Saturday, March 30, 2019

Child With Failure To Thrive Health And Social Care Essay

Child With sorrow To Thrive Health And societal Cargon raiseIn this surveil article, the definition, etiology, paygrade, differential diagnoses, man long timement, pr nonethelesstion and prognosis of bolture to dilate are discussed.Failure to prosper (FTT) is a common problem in paediatric practice, affecting 5-10% of under-fives in true countries with a higher incidence in developing countries. Majority of cases of FTT are payable to a combine of nutritional and environmental deprivation secondary to provokeal poverty and/or ignorance. M from each one babys with FTT are non identify. The key to diagnosing FTT is finding the era in busy clinical practice to accu steply measure and diagram a childs heaviness, top of the inning and cope circuit, and then assess the trend. In the paygrade of the child who has failed to extend, three initial steps required to develop an frugal treatment-centred progress are (i) A thorough annals including itemized psychosocial review, (ii) Careful physiological examination and (iii) Direct observation of the childs conduct and of parent-child interaction. Laboratory evaluation should be guided by annals and tangible examination findings only. Once FTT is identified in a fall aparticular child, the man seasonment should begin with a detailed hunt for its etiology. Two principles that hold true irrespective of aetiology are that solely children with FTT need a high- calorie diet for catch-up proceeds (typically 150 part of their caloric requirement for their expected, not actual cargo) and all children with FTT need a careful follow up. Social issues of the family must overly be addressed. A multidisplinary access code is recommended when FTT persists despite intervention or when it is severe. Overall, only a one- third base of children with FTT are ultimately judged to be normal.Keywords Failure to thrive, proceeds deficiency, undernutrition.INTRODUCTIONAlthough the landmark failure to thr ive (FTT) has been in use in the aesculapian idiom for quite some cartridge c mouthpiece now, its precise definition has remained debatable1. consequently, early(a) basis such as undernutrition1 and issue deficiency2 feature been proposed as preferable. FTT is a descriptive term applied to young children physical reaping is little than that of his or her peers.3 The growth failure whitethorn begin either in the neonatal period or afterward a period of normal physical increase.4 The term FTT is not, in itself, a affection exclusively a prognostic or sign common to a wide variety of disorders which whitethorn have little in common except for their negative act on growth.5 In this regard, a cause must al focal points be sought.Often, the evaluation of children who fail to thrive pose a difficult diagnostic problem. Some of the difficulties result from the numerous differential diagnoses, the definition use or misdirected tendency to search aggressively for underlie or ganic maladys while neglecting aetiologies ground on environmental deprivation.6 In addition, early accusations and alienation of the childs parents by the wellness-care supplier impart make the evaluation and man long timement of the child who has failed to thrive more difficult.7In general, factors that influence a childs growth take on (i) A childs nutritional status (ii) A childs health (iii) Family issues and (iv) The parent-child interactions.3,8,9 All these factors must be considered in evaluation and man mountment of child who has failed to thrive. This paper presents a simplified but detailed cost to the evaluation and management of the child with FTT.DEFINITIONThe trounce definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time using a metre growth chart, such as the National Center for Health Statistics (NCHS) growth chart.10 All authorities agree that only by comparing raising and fish on a grow th chart over time can FTT be assessed accurately.11 So far, no consensus has been reached concerning the specific anthropometrical criteria to circumscribe FTT.11 Consequently, where serial anthropometric records is not available, FTT has been variously outlined statistically. For instance, some authors defined FTT as weight under the third percentile for age on the growth chart or more than devil standard deviations below the mean for children of the same age and sex1-3 or a weight-for-age (weight-for-hieght) Z-score less than electronegative two.1 Others cite a downward change in growth that has cover two major growth percentiles in a hornswoggle time.3 bland early(a)s, for diagnostic purposes, defined FTT as a disproportionate failure to hit weight in comparison to aggrandisement without an apparent aetiology.6 Brayden et al.,2 suggested that FTT should be considered if a child less than 6 months old has not grown for two consecutive months or a child older than 6 mont hs has not grown for three consecutive months. Recent research has validated that the weight-for-age approach is the simplest and close to reasonable marker of FTT.12Pitfalls of these definitionsOne limitation of using the third percentile for defining FTT is that some children whose weight fall below this coercive statistical standard of normal are not failing to thrive but represent the three percent of normal population whose weight is less than the third percentile.5,6 In the maiden 2 years of life, the childs weight changes to follow the genetic predisposition of the parents height and weight.13,14 During this time of transition, children with familial short stature whitethorn cross percentiles downward and still be considered normal.14 more or less children in this category find their true curve by the age of 3 years.6,14 When the percentile drop is great, it is helpful to compare the childs weight percentile to height and head circumference percentiles. These should be c onsistent with the position of height and head circumference percentiles of the patient.5 Anformer(a) limitation of the third percentile as a criterion to define FTT is that infants can be failing to thrive with marked deceleration of weight gain, but they remain undiagnosed and in that locationfore, untreated until they have fallen below the arbitrary third percentile.6 These normal lower-ranking children do not demonstrate the disproportionate failure to gain weight that children with FTT do.6 This approach attempts not only to prevent normal small children from be incorrectly labeled as failing to thrive, but also excludes children with ghoulish proportionate short stature.14 Having excluded these easily distinguishable disorders from the differential diagnosis of FTT, simplifies the approach to evaluation of the child who has failed to thrive.6A more encompassing definition of FTT acknowledges any child whose weight has fallen more than two standard deviations from a prev ious growth curve.3,15,16 Normal shifts in growth curves in the first 2 years of life will result in less severe decline (i.e, less than 2 SD).13Some authors have even limited the definition of FTT to only children less than 3 years old17,18 A precise age limitation is arbitrary. However, most children with FTT are under 3 years of age.6,8EPIDEMIOLOGYIn young children, FTT which does not reach the severe continent syndrome of marasmus is common in all societies.19 However, the true incidence of FTT is not cognize as many infants with FTT are not identified, even in developed countries.20-22 It is estimated to affect 5 10% of young children and approximately 3 5% of children admitted into teaching hospitals.3,5,23 Mitchell et al,24 using multiple criteria found that nearly 10% of under-fives tending primary health care centre in the United States showed FTT. just about 5% of paediatric admissions in United Kingdom are for FTT.4 The preponderance is even higher in developing co untries with wide-spread poverty and high evaluate of malnutrition and/or HIV infections.3,19 Children born to single teenage mothers and useing mothers who work for long hours are at increased chance.22 The same is true of children in institutions such as orphanage homes and homes for the mentally retarded5,22 with an estimated incidence of 15% as a group.5 down the stairs- cater is the single commonest cause of FTT and results from parental poverty and/or ignorance.19,22,24 cardinal five percent of cases of FTT are callable to not full fare world offered or taken.25 The peak incidence of FTT occurs in children between the age of 9 24 months with no significant sex difference.22 Majority of children who fail to thrive are less than 18 months old.3 The syndrome of FTT is uncommon after the age of 5 years.3,22AETIOLOGYTraditionally, causes of FTT have been classified as non-organic and organic. However, some authors have stated that this terminology is mis starring(p).27 Th ey establish their opinion on the fact that all cases of FTT are produced by inadequate forage or undernutrition and in that context, is organically determined. In addition, the distinction based on organic and non-organic causes is no overnight favoured because many cases of FTT are of mixed aetiologies.3Based on pathophysiology (the preferred potpourri), FTT whitethorn be classified into those due to (i) light caloric intake (ii) Inadequate absorption (iii) increase caloric requirement and (iv) Defective utilization of calories. This classification leads to a logical organization of the many conditions that cause or collapse to FTT.10Non organic (psychosocial) failure to thriveIn non-organic failure to thrive (NFTT), there is no known checkup examination condition causing the poor growth. It is due to poverty, psychosocial problems in the family, maternal deprivation, lack of knowledge and skill in infant nutrition among the care-givers5,11. Other risk of infection fa ctors include substance abuse by parents, single parenthood, general immaturity of one or both parents, economic stress and strain, temporary stresses such as family tragedies (accidents, illnesses, deaths) and marital disharmony.6,8,22 Weston et al,28 reported that 66% of mothers whose infants failed to thrive has a positive tale of having been abused as children themselves, compared to 26% of controls from similar socioeconomic background. NFTT accounts for over 70% of cases of FTT.6 Of this number, approximately one-third is due to care-givers ignorance such as incorrect victuals technique, improper preparation of look or misconception of the infants nutritional needs,29 all of which are easily corrected. A coating look at these risk factors for NFTT suggest that infants with growth failure may represent a flag for serious social and psychological problems in the family. For example, a depressed mother may not feed her infant adequately. The infant may, in turn, become with drawn in response to mothers first and feed less sound.10 Extreme parental attention, either neglect or hypervigilance, can lead to FTT.10Organic failure to thriveIt occurs when there is a known underlying medical cause. Organic disorders causing FTT are most commonly infections (e.g HIV infection, tuberculosis, intestinal parasitosis), gastrointestinal (e.g., chronic diarrhoea, gastroesophageal reflux, pyloric stenosis) or neurologic (e.g., cerebral palsy, mental retardation) disorders.6,19,22 Others include genitourinary disorders (e.g., hinder(prenominal) urethral valve, renal tubular acidosis, chronic renal failure, UTI), congenital midsection disease, and chromosomal anomalies.6,7 Together neurologic and gastrointestinal disorders account for 60 80% of all organic causes of under nutrition in developed countries.30 An all important(predicate) medical risk factor for under nutrition in childhood is premature redeem.1 Among preterm infants, those who are small for gestati onal age are curiously vulnerable since antenatal factors have already exerted deleterious effect on somatic growth.1 In societies where lead poisoning is common, it is a recognized risk factor for poor growth.5,31 Organic FTT virtually never presents with isolated growth failure, other signs and symptoms are generally evident with a detailed taradiddle and physical examination.32 Organic disorders accounts for less than 20% of cases of FTT.6Mixed failure to thriveIn mixed FTT, organic and non organic causes coexist. Those with organic disorders may also suffer from environmental deprivation. Likewise, those with severe undernutrition from non-organic FTT can develop organic medical problems.FTT with no specific aetiologyReview of the literature on FTT imply that in 12 32% of cases of children who have failed to thrive, no specific aetiology could be established.23,33-34Causes of failure to thriveA. Prenatal cases (i) Prematurity with its complication (ii) cyanogenic exposure in utero such as alcohol, smoking, medications, infections (eg rubella, CMV) (iii) Intrauterine growth childbed from any cause (iv) Chromosomal abnormalities (eg Down syndrome, Turner syndrome) (v) Dysmorphogenic syndromes.B. Postnatal causes based on pathophysiologyA. Inadequate caloric intake which may result fromi. Under feedingIncorrect preparation of formula (e.g. too dilute, too concentrated).conduct problems affecting eating (e.g., childs temperament).Unsuitable feeding habits (e.g., uncooperative child) meagreness leading to food shortages.Child abuse and neglect.Mechanical feeding difficulties e.g., congenital anomalies (cleft lip/palate), oromotor dysfunction.Prolonged dyspnoea of any causeB. Inadequate absorption which may be associated withMalabsorption syndromes e.g. Celiac disease, cystic fibrosis, cows milk protein allergy, giardiasis, food predisposition/intoleranceVitamins and mineral deficiencies e.g., zinc, vitamins A and C deficiencies.Hepatobiliary diseases e. g., biliary atresia.Necrotizing enterocolitisShort gut syndrome.C. Increased Caloric requirement due toHyperthyroidism continuing/ perennial infections e.g., UTI, respiratory tract infection, tuberculosis, HIV infectionChronic anemiasD. Defective manipulation of CaloriesInborn errors of metabolism e.g., galactosaemia, aminoacidopathies, organic acidurias and storage diseases.Diabetes inspidus/mellitusRenal tubular acidosisChronic hypoxaemiaClinical manifestations of FTT3,22Commonly the parents/care-givers may complain that the child is not ontogenesis well or losing weight or not feeding well or not doing well or not like his other siblings/age mates. Usually FTT is discovered and diagnosed by the infants physician using the birthweight and health clinic anthropometric records of the child.The infant looks small for age. The child may exhibit qualifying of subcutaneous fat, reduced muscle mass, thin extremities, a narrow face, bad ribs, and wasted buttocks, Evidence of neglecte d hygiene such as serviette rash, unwashed skin, overgrown and dirty fingernails or unwashed clothing. Other findings may include avoidance of eye contact, lack of facial expression, absence of fondling response, hypotonia and assumption of infantile posture with clenched fists. There may be marked preoccupation with thumb sucking.EVALUATIONA. Initial evaluationIt has been proposed that only three initial investigations are required to develop an economical, treatment-centred approach to the child who presents with FTT and this include35 (i) A thorough history including an itemized psychosocial review (ii) Careful physical examination including determination of the auxological tilts and (iii) Direct observation of the childs behaviour and of parent-child interactions.The Psychosocial Review The psychosocial history should be as thorough and organisationatic as a classic physical examination Goldbloom35 suggested that the interviewers should ask themselves three questions about e very family (i) How do they look (ii) What do they say and (iii) What do they do?a. HISTORY(1) Nutritional historyNutritional history should include details of breast feeding to get an idea of number of feeds, time for each feeding, whether both breasts are given or one breast, whether the feeding is continue at night or not and how is the childs behaviour before, after and in between the feeds. It would give an idea of the adequacy or inadequacy of mothers milk. If the infant is on formula feeding Is the formula prepared correctly? disregard milk feed will be poor in calorie with excess water. Too concentrated milk feed may be unpalatable leading to refusal to drink. It is also essential to know the score amount of money of the formula consumed. Is it given by bottle or cup and take? Also assess the touch sensationing of the mother e.g., ask how do you feel when the baby does not feed well? Time of introduction of complementary color feeds and any difficulty should be noted.V itamin and mineral supplement when started, type, amount, duration.Solid food when started, types, how taken.Appetite whether the appetite is temporarily or persistently impaired (if prerequisite calculate the caloric intake).For older children enquire about food likes and dislikes, allergies or idiosyncracies. Is the child fed forcibly? It is desirable to know the feeding rule from the time the child wakes up in the morning till he sleeps at night, so that one can get an idea of the total caloric intake and the calories supplied from protein, fat and carbohydrate as well as adequacy of vitamins and minerals intake.(2) past times and current medical historyThe history of prenatal care, maternal illness during pregnancy, identified fetal growth problems, prematurity and birth weight. Indicators of medical diseases such as vomiting, diarrhoea, fever, respiratory symptoms and fatigue should be noted. Past hospitalization, injuries, accidents to evaluate for child abuse and neglect. S tool pattern, frequency, consistency, presence of blood or mucus to exclude malabsorption syndromes, infection and allergy.(3) Family and social historyFamily and social history should include the number, ages and sex of siblings. Ascertain age of parents (Down syndrome and Klinerfelter syndrome in children of elderly mothers) and the childs enter in the family (pyloric stenosis). Family history should include growth parameters of siblings. Are there other siblings with FTT (e.g., genetic causes of FTT), family members with short stature (e.g. familial short stature). Social history should determine occupation of parents, income of the family, identify those caring for the child. Child factors (e.g., temperament, development), parental factors (e.g., depression, interior(prenominal) violence, social isolation, mental retardation, substance abuse) and environmental and societal factors (e.g., poverty, unemployment, illiteracy) all may contribute to growth failure.5 Historical evalu ation of the child with FTT is summarized in plug-in 1.(b) PHYSICAL EXAMINATIONThe four main goals of physical examination include (i) identification of dysmorphic features suggestive of a genetic disorder impeding growth (ii) detection of under lying disease that may impair growth (iii) estimate for signs of mathematical child abuse and (iv) assessment of the severity and possible effects of malnutrition.36,37The basic growth parameters such as weight, height / distance, head circumference and mid-upper-arm circumference must be measured carefully. Recumbent length is measured in children below 2 years of age because rest measurements can be as such(prenominal) as 2cm shorter.36,37 Other anthropometric data such as upper-segment-to-lower-segment ratio, sitting height and arm thwart should also be noted. The anthropometric index used for FTT should be weight-for-length or height. Mid-parental height ( miles per hour) should be determined using the formula.40For boys, the form ula isMPH = FH + (MH 13)2For girls, the formula isMPH = (FH 13) + MH2In both equations, FH is fathers height in centimetres and MH is mothers height in centimetres. The target range is calculated as the MPH 8.5cm, representing the two standard deviation (2SD) confidence limits.14Assessment of grade FTTThe degree of FTT is usually measured by calculating each growth parameter (weight, height and weight/height ratio) as a percentage of the modal(a) value for age based on grant growth charts3 (See turn off 3)Table 3 Assessment of degree of failure to thrive (FTT) harvesting parameterDegree of Failure to ThriveMildModerate unspeakable incubus75-90%60 -74%Height90 -95%85 89%Weight/height ratio81-90%70 -80%Adapted from Baucher H.3It should be noted that appropriate growth charts are often not available for children with specific medical problems, therefore serial measurements are peculiarly important for these children.3 For premature infants, correction must be made for the ex tent of prematurity. Corrected age, rather than chronologic age, should be used in calculations of their growth percentiles until 1-2 years of corrected age.3Table 2 Physical examination of infants and children with growth failure.Abnormality diagnostic Consideration life-sustaining signsHypotensionHypertensionTachypnoea/TachycardiaAdrenal or thyroid insufficiencyRenal diseasesIncreased metabolic demandSkinPallorPoor hygieneEcchymoses monilia diseaseEczemaErythema nodosumAnaemaNeglectAbuseImmunodeficiency, HIV infectionAllergic diseaseulcerative colitis, vasculitisHEENTHair lossChronic otitis mediaCataractsAphthous stomatitisThyroid enlargementStressImmunodeficiency, structural oro- facial defectCongenital rubella syndrome, galactosaemiaCrohns diseaseHypothyroidismChestWheezescystic fibrosis, asthmaCardiovascularMurmurCongenital heart disease(CHD)Abdomen distension hyperactive Bowel sound HepatosplenomegalyMalabsorptionLiver disease, glycogen storage diseaseGenitourinaryDiaper rash esDiarrhoea, neglectRectumEmpty ampullaHirschsprungs diseaseExtremitiesOedema going of muscle mass ClubbingHypoalbuminaemiaChronic malnutritionChronic lung disease, Cyanotic CHDNervous dodgingAbnormal deep tendon Reflexes teachingal defyCranial nitty-gritty palsyCerebral palsyAltered caloric intake or requirementsDysphagiaBehaviour and temperamentUncooperativeDifficult to feed.Adapted from Collins et al 41Growth charts should be evaluated for pattern of FTT. If weight, height and head circumference are all less than what is expected for age, this may suggest an aggravate during intrauterine life or genetic/chromosomal factors.2 If weight and height are delayed with a normal head circumference, endocrinopathies or original growth should be suspected.2 When only weight gain is delayed, this usually reflects upstart energy (caloric) deprivation.2 Physical examination in infants and children with FTT is summarized in Table 2.Failure to thrive due to environmental deprivationChildr en with environmental deprivation originally demonstrate signs of failure to gain weight loss of fat, prominence of ribs and muscles wasting, especially in large muscle groups such as the gluteals.6Developmental assessmentIt is important to determine the childs developmental status at the time of diagnosis because children with FTT have a higher incidence of developmental delays than the general population.36 With environmental deprivation, all milestones are usually delayed once the infant reaches 4 months of age.42 Areas dependent on environmental interactions such as language development and social adaptation are often disproportionately delayed. Specific behavioural evaluations (e.g., recording responses to approach and withdrawal), have been developed to help differentiate underlying environmental deprivation from organic disease.43 Assess the infants developmental status with a full Denver Developmental Standardized test.44Parent-child interactionEvaluate interaction of the p arents and the child during the examination. In environmental deprivation, the parent often readily walks extraneous from the examination table, appearing to easily abandon the child to the nurse or physician.6 There is little eye contact between child and parent and the infant is held distantly with little moulding to the parents body.6 Often the infant will not reach out for the parent and little affectionate touch sensation is noted.6 There is little parental display of pleasure towards the infant.6Observation of feeding is an integral part of the examination, but it is ideally done when the parents are to the lowest degree aware that they are being observed. Breast-fed infants should be weighed before and after several feedings over a 24-hour period since volume of milk consumed may vary with each meal. In environmental deprivation, the parents often miss the infants cues and may distract him during feeding the infant may also turn aside from food and appear distressed.6 Unn ecessary force may be used during feeding. Developing a portrait of the child-parent relationship is a key to directing intervention.11LABORATORY EVALUATIONThe role of laboratory studies in the evaluation of FTT is to analyze for possible organic diagnoses suggested by the history and physical examination.33,34 If an organic aetiology is suggested, appropriate studies should be undertaken. If history and physical examination do not suggest an organic aetiology, extensive laboratory test is not indicated.6 However, on admission full blood count, ESR, urinalysis, urine culture, urea and electrolyte (including calcium and phosphorus) levels should be carried out. Screen for infections such as HIV infection, tuberculosis and intestinal parasitosis. diminished survey is indicated if physical abuse is strongly suspected. In addition to being unproductive, blind laboratory fishing expeditions should be avoided for the following reason5,6 (i) they are expensive (ii) they impair the child s ability to gain weight in a new environment both by frightening him/her with venepuncture, barium studies and other stressful procedures and the no oral feeds associated with some investigations prevent him/her from getting enough calories (iii) they can be misleading since a number of laboratory abnormalities are associated with psychosocial deprivation (e.g., increased serum transaminases , transient abnormalities of glucose tolerance, decreased growth endocrine and iron deficiency)21 and (iv) they divert attention and resources from the more productive search for evidence of psychosocial deprivation. In one study, a total of 2,607 laboratory studies were performed, with an average of 14 tests per patient. With all tests considered, only 10(0.4%) served to establish a diagnosis and an extra 1% were able to support a diagnosis.34Further Evaluation(1) hospitalization insurance Although some authors state that most children with failure to thrive can be treated as outpatients,4, 5,11,45 I think it is best to hospitalize the infant with FTT for 10 14 days. Hospitalization has both diagnostic and therapeutic benefits. Diagnostic benefits of admission may include observation for feeding, parental-child interaction, and consultation of sub-specialists. Therapeutic benefits include administration of intravenous fluids for dehydration, systemic antibiotic for infection, blood transfusion for anaemia and possibly, parenteral nutrition, all of which are often in-hospital procedures. In addition, if an organic aetiology is discovered for the FTT, specific therapy can be initiated during hospitalization. In psychosocial FTT, hospitalization provides prospect to educate parents about appropriate foods and feeding styles for infants. Hospitalization is necessary when the prophylactic of the child is a concern. In most situations in our set up, there is no viable alternative to hospitalization.(2) Quantitative assessment of intake A prospective 3-day diet record shoul d be a standard part of the evaluation. This is useful in assessing under nutrition even when organic disease is present. A 24-hour food recall is also desirable. Having parents write down the types of food and amounts a child eats over a three-day is one way of quantifying caloric intake. In some instances, it can make parents aware of how much the child is or is not eating.11Table 4 Summary of risk factors for the development of failure to thriveInfant characteristicsAny chronic medical condition resulting in Inadequate intake (e.g, swallowing dysfunction, central nervous systemdepression, or any condition resulting in anorexia) Increased metabolic rate (e.g, bronchopulmonary dysplasia, congenital heartdisease, fevers) Maldigestion or malabsorption (e.g, AIDS, cystic fibrosis, short gut,inflammatory intestine disease, celiac disease). Infections (e.g., HIV, TB, Giardiasis)Premature birth (especially with intrauterine growth restriction)Developmental delayCongenital anomaliesIntra uterine toxin exposure (e.g. alcohol)Plumbism and/or anaemiaFamily characteristicsPovertyUnusual health and nutrition beliefsSocial isolationDisordered feeding techniquesSubstance abuse or other psychopathology (include Muschausen syndrome by proxy) ferocity or abuseAdapted from Kleinman RE.1Table 1 Summary of diachronic evaluation of infants and children with growth failurePrenatalGeneral obstetrical historyRecurrent miscarriagesWas the pregnancy planned?Use of medications, drugs, or cigarettesLabour, delivery, and neonatal eventsneonatal asphyxia or Apgar scoresPrematuritySmall for gestational ageBirth weight and lengthCongenital malformations or infectionsMaternal stick at birthLength of hospitalizationBreastfeeding supportFeeding difficulties during neonatal periodMedical history of childRegular physicianImmunizationsDevelopmentMedical or surgical illnessesFrequent infectionsGrowth history eyepatch previous pointsNutrition historyFeeding behavior and environment sensed sensiti vities or allergies to foodsQuantitative assessment of intake (3-day diet record, 24-hour food recall)Social historyAge and occupation of parentsWho feeds the child?Life stresses (loss of job, divorce, death in family)Availability of social and economic support (Special Supplemental Nutrition weapons platform forWomen, Infants and Children Aid for Families with Dependent Chi

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