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Breastfeeding and Racial Inequality

Helping Mothers of Color Reach Their Breastfeeding Goals

Last year I joined a group of healthcare providers and concerned individuals in Southern California to form the Asian Breastfeeding Task Force. We feel it’s clear that there are special and unique cultural and education issues when working with this population and breastfeeding practices.

I used to be a staff writer at a self-describe largest Chinese language newspaper in North America. Four years ago when I returned to work after giving birth to my first child, my employer refused to provide a reasonable area for nursing moms to pump. When I talked to my supervisor and our HR about the lactation accommodation rights, they responded to me that they were not aware of the law. One of my colleagues told me to formula feed, adding that “my son was formula fed and he goes to Harvard. Formula-fed babies are smarter.” I tried to invite some medical or lactation professionals to the company and talked about the benefits of breastfeeding, but I couldn’t find even one Chinese-speaking professional who would talk about breastfeeding. And that was in Los Angeles, home to the largest Asian American population in the US.

Speaking of breastfeeding, a persistent racial disparity exists: Colored mothers have lower breastfeeding rates than white mothers. African American women have the lowest rates of breastfeeding initiation: 62 percent of American black babies were breastfed at birth, compared to 79 percent of white babies.

A study by the Centers for Disease Control (CDC) found that certain hospitals that serve black communities are failing to support breastfeeding. In a recent Morbidity and Mortality Weekly Report, the CDC reported that hospitals may play a role in the racial discrepancies. The CDC found that facilities in zip codes with more than 12.2 percent black residents were less likely than hospitals in zip codes with fewer black residents to meet five of 10 indicators that show hospitals are supporting breastfeeding.

The CDC looked at the 10 indicators it identified in its Maternity Practices in Infant Nutrition and Care (mPINC) survey. They included: educating mothers and health care staff properly, helping mothers initiate breastfeeding within one hour of birth and making sure not to give pacifiers or artificial nipples to infants. The researchers coupled these mPINC indicators with U.S. Census data to analyze 2,643 hospitals across the country.

Culture, education and family support are also huge equalizers. Of infants born in 2013 in China, 20.8% were breastfed at 6 months, comparing with 49% were breastfed in the US. High percentage of foreign born Asian mothers brought their formula culture to the US. It is also reported that black mothers often believe that “breastfeeding is for poor people.”

Before these factors—preconceptions about breastfeeding, family influence, professional support—come into play, there is something that hospitals can do. A 2016 research published by Chapman University found that in-hospital formula introduction is something that hospital policy makers and breastfeeding advocates can seek to change.

Given that most babies in the United States are born in a hospital, the short time that a mother and a newborn spend there can have a long-lasting effect on breastfeeding.

After that, professional support is much needed. And this is when breastfeeding organizations kick in!

To-wen TsengBreastfeeding and Racial Inequality
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Moms Beware! Scammers on FB page requesting donated breastmilk are selling it on other pages

Facebook groups for breastfeeding mothers are sending out a warning to its users.

Human Milk 4 Human Babies Ohio said it received a large number of complaints from multiple people about a couple from Cleveland, OH requesting breastmilk and then selling it in other places. The page was not set up for selling breastmilk for money. It has banned the couple.

Human Milk 4 Human Babies Kentucky also received similar complaints. Ronna Mariah Rhodes, a mother from Lexington, KY and a member of the group, posted on the page and warned other mothers.

“I am making this post as a public announcement to this community about a local mom getting donated milk from many of you and turning around to sell it…” wrote Rhodes. “Lexie Whittaker has been asking for donations since December because she was ‘returning to college and needed help.’ Now she has 1,500 ounces in her possession that she was caught trying to sell.”

Rhodes had screen shots captured to back up her claim. “As a fellow donor, this is frustrating,” she wrote. “Milk sharing is an amazing thing that helps babies in need. It is disgusting that someone turn it into something so ugly. Please get to know your donor or donee!”

This post upset many other mothers.

“As a donor, this is heart breaking,” responded Jenna Michele, a member of the group who donated milk. “I never considered selling my milk. There are so many people who need to supplement their supply or don’t produce at all. It is an incredible gift to be able to help nourish another human being. I echo others—to reach out to the person who is in need of milk. There are a lot of people who are genuinely in need of milk and are very grateful and appreciative of donors’ gifts.”

“This makes me so mad!” responded Lizz Swift, another member of the group who rely on donor’s milk. “My son can’t gain weight because I don’t produce enough…then there are women like this getting the milk then selling it? This is ridiculous!”

It is understandable that moms rely on online forums to get donated milk, but some dangers need to be considered. The main risk is disease from bacterial infections to HIV. Another risk is the medication that the donating mother may be taking.

Here at San Diego County Breastfeeding Coalition, we encourage lactating mothers to become breastmilk donors, but only through Mothers’ Milk Bank.

Currently Mothers’ Milk Bank of San Jose is in need of donated breast milk. Moms interested in donating can fill out the form here to be screened and registered with Mothers’ Milk Bank. Once screening is completed, it’s pretty simple: Milk can be dropped-off at Sharp Mary Birch Hospital for Women and Newborns or the Milk Bank will arrange for pick-up and shipping.

It’s a beautiful to share and donate your breast milk. And beware, don’t let anyone to take advantage of your generosity and sell your liquid gold!

To-wen TsengMoms Beware! Scammers on FB page requesting donated breastmilk are selling it on other pages
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Breastfeeding in Public: Why and Why Not?

This is a selfie I recently snapped of myself breastfeeding my 2-month-old in our local YMCA’s “mother’s privacy room”— a great nursing room with beautiful furniture, soft carpet, comfortable couch, dim light, and everything that a great nursing room should have.

But what I really wanted was to breastfeed by the pool, so that I can feed my baby and watch my 4-year-old swimming at the same time.

My baby finished the nursing session just when my preschooler finished his swimming lesson for that day. When I stepped out of the mother’s privacy room, my older child grumbled, “I did very well today, Mom. But you were not there to watch me!”

“I’m sorry,” I said. And I meant it. “I wanted to watch you but Jasper was hungry. I had to feed him.”

“Why don’t you just feed him by the pool? I saw other kids eating on the pool chaise lounge. That should be okay.”

For one moment, I wasn’t sure how to answer his question. Apparently breastfeeding is a totally natural thing to him. He sees babies eating mother’s milk just like toddlers eating gold fish.

But to many adults, that’s not the case. We’ve seen mothers shamed for breastfeeding at Walmart, Disneyland, and yes, YMCA.

The hostility makes many moms, including me, hesitate to nurse in public. In theory, I am all for breastfeeding in public. But in reality, I don’t always feel comfortable breastfeeding in public. I would only nurse in public when my baby is absolutely hungry, I absolutely cannot find a nursing room, and I am absolutely sure that no one would notice me.

That’s unfortunate. Breastfeeding in public is a civil right. And it should be not just a civil right, but also a social norm for two reasons.

One, mothers need to have their normal life keep going while breastfeeding. No mother could breastfeed for one year (which is really just the minimum recommendation) if she could not continue her life while doing so. If a nursing mom has to stay at home, unable to dine out, to go shopping, or to watch her older children swimming in the pool, how can it be possible for her to breastfeed for one whole year?

Two, children need to see breastfeeding in public. Some argue that breastfeeding in public would offend other parents with kids. This is insane. Breastfeeding mothers are not something that was recently invented. Merely two generations ago, it was not unusual to see a woman nurse her baby in public. All the trouble started with the using of female bodies to sell cars. There is nothing inappropriate about breastfeeding in public, except the people who are sexualizing it. And if our children grow up surrounded by sexualized images of breasts from Hollywood but never, or only rarely, see the normal, natural act of breastfeeding a baby, how can they have healthy ideas about women’s bodies?

Breastfeeding will not be seen to be natural until we see more women breastfeed in public. If you’re a nursing mom, please breastfeed on​. If you’re not nursing, please show some support.

To-wen TsengBreastfeeding in Public: Why and Why Not?
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Postpartum mood disorders 2017

COURSE OBJECTIVES: At the conclusion of this seminar the participant should be able to: Utilize the Edinburgh Postnatal Depression Screen (EPDS) and refer high-risk patients to maternal mental health experts. Describe treatment options for a breastfeeding mother identified with postpartum depression and/or anxiety. List 3 commonly used medications for treating maternal mood disorders in the
leonardbrunoPostpartum mood disorders 2017
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SDCBC Members Empower the Coalition to Empower Breastfeeding Moms

SDCBC—the San Diego County Breastfeeding Coalition—is a non-profit association whose mission is to protect, promote and support breastfeeding. With the help from its members, the coalition is able to fulfill its mission through education and outreach in the community.

Breastmilk is powerful stuff, but moms determined to breastfeed can face all kinds of challenges. It can be a baby with tongue tie or lip tie and therefore can not suck efficiently. It can be an unsupportive or even hostile working environment. It can be postpartum mood disorder. Of the approximately 45,000 infants born each year in San Diego County, 89% have the opportunity to breastfeed in the hospital, but far fewer (less than 20%) receive any breastmilk by six months of age.

Breastfeeding is team work. It takes a whole village.

In response to the challenges, a group of concerned individuals formed SDCBC in May, 1994. For the past 23 years, the coalition has distributed more than 400,000 free Breastfeeding Resource Guides in English and Spanish to help families obtain needed breastfeeding resources and support, sponsored health care professional breastfeeding education programs, and conducted county-wide billboard campaign “GOOD HEALTH BEGIN WITH BREASTFEEDING.”

And in the past year, the coalition distributed 28 hospital grade, multi-user and personal-use breast pumps to community clinics and local NICUs. It published a biweekly e-mail Breastfeeding Update with the latest news and views. It continued to distribute more than 2,500 copies of the San Diego County Breastfeeding Resource Guide.

It wasn’t always easy. Just in this past year, local lactation consultants reported to the coalition that a hospital was giving teen moms infant formula samples which created an impression that “medical professionals approve baby formula” and made it much harder for the consultants to encourage breastfeeding.

To promote breastfeeding-friendly efforts, the coalition sponsored a county-wide World Breastfeeding Week hospital celebration contest, and recognized three hospitals. It further awarded breastfeeding-friendly workplaces.

The results made an impact in the community which encouraged more hospitals to commit to baby-friendly initiatives and more employers to support their employees. San Diego City’s Chief Operating Officer Scott Chadwick signed the City’s Lactation/Breastfeeding Accommodation Policy in March of this year.

“Caring for young children is as challenging as it is rewarding,” said Mr. Chadwick, “So we’re proud of our policy providing a positive workplace environment, reasonable accommodations and comfortable facilities that assist new mothers with their work-life balance.”

The City of San Diego was later named a “Breastfeeding-Friendly Workplace” by the SDCBC.

Next year, the coalition will recognize breastfeeding champion policy makers, OBs, and pediatricians. The coalition cannot do this without the support from its members. In fact, the breast pumps that the coalition distributed this year were funded by Rest Haven grant.

You can help the coalition with its mission and vision, too. You may complete the membership application form online at Thank you for your membership in the San Diego breastfeeding Coalition!

To-wen TsengSDCBC Members Empower the Coalition to Empower Breastfeeding Moms
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Paternity Leave—Not Just Maternity Leave—Is Crucial Support for Breastfeeding

I’m having a miserable day. So miserable that I feel an urgent necessity to write this post.

Earlier this week, my husband flew to Asia for work on the day our new baby turned 6 weeks old. At this age, the baby still eats every two to three hours, and sleeps only a few hours at a time, day or night. Surely I always get out of the bed much more quickly than my husband when our baby cries in the middle of the night, but still, breastfeeding is much easier when there is someone who does the laundry, washes the dishes, and watches the older children.

My husband is a supportive partner and has been doing all these for me—until he has to return to work six weeks after the baby was born. Now on top of breastfeeding every three hours, I’m cooking, washing the dishes, doing the laundry, and running after our 4-year-old. I’m ridiculously tired. Right now I’m covered in spit-up, which really adds insult to injury when being sleep-deprived. Unfortunately, I don’t have the energy to do anything about it. So I’m sitting here, with the baby in my left arm, and typing this article with my right hand.

And that’s not a bad version of what most working parents in the US experience. At least my husband has six weeks of paid family leave. According to OECD, out of 41 countries, the US is the only one that does not mandate any paid leave for new parents. The Family Medical Leave Act ensures that women cannot lose their jobs for 12 weeks after having a baby, provided the company they work for has more than 50 employees. It does not concern itself with how to cover the parent’s lost earnings. Only 16% of employers offer fully-paid maternity leave, fewer offer paid paternity leave.

And paternity leave—not just maternity leave—is crucial for breastfeeding. Breastfeeding is team work; it actually takes three people—mom, baby, and dad—to breastfeed. Research shows that the chance of a baby being breastfed for six months is significantly higher if the dad supports breastfeeding. Among other things, a supportive father can offer rest, food, water, and encouragement. Paid paternity leave can empower dads to be supportive dads.

When it comes to baby feeding, the science is clear—there’s nothing better than breastmilk for baby, mom and the environment. Breastfed babies get fewer infections, mother who breastfeed have lower risk of osteoporosis, and breastfeeding leaves no foot print. However, breastfeeding would never work without paid family leave.

My husband is flying home next week. I miss him. He is a very hands-on dad. He burbs and holds our baby after each feeding, he reads with our 4-year-old every evening. I only wish men in this country could have a longer paternity leave. Japanese fathers have 30 weeks. Korean dads have 16 weeks. I’d be happy with just 12 weeks.

To-wen TsengPaternity Leave—Not Just Maternity Leave—Is Crucial Support for Breastfeeding
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Tell Me About Tongue Ties and Lip Ties

It all started with one fuzzy baby and two sore nipples.

I gave birth at midnight on Sunday. It wasn’t my first baby—I’ve breastfed for two years, and I thought I knew exactly what to do. Yet the latch was painful, even worse than what I experienced when my first child was teething.

By the end of Monday, my baby was hungry and angry, and my nipples were cracked and bleeding. On Tuesday, the nurse came to check on me and kindly offered some infant formula to supplement the baby. I didn’t like the idea. I had lots of milk; I could feel it. But by Wednesday, the baby had already dropped his birth weight by 7%.

Then on Thursday the baby dropped weight by another 3%. We were discharged from the hospital with two boxes of infant formula. When I saw the pediatrician on Friday I almost burst into tears while telling him that I wasn’t able to breastfeed even though I know I have milk.

“He might not suck efficiently. You should see a lactation consultant and see what she says. Before we find out what’s going on, I want you to supplement him with 1 oz of formula after each feeding.”

The baby started to gain weight after we supplemented him. It’s embarrassing, felt like being told that my own milk was not good as formula.

I saw the lactation consultant on the next Friday. It turned out the baby had tongue tie! It’s almost funny because I’ve been writing for the breastfeeding coalition for years and tongue tie was a topic that has been brought up often. Yet I was clueless when it actually happened to my baby.

Knowing what’s causing all those problems, we immediately scheduled an appointment with a pediatric dentist. At the dentist’s office she showed us how my baby didn’t only have a tongue tie but also a lip tie. It did look abnormal. I wondered how I didn’t notice it earlier.

We decided to have the ties released on the same day. The dentist explained to us how a frenotomy is performed and how to take care of the baby’s tongue and lips after the procedure, including massaging his mouth with coconut oil and giving him Tylenol to control the pain.  She suggested us to wait in the reception so that we wouldn’t hear the baby cry during the procedure, “it might be upsetting.”

But I could still hear the baby cry at the reception even though we were three rooms away from where the baby was being treated.  That was scary. I told my husband, “Oh my goodness it sounds like he’s in great pain!” For one minute I wanted to stop the procedure and just formula feed. My husband stared at me, “are you out of your mind?”

The dentist brought us our baby in 10 minutes, probably the longest 10-minute in my life. I saw a diamond-shaped wound under his tongue and a little bit of blood in his mouth—just a little, but was enough to freak me out.

That night the baby was very difficult. Every time I tried to massage his mouth with coconut oil, he cried as if I was trying to cut his head off. I worried that our neighbors might call the police; thank God that did not happen. We gave the baby two doses of Tylenol to control the pain.


But things became very easy after that first night! Latching was a breeze, and the baby effortlessly gained one whole pound in just one week after the procedure (without formula!) I’m glad we had it done early. He turned one month today. We have two more years to breastfeed.

To-wen TsengTell Me About Tongue Ties and Lip Ties
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Breastfeeding and Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) is a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. It is a concern because when a mother uses illicit substances, she places her baby at risk for many problems.

Most neonatal clinicians are acutely aware of the increase in neonatal abstinence syndrome: a nationwide increase from 7/1000 births in 2004 to 27/1000 births in 2013 is reported. Here in California, about 1,190 newborns were diagnosed with drug withdrawal syndrome in 2014, up more than 50 percent from a decade earlier.

Symptoms of withdrawal in full-term babies may include:

  • Tremors (trembling)
  • Irritability (excessive crying)
  • Sleep problems
  • High-pitched crying
  • Tight muscle tone
  • Hyperactive reflexes
  • Seizures
  • Yawning, stuffy nose, and sneezing
  • Poor feeding and suck
  • Vomiting
  • Diarrhea
  • Dehydration
  • Sweating
  • Fever or unstable temperature

The cost of care for infants with NAS is quite hight as many of them are admitted to the NICU for withdrawal symptoms and associated care. The length of stay is 16.4 days, comparing with an average 3.3 days of stay for healthy infants. A 2015 study cites more frequent readmissions for these infants. Researchers found these infants were 2.5 times more likely to be readmitted within 30 days than healthy infants.

The current standard care for narcotics-exposed infants involves limiting exposure to lights and noise, promoting clustering of care to minimize handling and promote rest, swaddling and holding the infant, and providing opportunities for non-nutritive sucking. These soothing techniques, though commonly used to comfort infants, have not been evaluated in relation to such outcomes as the severity of the neonatal abstinence syndrome or the length of the hospital stay.

The strongest evidence from systematic reviews for improving outcomes is in support breastfeeding, with emerging evidence that favors rooming-in. Studies have consistently shown that infants with NAS who are breastfed tend to have less severe symptoms, require less pharmacologic treatment, and have a shorter length of stay than formula-fed infants. Breastfeeding should there for be encouraged for mothers who are stable and receiving opioid-substitute treatment, unless there are contraindications, such as HIV infection or concurrent use of illicit substances. Similarly, emerging evidence suggests that babies who stay in the room with their moms have a shorter hospital stay and duration of therapy and are more likely to be discharged home with their moms. Rooming-in has also been associated with improved breastfeeding outcomes, enhanced maternal satisfaction, and greater maternal involvement in the care of the newborn.

The increased incidence of the NAS and soaring increased in associated health care costs warrant a consistent and comprehensive approach to mitigating the negative outcomes for affected infants, their mothers, and the health care system. Recent innovations in management include standardized protocols for treatment, which have positive effects on important outcomes such as the duration of opioid treatment, the length of the hospital stay, and the use of empirically based dosing protocols. Breastfeeding and rooming-in are promising nonpharmacologic strategies that may also improve outcomes for babies and moms.

Heidi Burke-PevneyBreastfeeding and Neonatal Abstinence Syndrome
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For Dads: Breastfeeding and You

A Maryland mother was ordered to give her breastfed infant formula at father’s request because the judge considered “giving a father time with his child is more important than breastfeeding a baby.”

Mom’s milk is powerful stuff, so is the relationship between dad and the baby. It is unfortunate that parents have to choose between the two. Of course, in this case, the couple are separated and embroiled in a court battle. But, in most cases, there shouldn’t be any conflicts between breastfeeding and father-baby-time. In fact, breastfeeding can help dad build a meaningful relationship with the baby.

Breastfeeding takes teamwork. Research shows that moms whose partners support their breastfeeding efforts breastfeed longer. As a dad, there are many ways you can be helpful.

During pregnancy, you can encourage mom to make a breastfeeding plan and set goals, letting her know that you’ll be there to help along the way. You can plan the delivery together, that means choosing a doctor and hospital that supports breastfeeding, going to doctor’s appointments, and going to prenatal classes. You can tour hospitals or birthing facilities together and choose one that supports their breastfeeding goal. You can also start learning about baby behavior so that you’ll be prepared to help the mom when baby comes.

After delivery, you can support skin-to-skin time for mom and baby during the first hour after delivery. Even babies who are delivered by cesarean can do skin-to-skin in the first hour. You can request rooming-in at the hospital so that you and mom have more time to get to know your baby and settle into a healthy routine. You can get plenty skin-to-skin time where you cuddle the baby on your bare chest. This is great bond time with lots of benefits for both of you.

Back at home, you should be prepared: newborns eat at least 8 or more times a day and sleep only a few hours at a time. You can be encouraging by letting the mom know you’re proud of her. You can be helpful by holding the baby after a feeding until he falls sound asleep, changing diapers, learning how to calm the baby when he cries, taking care of meals and household chores, and giving mom a break so she can shower or nap. She will be grateful, and you’ll get more time with the baby.

If the mom plans to return to school or work, she needs your support so she can keep breastfeeding. You can encourage her to pump and store her breastmilk once she’s gotten the hang of breastfeeding and her supply is set. Mom should start pumping at least two weeks before going back to work. At first she may not get a lot of milk, but pumping once a day will help build a supply of milk in the freezer to use while the is away. When mom and baby are together, regular breastfeeding will keep her milk supply up.

To-wen TsengFor Dads: Breastfeeding and You
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How hard (or easy) breastfeeding can be

A mother shared a tearful photo about the pain of breastfeeding, saying that “I cannot hide the struggle.” She wrote, “I love seeing all these beautiful women in their beautiful nursing clothes smiling down at their babes as they lovingly look up back at them hand in hand while breastfeeding…That is not my reality.” As the post going viral, we have to ask, how hard breastfeeding can be?

The truth is, it can be as hard as one can imagine, for both stay-at-home and working moms.

Breastfeeding moms can have a variety of issues: Whether the baby is latching on properly; whether the mom is producing enough milk; whether the mom’s nipples are adequate. Maybe the new role overwhelms the mom; maybe the hormones have her; maybe the nipple shield is ill-fitted. Some babies demand nursing every 10 minutes and it exhausts their moms. Some breastfeeding moms are starving all the time and have to get up at 3 a.m. and eat. Some moms struggle with nursing twins. Some preemies are too small to nurse.

And it’s even harder if the mom’s breastfeeding while working. Even before going back to work, these moms have to build up their breastmilk supply and store extra milk. Pumping can be an unpleasant, sometimes hour-long process. And pumping at work sucks for many women. In spite of the workplace support in federal law, many of the working moms are still stuck pumping in bathrooms, or attempting to find privacy. Those lucky moms who actually get support at work still have to block off at least two 30-minute increments on their calendar to protect pumping time. The stress at work can impact breast milk production, not to mention some mothers are facing breastfeeding discrimination situation at workplace.

The “breast is best” message has returned after the formula-filled decades from the not-so-distant past. Breastmilk helps build crucial antibodies. Breastfed babies are less likely to face obesity, diabetes or other problems. Breastfeeding moms will lose the pregnancy weight easier… Most moms learned all of these in the lead-up to their babies’ birth and set their breastfeeding goals. But this kind of determination is not enough to help moms to reach their goal. According to a 2016 study, only 40 percent babies were breastfed at 12 month, though 63 percent of the mothers had planned to go to a year.

What helps mothers to reach their breastfeeding goal, said the lead author of the study, is support.

Breastfeeding is a team effort. During this period of time, moms need their partners to be patient and assist them with a variety of houseworks. They need nurses in the hospital to assess their milk production. They need lactation consultants help them with the various holds until finding the one that feels quite right. They need encouragement from family members and friends.

Breastfeeding is hard. But with proper support, it can be wonderful like a breeze. Let’s help breastfeeding moms thrive, not just survive.

To-wen TsengHow hard (or easy) breastfeeding can be
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