Improving
Neonatal
Skin Care
Gayla Eppinger, NNP-BC
Emory University
Atlanta GA
2
Improving Neonatal Skin Care
Learning Objectives





Describe the structure and function of neonatal skin
Explain and apply the Neonatal Skin Condition Scale
Identify clinical practice goals related to neonatal skin care
Describe recommended skin care practices
Understand new evidence-based research and recommendations
Function of the Skin
1)
2)
3)
4)
Serves as barrier against infection and protects internal organs
Plays major role in thermoregulation and storage of fat
Regulates insensible water loss, also secretes electrolytes & water
Provides tactile sensory input and sensations of touch, pressure, temperature, pain & itch
a) Difference in Neonatal Skin
i) Skin of the premature neonate accounts for 13% of their body weight as compared to 3% of the body weight of
an adult
ii) Premature neonate has body surface/weight ratio ~ five times greater than that of an adult
iii) The skin of a premature neonate is 40-60% thinner than adult skin
1)
Epidermis: functions as a barrier, preventing penetration and absorption of potential toxins and microorganisms, as well
as retaining heat and water.
a) Stratum Corneum: outermost layer of cells forming the epidermis. Non-living layer made up of dead cells
constructed like a wall of bricks and mortar
b) Forms part of the vernix caseosa, controls transepidermal water loss (TEWL), prevents absorption of toxic
substances
c) Difference in Neonatal Skin
i) 10-20 layers of stratum corneum in full-term infants and adults
ii) Neonate <30 weeks gestation has only 2-3 layers and at 23-24 weeks virtually no stratum corneum
iii) Maturation rate of stratum corneum varies based on the gestation age:
At <27 weeks the process is slowed;
At 23-25 weeks it takes 8-10 weeks to develop the function of full term skin;
At >27 weeks approaches full-term skin function by ~10 days postnatal age
d) Risks of underdeveloped Stratum Corneum
i) Infections and skin irritation
ii) Increase in insensible water loss
iii) Increased evaporative water loss
iv) Toxicity from topically applied substances
v) Epidermal stripping
Anatomy of the Skin
Note: Percutaneous absorption of Neomycin (topical antibiotic) has been reported to cause neural deafness.
Bacitracin has been noted as one of the 12 most frequent allergens causing a positive patch test reaction in patients ages 892 years. Marks, et al (1995). North American Contact Dermatitis Group standard patch test results. American Journal of
Contact Dermatitis, 6, 160-165.
2)
The Basal Layer: near the junction of the epidermis and dermis, is the bottom layer of the epidermis. A source of
renewal for the epidermis. Living cells which replace cells of the stratum corneum.
a) Difference in Neonatal Skin
i) Dermal-epidermal junction is connected by fibrils which are fewer and more widely-spaced in premature infants
than in full-term infants
3
ii)
b)
As gestational and postnatal age advances, fibrils become stronger
Risks of fewer fibrils
i) Diminished cohesion between dermis and epidermis places premature at higher risk for injury
ii) Bond between adhesives and epidermis may be stronger than the cohesion between dermis and epidermis,
resulting in epidermal stripping when adhesives are removed
iii) Premature infant at greater risk of blistering from friction or thermal insults
3)
Dermis: under the epidermis. Composed of collagen and elastin fibers. Contains nerves, blood and lymph vessels, mast
cells and inflammatory cells. The carrier of heat, pressure and pain.
a) Difference in Neonatal Skin
i) Premature infants prone to edema due to less collagen and fewer elastin fibers in the dermis
ii) Edema places the neonate at increased risk of ischemic injury and pressure necrosis due to reduced blood flow
to the epidermis
iii) Full-term infant’s dermis is thick and well-organized, but, thinner and higher water content than adult’s
4)
Subcutaneous: fatty connective tissue. Heat insulator, shock absorber, and caloric reservoir. Fat deposition occurs
primarily in last trimester
Characteristics of Neonatal Skin
1)
Skin appearance: soft, wrinkled, velvety, covered with vernix caseosa
a) Difference in Premature Skin
i) More transparent, gelatinous and wrinkle-free
ii) Lanugo present in varying degrees
iii) Subcutaneous edema may be present
2)
Skin pH: alkaline skin surface with mean pH of 6.34. During next four days, skin pH falls to mean of 4.95 creating “acid
mantle”. Provides protection against microorganisms, particularly pathogenic bacteria and fungus.
a) Difference in Premature Skin
i) Skin pH greater than 6.0 at birth
ii) Declines to 5.5 over the first weeks, and gradually declines to 5.0 over the first month
3)
Nutritional stores: fat and trace mineral zinc accumulates during the third trimester. Necessary to prevent nutritional
deficiencies that cause skin disruptions.
a) Breast milk or infant formulas contain adequate levels of nutrients
b) Premature and sick neonates at risk for fatty acid deficiency
c) Infants requiring TPN need adequate replacement of fat and zinc in IV solutions
4)
Difference in Neonatal Skin: premature and sick newborns are vulnerable to infection due to
a) Immature immune system
b) Invasive tubes and catheters
c) Frequent use of antibiotics
d) Immature skin structure and function
e) Excoriations and other sites of skin trauma
f) Changes in skin pH
5)
What Families Need to Know: Skin of the premature newborn is different than that of the full-term newborn. All
neonates admitted to the NICU are at risk for developing skin conditions which may require special skin care.
Goals of Neonatal Skin Care
1)
2)
3)
4)
Reduce traumatic injury
Prevent dryness
Avoid exposure to toxins
Minimize exposure to unnecessary substances
4
5)
Promote normal skin development
1)
First Bath: should be given once the newborn’s condition, vital signs and temperature have been stable >2 – 4 hours.
a) Recommended Practices
i) Wear gloves and implement universal precautions before and during first bath
ii) Removing all vernix is not necessary for hygienic reasons
iii) Do not use antiseptic soaps or cleanser
iv) Use warm water
v) Use cotton balls or soft cloth
vi) Avoid rubbing skin surfaces to prevent chafing and irritation
2)
Routine Bathing: main purpose is to remove debris. A time for contact between newborn and caregiver, which, if not
handled properly, can result in physiological and behavioral problems for the newborn.
a) Recommended Practices
i) Use cleansers with a neutral pH with minimal dyes and perfumes to lessen the impact on the acid mantle, and
reduce the risk of future skin sensitization
ii) Avoid rubbing skin surface as it can cause chafing and irritation
iii) Rinse with water
b) Recommended Practices for Infants < 32 Weeks Gestation
i) Bathe with warm water and cotton balls or soft cloth during first few weeks of life
ii) Use warm sterile water on areas of breakdown
3)
Immersion Bathing: placing the infant’s entire body, with the exception of head and face, into a tub of water.
a) Recommended Practices
i) Use water at a temperature of 100.4 degrees (38 degrees C) to ensure an even temperature and decrease
evaporative heat loss
ii) After the bath: dry, diaper, and double-wrap (with cap)
iii) After 10 minutes: dress, change the cap, and wrap in dry warm blankets
4)
What Families Need to Know: gather all supplies and clothing prior to starting the bath; perform bath in draft-free
First Bath and Routine Bathing
location; avoid using soaps and lotions with perfumes and dyes to prevent sensitizations later in life.
Cord Care
1)
2)
3)
Studies have shown that disinfectants do not affect bacterial colonization or cord and skin infections
Certain antiseptic ointments and isopropyl alcohol have been shown to delay cord separation
Recommended Practices
a) Clean cord and surrounding skin with skin cleanser used for first or routine bath and rinse thoroughly
b) Alternatively, clean cord with sterile water
c) Keep cord clean and dry
d) Fold diaper below umbilicus
e) Clean cord with water if soiled with urine or stool
4)
What Families Need to Know: normal cords may seem moist and “mucky” in appearance. Educate them about the
normal process of cord healing.
Circumcision Care
1)
2)
Before the procedure
a) Disinfect penis and surrounding skin
After the procedure
a) Remove disinfectant with water, focus on leg creases, buttocks, and lower back
b) Cover penis with petrolatum-impregnated gauze strips or sterile gauze pads over petrolatum for the first 24 hours
c) Do not use petrolatum or other lubricants if the circumcision was performed using the PlastiBell technique
5
d)
e)
3)
Cleanse with water only for 3-4 days to prevent irritation from cleansers
No proven benefit to using antimicrobial ointments as compared with petrolatum
What Families Need to Know: use petrolatum product and gauze first 24 hours. For the next 3-4 days, clean penis
with warm water only.
Diaper Dermatitis
1)
2)
3)
4)
Causes
a) Exposure to stool and fecal enzymes. Prolonged contact with urine-soaked diaper leads to skin becoming moist and
macerated and more susceptible to injury
b) Skin pH rises – as the skin becomes more alkaline, fecal enzymes and bile salts that cause skin breakdown become
activated
Identify and treat underlying conditions (malabsorption, diarrhea, intestinal resection, opiate withdrawal)
Recommended Practices
a) Preventative Strategies: keep skin surface dry
i) Change diapers frequently
ii) Use super absorbent gel disposable diapers
iii) Apply petrolatum to slightly reddened, intact skin
b) Treatment After Skin Breakdown: protect skin from more injury
i) Generously apply skin barriers containing zinc oxide
ii) Apply pectin paste without alcohol followed by a greasy coating with petrolatum or zinc oxide to prevent diaper
from sticking to the barrier
iii) Remove as much waste material as possible when changing diaper, and re-apply barrier in a thick layer
iv) Exposure to air and light is not as effective, re-injury occurs when stool contacts injured skin
v) Use anti-fungal ointment or creams to treat candida diaper dermatitis
What Families Need to Know: how diaper dermatitis develops and proper preventative and treatment strategies.
Avoid products with perfumes and dyes.
Emollients
1)
Purpose: to protect and restore skin integrity
a) When applied twice daily to neonates with birth weights 500-1000 grams, emollient use resulted in reduced visible
dermatitis and improved skin integrity
b) Have been shown to reduce transepidermal water loss in neonates <32 weeks gestation, but the effect diminishes
after 6 hours
c) May be safely used on neonates under radiant warmers and phototherapy
d) Caution: with twice daily use, higher risk of coagulase-negative Staphylococcus epidermidis sepsis in infants
<750grams
2)
Recommended Practices
a) Use emollients that are petrolatum-based, water miscible, and free of preservatives, dyes and perfumes
b) Use on skin that is dry, with scaling, fissures or visible cracking
c) Use to protect skin that is prone to breakdown (in groin or thigh)
d) Use single patient tubes to prevent cross-contamination
6
Product
A&D ointment
Aloe Vesta
Protective
ointment
Aquaphor
Aquaphor
Natural Healing
ointment
Baby Magic
Baby Lotion
Balmex
Diaper Rash
ointment
Cholysteramine
in Aquaphor
Critic-aid
Desitin Diaper
Rash ointment
Dr. Danis
Buttocks Cream
Dyprotex
Elase ointment
Eucerin cream
Happy Hiney
Diaper Rash Products and Emollients: Composition and Cost
Manufacturer
Ingredients
Schering-Plough
Cholecalciferol, fish liver oil, petroleum,
Memphis, Tenn
fragrance, lanolin, mineral oil, paraffin
ConvaTec
Propylparaben, aloe vera gel, quaternium-15,
Princeton, NJ
water, hydroxylated lanolin, ozokerite, glycerin,
fragrance
Beiersdorf, Inc
Petrolatum, mineral oil, mineral wax, wool wax
Norwalk, Conn
alcohol
Beiersdorf, Inc
Petrolatum, mineral oil, mineral wax, wool wax,
Norwalk, Conn
alcohol, panthenol, bisabolol, glycerin
Mennen
Morristown, NJ
Block Drug Company
Jersey City, NJ
Bristol-Myers Squibb
Princeton, NJ;
Beiersdorf Norwalk,
Conn; locally
compounded
Sween Products
N. Mankato, Minn
Pfizer
New York, NY
Compounded at St.
John’s Mercy Medical
Center, St. Louis, Mo
Blistex
Oakbrook, Ill
Fujisawa
Deerfield, Ill
Beiersdorf
Norwalk, Conn
Bristol-Myers, Squibb
Princeton, NJ;
Beiersdorf Norwalk,
Conn compounded at
Cost/Oz.
2.12
1.02
.68
.68
Water, glycerin, glyceryl stearate, cetyl alcohol,
mineral oil, Peg-100 stearate, lanolin alcohol,
fragrance, lanolin, methylparaben, lapyrium
chloride, propylparaben, benzalkonium chloride,
diazolidinyl urea
11.3% zinc oxide, balsam of Peru, beeswax,
benzoic acid, bismuth subnimitrate, mineral oil,
purified water, silicone, synthetic white wax
15% cholestyramine liquid (aspartame, citric acid,
A&C yellow #10, FD&C red #40, flavor, propylene
glycol alginate, colloidal silicon dioxide, sucrose,
xanthan gum) in Aquaphor
.28
Benzethonium chloride in a soothing, occlusive
moisture-resistant paste of proprietary
ingredients
40% zinc oxide; BHA, cod liver oil, fragrance,
lanolin, methyl paraben, petrolatum, talc, water
32g zinc oxide, 32g starch, 32g talc, 60 ml
glycerin, 112 g Aquaphor
2.91
40% micronized zinc oxide, 37.6% petrolatum,
2.5% dimethicone, cod liver oil, aloe
1U fibrinolysin and 666.6 U of deoxyribonuclease
in a base of petrolatum and polyethylene
Water, mineral oil, isopropyl myristate, Peg-40
sorbitan peroleate, glyceryl lanolate, sorbitol,
propylene glycol, cetyl palmitate, magnesium
sulfate, aluminum stearate, lanolin alcohol, BHT,
methylchloroisothiazolinone,
methylisothiazolinone
12 x 4.1 g packets of Questran powder
(cholestyramine resin, acacia, citric acid, D&C
yellow #10, FD&C yellow #6, flavor, polysorbate
80, propylene glycol, alginate, sucrose)
2.85
1.47
8.40
1.72
13.50
52.72
.84
2.50
7
Carbondale Memorial
Hospital
compounded in 1 pound of Aquaphor
Ilex Paste
Calgon-Vestal
St. Louis, Mo
5.75
Neosporin Plus
Maximum
Strength
ointment
Nystatin cream
Burroughs-Wellcome
Triangle Park, NC
Petrolatum, calcium/sodium PVM/MA copolymer,
DMDM hydantoin, iodopropynyl-butycarbamate,
mineral oil, peppermint oil, sodium carboxymethyl
cellulose
Polymyxin B sulfate 10,000U, bacitracin zinc
500U, neomycin 3.5mg, lidocaine 40mg, in a
special white petrolatum base
11.78
Nystatin
ointment
Proshield
E. Fougera
Melville, NJ
Health Pointe Medical
Forthworth, Tx
100,000U Nystatin, polysorbate 60, aluminum
hydroxide compressed gel, titanium dioxide,
glyceryl monostearate, polyethylene glycol
monostearate 400, simethicone, sorbic acid,
propylene glycol, ethylenediamine,
polyoxyethylene fatty alcohol ether, sorbitol
solution, methyl paraben, propyl paraben,
hydrochloric acid, white petrolatum, purified
water
100,000U Nystatin per gram, in a polyethylene
and mineral oil base
Cleansing foam: purified water, glycerine,
cocoamphodiacetate, polaxymer 188,
cocamidopropylpeg-dimmiumchloride phosphate,
DMSM hydantoin, laureth-23, citric acid,
fragrance
Lanolin, petrolatum
Super Dooper
Diaper Doo
E. Fougera
Melville, NJ
22.50
11.78
6.09
Peacock
5.75
Pharmaceuticals
Springfield, Mo
Vaseline
Cheseborough-Ponds
White petrolatum USP
.29
Greenwich, Conn
Zinc oxide
E. Fogera
20% zinc oxide, mineral oil, white wax, white
.56
ointment
Melville, NY
petroleum base
Eichenfield, LF, Frieden, IJ, Esterly, NB. 2001. Textbook of Neonatal Dermatology. Philadelphia: WB Saunders.
White petroleum is currently regarded as the gold standard. It acts primarily by trapping water in the
epidermis. Oils, oil-and-water-based creams and lotion emollients have greater tactile acceptance than greasy
ointments. Compared with ointments- oils, creams, and lotions provide a much less-effective moisture barrier. In
addition, formulation of a cream or lotion emulsion requires the addition of several potentially irritating,
sensitizing, or toxic ingredients.
Eucerin Crème contains methylchloroisothiazolinone/methylisothiazolinone (CMI/MI, also known as Kathon CG).
CMI/MI has been associated with allergic contact sensitization in up to 10% of exposed adults and is the third
most common sensitizer in children with chronic dermatitis.
Wood alcohols, along with Kathon CG, thimerosal, nickel, fragrances, and neomycin rank among the most common
causes of allergic contact dermatitis in children.
8
Skin Disinfectants
1)
Recommended Practices
a) Disinfect skin surfaces before invasive procedures
b) All disinfectants have the potential to damage tissue; use judiciously
c) Use with caution on underdeveloped or damaged skin
2)
Disinfectant Products
a) Chlorhexidine gluconate (CHG)
i) Most effective agent to reduce catheter-related infections in adults
ii) Has been shown to reduce colonization with bacteria in NICU patients
b)
Povidone-iodine 10% aqueous solution (PI)
i) More efficacious than alcohol for skin disinfection
ii) Can be absorbed through the skin of premature neonates and result in thyroid suppression
c)
Isopropyl alcohol (70%)
i) Use cautiously, it is irritating and drying to skin and may cause chemical burns
ii) Do not use for removing CHG or PI
Note: After use, always remove disinfectant with sterile water or saline to minimize absorption and prevent
tissue damage.
Adhesives
Adhesive removal is the primary cause of skin breakdown.
1) Recommended Practices
a) Applying Adhesive
i) Minimize amount of adhesive in contact with skin
ii) Use smaller pieces of tape
iii) Use “double-backed” tape
iv) Deactivate adhesive with cotton balls when full adhesion not required
v) Do not use bonding agents (benzoin) to enhance adhesion
vi) Avoid bandages after heel sticks. Use pressure with a cotton ball or gauze
b)
2)
Removing Adhesive
i) Loosen adhesive with mineral oil or petrolatum-based emollients
ii) Slowly fold adhesive back onto itself while moistening the adhesive-skin surface with water-soaked cotton balls
iii) Avoid solvents due to potential and proven toxicity
Adhesive Products
a) Hydrogel Electrodes and Adhesive Strips
i) Cause little or no trauma
ii) Recommended for premature and full-term infants
iii) Cannot be used to secure catheters, endotracheal tubes or other life support equipment
b)
Pectin Barriers
i) Mold to skin surfaces and adhere well
ii) Can be used under tape to prevent epidermal stripping caused by tape removal
9
iii) Absorb moisture
iv) Removal can cause skin trauma, so use care when removing
v) Hydrocolloid adhesives are similar to pectin barriers
c)
Stretchy Gauze and Other Wraps
i) Use to anchor electrodes, probes, and secure limbs to IV boards
ii) Use with caution to prevent constriction of blood flow and decrease tissue perfusion
d)
Transparent Dressings
i) Use to anchor silicone catheters, central venous lines, peripheral IVs, nasal cannulas and nasogastric tubes
ii) Semi-permeable film allows the skin to breathe and catheter sites to be visible
iii) Can cause epidermal stripping when removed
e)
Alcohol-Free Skin Protectants
i) Coat skin with plastic polymers to create a barrier between skin and adhesives
ii) Recommended for infants over 30 days of age
iii) Safety in premature and full-term infants has not been evaluated
Importance of Skin Assessment: facilitates early identification and treatment of skin problems. Head-to-toe inspection
of skin surfaces should be done every 12 hours.
a) Use an objective scale
b) Evaluate risk factors that may impede skin integrity
i) Monitoring probes and electrodes
ii) Adhesives to secure tubes and catheters
iii) Paralyzing agents and vasopressors
iv) Surgical wounds and ostomies
v) Technology that limits position and mobility
Neonatal Skin Condition Scale
Dryness:
1 = normal, no sign of dryness
2 = dry skin, visible scaling
3 = very dry skin, cracking/fissures
Erythema:
1 = no evidence of erythema
2 = visible erythema < 50% body surface
3 = visible erythema > 50% body surface
Breakdown:
1 = none
2 = small localized areas
3 = extensive
Prevention of Skin Breakdown
1)
Risk factors for pressure sores
a) Treatments or technologies that make turning or moving difficult
b) Severe edema, hypotension, peripheral tissue hypoperfusion
10
c)
Common sites include occiput of head, ears due to relatively large size and weight of newborn’s head
2)
Friction injuries are another source of skin breakdown
3)
Recommended Practices for preventing pressure ulcers
a) Use cotton surfaces or sheepskin
b) Reduce the impact of pressure on a small surface area with the use of water or air mattresses, gel mattresses, and
pads
c) Protect areas that have skin-on-skin contact with petrolatum ointment
d) Use transparent dressings to protect knees and elbows
1)
Recommended Practices for Skin Breakdown
a) Flush affected areas with warm solution of half saline/half sterile water using 18- or 20- gauge IV catheter and
30cc syringe every 4-6 hours
b) Cover superficial wounds and scrapes with petrolatum-based ointment
c) Use antibiotic ointment if extensive bacterial colonization with gram positive organisms
d) Triple antibiotic ointment is not recommended
e) Use transparent dressings, hydrogel and hydrocolloid wound care products on deeper wounds
f) Hydrogel dressings can be used in conjunction with antimicrobial or antifungal ointments
g) Transparent dressings and hydrocolloids should not be used on infected wound
h) No disinfectant solutions directly on wounds
2)
Recommended Practices for Fungal Infections
a) Asses for early symptoms (erythematous skin surfaces, crusting or erosive lesions)
b) Obtain skin culture, gram stain or potassium hydroxide (KOH) prep
c) Apply antifungal ointment to skin breakdown & discontinue petrolatum-based ointments
d) Observe closely for systemic fungal infection
Treatment of Skin Breakdown
Transepidermal Water Loss
Underdeveloped stratum corneum leads to excessive TEWL and evaporative heat loss.
1) Recommended Practices
a) At birth, use occlusive polyethylene bag to cover body torso and extremities
b) Place infant in high humidity environment (relative humidity >70%) first seven days
c) Cover body surfaces with transparent dressings
d) Apply petrolatum-based ointment every 6 hours to body surface
e) Maintain relative humidity >40%
f) Use double-walled incubators
g) Provide supplemental conductive heat using heated mattress to reduce radiant warmer output
h) Use polyethylene tents or blankets, that do not touch the skin, to trap moisture
Nutrition
Zinc is required for wound healing and maintenance of skin integrity; essential fatty acid deficiency (EFAD) can result in
scaly dermatitis.
1) Recommended Practices
a) Add zinc to parenteral nutrition
b) Additional amounts of zinc may be required for infants with high ostomy output, chronic diarrhea, short bowel
syndrome or large wounds
c) Prevent EFAD with daily intravenous intralipid infusion
11
New Skin Care Research
Carolyn Lund, MS, RN, FAAN, Children's Hospital, Oakland, California, a member of the Evidence-Based Clinical Practice
Development team, presented a poster on the clinical outcomes of the AWHONN/NANN clinical practice guideline.[4] The
clinical practice guideline provided the studied institutions with a foundation for practice that was integrated into care.
Statistically significant changes in practice were described after implementation of the skin care guideline: bathing
frequency decreased and emollient use increased yet there was no increase in positive blood cultures. Using a standardized
assessment score, the Neonatal Skin Condition Score (NSCS), there was a statistically significant improvement in skin
condition noted in both well newborns and premature newborns after implementation of the evidence-based neonatal skin
care guideline.
Dolores Quinn, RN, NNP,[5] UCSF Medical Center, San Francisco, California, presented the results of a randomized
controlled trial that compared the impact of bathing every other day vs every fourth day on skin flora type and colony count
in premature infants 25 to 33 weeks of gestation. There was no statistical significance between the groups. Skin flora and
colony count did not increase with the increased interval between bathing. The limitations of the study include the small
sample size. This research supports the skin care practice recommendation related to bathing, which limits bathing
frequency to 2-3 times per week and attempts to define a bathing timetable that is safe, as defined by increase in skin
colony counts and infection.
Guidelines for Clinical Practice
Evaluation and implementation of research-based evidence is the foundation of nursing care. Implementation of the
AWHONN-NANN Skin Care Guideline improves overall skin condition of newborns and reduces iatrogenic injury. Nurses
need to continue to review and evaluate new research and products for implementation in their practice as well as
conduct/support new research that describes skin care practices with clinical outcomes.
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Obstetric and Neonatal Nurses; 2001.
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infants. J Pediatr. 1997;131:434-439.
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