convene an editorial team consisting of myself,
a nurse colleague, and two neonatologists. Together
we bring 180 years of clinical practice, research,
teaching, writing, and consulting in neonatal, pediatric, and family care to this ninth edition.
In the eighth edition, we have the distinction of
translation to Korean and Portuguese. We are still
working on a Spanish translation because this was
an ongoing wish of Gerry Merenstein. In addition,
the Handbook is available on multiple e-platforms
to facilitate use at the bedside. Multiple editions of
the Handbook (first in 1985; fifth in 2002; seventh in
2011; and eighth in 2016) have won the American
Journal of Nursing Book of the Year Award. The
eighth edition of the Handbook placed first in the
Critical Care/Emergency Nursing category.
For our new audience and for our continuing
loyal readers, this is my opportunity to introduce
myself and all members of the editing team.
I am currently the Director of Professional
Outreach Consultation (www.professionaloutreach-
consultation.org), a national and international con-
sulting firm established in 1980. I plan, develop,
teach, and coordinate educational workshops on
perinatal/neonatal/pediatric topics. I graduated
from a hospital school of nursing in 1967 with a
diploma, obtained my BSN at Spalding College in
1973 (magna cum laude), and completed my MS
at the University of Colorado School of Nursing
in 1975 and my PNP in 1978. I have worked in
perinatal/neonatal/pediatric care since 1967 as a
clinician (37 years in direct bedside care), practitioner, teacher, author, and consultant. In 1974, I
was the first Perinatal Outreach Educator in the
United States funded by the March of Dimes. In this
role, I taught nurses and physicians in Colorado and
the seven surrounding states how to recognize and
stabilize at-risk pregnancies and sick neonates. I also
consulted with numerous March of Dimes grantees
to help them establish perinatal outreach programs.
In 1978, I was awarded the Gerald Hencmann
Award from the March of Dimes for “outstanding
service in the improvement of care to mothers and
babies in Colorado.” I am a founding member of
the Colorado Perinatal Care Council (now the
Colorado Perinatal Care Quality Collaborative).
I am an active member of the Colorado Nurses
Association/American Nurses Association, the
Academy of Neonatal Nurses, and the National
Association of Neonatal Nurses.
Mary Enzman-Hines, PhD, APRN, CNS, CPNP,
APHN-BC, is currently Professor Emeritus at BethEl College of Nursing at the University of Colorado
xv

INTRODUCTIONxvi
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in Colorado Springs and co-owner and certified
Pediatric Nurse Practitioner at Integrative Pediatric
Health Care in Englewood, Colorado (www.ip-
hcdenver.com). This is the first nurse practitioner
owned and operated practice in Colorado. Early in
her nursing career, Mary worked in the NICU and
PICU as a staff nurse, charge nurse, and nurse manager. After completing her PNP/CNS program and
her master’s degree at the University of Colorado,
Mary became the Neonatal and Pediatric Clinical
Nurse Specialist at Denver Health and Hospital,
where she created a beginning, intermediate, and
advanced orientation for nurses in the NICU and
PICU. At the University of Colorado, Mary accepted
the practitioner/teacher role in maternal-child services, providing clinical care and mentorship in the
NICU and pediatric units where nursing students
were placed from the CU nursing program. When
University Hospital and The Children’s Hospital
combined their pediatric services, Mary became the
Clinical Nurse Specialist in Research and Education
and consulted in the NICU, PICU, and pediatric
medical-surgical areas. In this role, she was a founding
member of the interdisciplinary Pain Management
Team and provided consultation throughout The
Children’s Hospital for pain management issues. In
1996, Mary became a nursing faculty member at
Beth-El College of Nursing and Health Sciences,
where she created a student health center at the
University of Colorado Colorado Springs and a
school-based clinic for schoolchildren in Fountain,
Colorado, while maintaining an active pediatric practice at Colorado Springs Health Partners. Currently
Mary provides pediatric care at her own practice and
continues to teach courses to DNP students at the
University of Northern Colorado as an adjunct faculty. Mary is well published in the areas of pediatric,
neonatal, and family health care, as well as in legal
issues in maternal-child nursing. Mary is also a nurse
researcher in the areas of pain, chronic illness, caring/
healing praxis, pediatric pain, holistic nursing, and
technology in health care.
Brian S. Carter, MD, FAAP, is a graduate of
David Lipscomb College in Nashville, Tennessee,
and of the University of Tennessee’s College of
Medicine in Memphis, Tennessee. Brian completed
his residency in pediatrics at Fitzsimmons Army
Medical Center in Aurora, Colorado. He completed
his fellowship in neonatal-perinatal medicine at the
University of Colorado Health Sciences Center in
Denver. During the “Baby Doe” era, Brian trained
in bioethics, and, in addition to clinical neonatology and neonatal follow-up, he has dedicated
most of his academic career to the advancement
of clinical ethics in neonatology and pediatric palliative care. Brian has been recognized nationally
for his efforts in both of these fields. Currently he
is William T. and Marjorie Sirridge Professor of
Medical Humanities and Bioethics and Professor
of Pediatrics at the University of Missouri–Kansas
City School of Medicine. He also practices in the
NICU/Follow-Up clinics and antenatal counseling
at the Children’s Mercy Hospital in Kansas City,
where he works in the Bioethics Center, serves
on the Ethics Committee, and mentors students,
residents, and fellows in the areas of clinical ethics,
neonatology, pain management, and palliative care.
Brian has previously co-edited the book Palliative
Care for Infants, Children, and Adolescents: A Practical
Handbook, whose second edition was published
in 2011 by Johns Hopkins University Press. He
has a forthcoming book on perinatal palliative
care, co-edited with Rana Limbo, PhD, RN, and
Charlotte Wool PhD, RN.
Susan Niermeyer, MD, MPH, FAAP, is Professor
of Pediatrics at the University of Colorado School
of Medicine and Colorado School of Public Health.
She also serves as Senior Medical Advisor for
newborn health to the United States Agency for
International Development. Susan graduated from
Vanderbilt University School of Medicine and
completed training in pediatrics and neonatal-perinatal medicine at the University of Colorado and
Children’s Hospital Colorado. She earned an MS
in Public Health in 2010 at the Colorado School
of Public Health. Susan practices and teaches at
Children’s Hospital Colorado and the University
of Colorado Hospital as well as community hospital nurseries in the Denver area. She has served
as co-chair of the American Academy of Pediatrics
(AAP) Neonatal Resuscitation Program Steering
Committee and editor of the International Liaison
Committee on Resuscitation (ILCOR) neonatal
resuscitation guidelines. She is editor of Helping
Babies Breathe, the AAP educational program for
neonatal resuscitation in resource-limited settings
and a member of the Helping Babies Survive
Planning Group. Susan’s research interests center on
adaptation in the neonatal period, with a focus on
delayed umbilical cord clamping and cardiopulmonary adaptation at high altitude. She has been honored as a Career Teaching Scholar at the University

INTRODUCTION
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xvii
of Colorado and received the Avroy Fanaroff
Neonatal Education Award from the AAP.
Borrowing from the words of Brian Carter in the
introduction to the sixth edition of the Handbook:
The goals of care should be patient- and family-centered. It is the patient we treat, but it is the family,
of whatever construct, with whom the baby will go
home. Indeed, it is the family who must live with
the long-term consequences of our daily decisions in
caring for their baby.
These goals include the provision of skilled professional care. An effective neonatal intensive care
team consists of educated professionals of many
disciplines—none of us can do it alone.
It has been my honor and privilege to work
with these co-editors, who are all patient- and family-centered, and with the amazing editing team of
Laura Klein, Lee Henderson, and Carol O’Connell
for this ninth edition.
Sandra L. Gardner, RN, MS,
Retired Clinical Nurse Specialist and Pediatric
Nurse Practitioner
Senior Editor

CONTENTS
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UNIT ONE
Evidence-Based Practice
1 Evidence- Based Clinical Practice, 1
Alfonso F. Pantoja and Mary Enzman-Hines
UNIT TWO
Support of the Neonate
2 Prenatal Environment: Effect on Neonatal
Outcome, 17
Jennifer Woo, Suzanne M. Carrington, and Anne Ambia
3 Perinatal Transport and Levels Of Care, 45
Mario Augusto Rojas, Amanda Flaherty, Heather Furlong Brown, and
Tamara Rush
4 Care at Birth, 67
Susan Niermeyer and Susan B. Clarke
5 Immediate Newborn Care After Birth, 93
Sandra L. Gardner and Susan Niermeyer
6 Heat Balance, 137
Sandra l. Gardner and Betsy H. Cammack
7 Physiologic Monitoring, 165
Kristi Coe, Wanda T. Bradshaw, and David T. Tanaka
11 Drug Withdrawal in the Neonate, 250
Jodi Jackson, Betsy Knappen, and Steven L. Olsen
12 Pain and Pain Relief, 273
Sandra L. Gardner, Mary Enzman-Hines, and Rita Agarwal
13 The Neonate and the Environment Impact
on Development, 334
Sandra L. Gardner and Edward Goldson
UNIT THREE
Metabolic and Nutritional Care of
the Neonate
14 Fluid and Electrolyte Management, 407
Michael Nyp, Jessica L. Brunkhorst, Daphne Reavey, and
Eugenia K. Pallotto
15 Glucose Homeostasis, 431
Paul J. Rozance, Jane E. Mcgowan, Webra Price- Douglas, and William
W. Hay Jr.
16 Total Parenteral Nutrition, 459
Steven L. Olsen, Alexandria Oschman, and Kelly Tracy
17 Enteral Nutrition, 480
Laura D. Brown, Kendra Hendrickson, Ruth Evans, Jane Davis, and
William W. Hay JR.
8 Acid- Base Homeostasis and Oxygenation, 186
James S. Barry, Jane Deacon, Carmen Hernandez, and M. Douglas Jones, Jr.
9 Diagnostic Imaging in the Neonate, 201
Jason P. Weinman, Bridget M. Bronsert, and John D. Strain
10 Pharmacology in Neonatal Care, 226
Lawrence C. Ku, Chi Hornik, and Deanne Buschbach
xviii
18 Breastfeeding the Neonate with Special
Needs, 534
Sandra L. Gardner, Ruth A. Lawrence, and Robert M. Lawrence
19 Skin and Skin Care, 602
Carolyn Lund and David J. Durand
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