Tipat Chalav Survival Guide for Parents

girl-climb-stairs On Twitter, @mrsroth mentioned how a nurse handed her 18-month-old a cup and spoon. The little girl started to “stir” with the spoon, but failed that developmental task because she was supposed to pretend to eat from the bowl.

Everyone loves to complain about Tipat Chalav, the network of well-baby clinics run by Israel’s health ministry. Sometimes the staff gives silly suggestions, or even dangerous ones. And nothing is more upsetting to an anxious new mother than having her baby “fail” one of Tipat Chalav’s many tests.

Overall, Tipat Chalav does its job very well. It’s important for new parents to understand Tipat Chalav’s strengths and limitations.

Tipat Chalav has several key roles:

  1. Weigh, measure and examine the baby. This is to ensure that  baby is getting enough to eat and has no underlying health issues. Even educated and experienced parents don’t pick up every problem. And if your baby has never been weighed, you won’t have a baseline to tell the doctor if something comes up later.
  2. Give immunizations.
  3. Share updated health and safety guidelines. These include vitamins, breastfeeding and bottle-feeding information, when to start solids, safety recommendations, and more. The Israel Health Ministry writes up the guidelines, many of which come via the World Health Organization. Many Tipat Chalav nurses have even taken courses in breastfeeding, but the quality of their advice varies.
  4. Test the baby’s development. This includes physical and cognitive ability, communication, hearing, and eyesight.
  5. Schedule regular appointments with the resident pediatrician.

In addition, Tipat Chalav provides services for women during pregnancy and in the post-partum period, including birth control.

Tipat Chalav’s goal is to prevent babies and their families from falling though the cracks. That’s why there’s one in nearly every neighborhood. In addition to spotting medical concerns, they involve social services when they suspect abuse or neglect. This is a good thing, even though it means some parents will be falsely accused.

One problem with Tipat Chalav is that the nurses administer standard tests, and they expect standard answers. If your baby starts to drop in the weight percentiles, some nurses are alarmed even when everything else is fine.

New mothers can be sensitive to the slightest criticism. If the nurse finds something “wrong” with the baby, you don’t have to act on it. But because they see so many children of the same age, they may pick up on things a mother might not notice.

If you’re not sure whether the concern is justified, you can say that you will check it out with your doctor. If you report that your doctor said the the baby is fine, there isn’t much more the nurse can say. You can also try to see a different nurse in the future.

The most important thing a Tipat Chalav nurse can do is to make parents feel good about their children. This is doubly true with mothers of new babies. I’ll never forget the time I took my son for a blood test, when he was about 11 months old. He was flirting and “joking” with the nurse. She was so enchanted she called over another nurse to see. There’s a huge difference when you walk into the clinic and are greeted by someone happy to see you and your baby, not looking down a checklist expecting to find something wrong.

Are you satisfied with your Tipat Chalav? Do they accomplish what they are supposed to, or do they just make parents overly anxious? What tips can you give to new parents?

Photo source: MollyPop

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Comments

  1. I am quite satisfied with Tipat Chalav. The kids get their immunizations and make sure the kids see a doctor regularly. With the right attitude the old Russian nurse telling me to keep my kids off the cold tile floor because it’s bad for their kidneys, or the Moroccan nurse telling me to hang garlic over my child’s crib can be endearing (kind of in the same way unwanted advice from great aunt is.) In the end of the day, you can always make an appointment for a well check up through your Kuppat Cholim with your own family doctor for free, so I don’t really see what could be so bad about Tipat Chalav.

  2. Thanks – you make some really good points here.
    It’s particularly important to stress to parents that if you’re not comfortable with your nurse, SWITCH. I’ve worked with three different nurses in my local tipat chalav. One was AMAZING, one was fine, and one made me feel awful. Guess which one I’ll never go back to again!

    Remember that they’re there to serve you and your child, not the other way around.

  3. Oh, boy. Tipat Halav is not my favorite institution.

    I once had a nurse ask me whether my baby grabs objects held in front of him. I answered, “Yes”. The nurse then approached my baby and said, “Now let’s see if your mommy was telling the truth.” How flattering.

    I had another nurse comment that I should not hold my 6 month old baby on my belly, since I was “obviously” pregnant – which I was not. Thanks…

    When I took my then-5-year-old for a pre-first-grade check, the doctor at Tipat Halav suggested he might be a little bit cross-eyed. Then he looked at me and said, “Ah, but you’re a little bit cross-eyed as well, so I guess it’s OK.” Gee, thanks! I’m not cross-eyed!

    Finally, when my youngest was diagnosed with autism, we reported it to our Tipat Halav. They responded, “Really? But he said a couple of words at his last appointment…” Obviously, they had never heard of regressive autism – and saying a couple of words does not rule out autism. They never checked for some basic signs of autism: joint attention (pointing, looking when someone else points, etc), eye contact, and so on.

    To sum up, new mothers should remember: Tipat Halav has its purpose. They can be useful. However, do not rely on them too much. Trust your own instincts – you are the baby’s mother, and you know him/her best, even if it’s your first baby! Listen and consider their ideas, but take everything with a grain of salt.
    And try to have really, really thick skin…!!!

    • Oh man, not funny at all but very familiar.

      I am so not a fan. Couldn’t figure out why our tipat halav always smelled like nicotine smoke and why there were so many mandatory breaks for 15- 20 minute schedule meetings: because the nurse was taking smoke breaks between seeing infants and the smoke was coming in through the air conditioning.

      I could go on, but sounds like we’re in the same leaky, garlicky, cross-eyed, pregnant boat.

      ~ Maya

  4. Just to clarify: Basic signs of autism: LACK OF joint attention (pointing, looking when someone else points, etc), LACK OF eye contact, and so on.

  5. Add me to the list of those with Tipat Chalav horror stories.

    My oldest daughter wasn’t growing at the rate they thought she should. They accused me of not feeding her. Thankfully, our family doctor suspected a growth hormone deficiency, which turned out to be the case.

    I was told another daughter might have a slight deafness problem because she wasn’t turning her head in the direction of the bell the nurse was ringing just off to the side. That’s because she was busy turning to the opposite side, to the open window, where a construction crew was jackhammering away.

    And lastly, there was the case of cognitive development, or a lack thereof, because yet another daughter wouldn’t follow the path of the toy being waved in front of her face. You see, the two bar electric heater just beyond the nurse was so much more interesting to stare at…

    And yet, when my third daughter wasn’t holding her head at two months, wasn’t turning over until 9 months, didn’t pull herself up to stand until she was 17 months old, and I was concerned, they told me to stop worrying, it will all work out until the wedding (ad hachatuna).

  6. rachel q says:

    Where I live we have two tipat chalav nurses. The one who’s in charge of babies I like. She is very unconcerned. When my baby “failed” his earing test she simply said to try again in a month. He is contantly dropping percentiles and she keeps telling me not to worry.
    The other one is a bigger issue, so far I’ve avoided her because my appointments coincided with her maternity leaves. Let’s see how long I can avoid her. Otherwise, I simply go to the Ped and confirm anything she tells me

  7. I’ve have had a relatively good experience with Tipat Chalav (Ahad Ha’Am, Petach Tikvah), even though it took us forever to get our first appointment since we moved here 6 months ago. The secretary is scary, but the nurse is nice and patient. I will only see a nurse who speaks English, so that narrows it down somewhat to educated Israelis. My baby is a couple months behind, but the nurse’s concern seems pretty appropriate for the circumstances and she is very accommodating in writing notes with her findings so I can show it to my baby’s other doctors and get their opinion. I appreciate that she wants to know what our pediatrician thinks about development and even vaccines. She checks that I’m doing the right things (or things she thinks are right) without being accusatory.

    My advice is if you are concerned about any findings or “diagnoses” ask the nurse to write a note for your pediatrician and ask your pediatrician to write a reply. Then you have it in writing if your pediatrician disagrees.

  8. My Tipat Chalav experiences are from long ago and were in a small moshav where most of the doctors and just about all the nurses were people neighbors, friends or at least acquaintances. I found the advice mostly helpful if sometimes different from child to child over the years. Some of the standardized ‘tests’ like the ones for hearing where they hit the cup with the spoon and hope your 6 month old will turn toward it (as if there were nothing else of interest going on in the room) was never worth much. I think historically Tipat Chalav was probably more important than it is now since most of the population (urban Jewish at least) has regular access to pediatricians and better medical care. That probably wasn’t such a given years ago when the system was set up.

  9. Shoshana says:

    I was overall happy with my tipat halav experience – in part due to the specific nurse I primarily dealt with though over the years I did have occassion to work with at least one of the others in my local tipat chalav macabbi clinic (ours was located in macabbi) and she was also good. I also really liked my pregnancy care there with first pregnancy (unfortunately for my 2nd pregnancy, we no longer got tipat halav support but had to use just the nurses station and I was far from happy with that service so…. just goes to show that its a matter of who is doing the providing – same level of nursing education but just different people/setting, different result in satisfaction)

    My older son had health issues (coming out of NICU) and I got good assistance and tracking. He had nursing issues so I was invited to stop in as often as I wanted to weigh him (and the nurse was extremely pro-BF – they assigned all the post NICU babies to her, perhaps for that reason) to make sure everything was ok. He was developmentally delayed in many areas and they got me hooked up with the needed services for Physical therapy, etc which would have been harder to do all on my own with the local physician – they pushed to make sure I knew which therapist was the best for this issue, etc.

    I found the ideal combination was my own pediatrician + tipat halav. I never just worried based on the nurses reports but discussed it with my regular dr and at the same time, had the advantage of getting that feedback so I knew when to double check. And our dr really did know what to filter and what to immediately flag from experience .

    By the way, one interesting thing I found was that our tipat halav nurse used to always ask, since my kids were in maon/pre-school, to ask their daily setting for any specific observations they wanted to add in. She felt that the people who saw them day to day and who also had extensive experience with kids would also be able to note anything that seemed ‘different’ and worth checking into – from her experience many small hearing/vision problems were often picked up this way separate from any one time test, because these people knew it was a day to day issue compared to similar children in the same setting where a new parent without a basis for comparison might not always see and certainly could be missed on one time testing.

    I guess i should just be thankful that I had a good experience – when i did hit on a less than stellar nurse or dr there, I just ignored them and let it be since i felt otherwise supported.

  10. You mentioned that they have to be on the look out to stop people falling through the cracks.

    You should see their questionaire for post-natal depression. (maybe someone who remembers could write about it) It is logical that they would want to identify post natal depression, but the questionaire there is so scary that I think everyone lies!!!

  11. having experienced early child health clinics in Australia, UK and now Israel, I have found that whilst the style here seems quite paternalistic, with a lot of advice and some rather archaic and informal evaluations, it really depends on the individual nurse. When my daughter, my first sabrait, didn’t initally put on weight (10 days after birth she was back at her birth weight, but not above it) I was advised to start bottle feeding, I just assumed it was that nurse’s style and had the confidence to ignore her. The next nurse I saw was far more supportive and I just try to always see her.

    I am glad I came to Israel having already had children though, since if your baby “fails” a developmental test (which are far from standardized, so yes, the 6 month old baby would rather look at the nurses’ noisy bangles than turn to a some boring teddy they have already played with) they can stress out a mom. But it just seems to depend on the actual nurse.

  12. On the whole I have found our Tipat Chalav mostly okay, and I have managed to take the few mishaps with a pinch of salt and a sense of humour.
    Our first nurse was pretty apathetic, did her job, but didn’t offer criticism or encouragement. When she went on maternity leave, we got nurse number 2, who was super-nice, very experienced, always positive and upbeat. She always phrased possible problems as “not necessarily something to worry about, but worth checking with your pedi”
    I don’t remember how we got to nurse number 3, but this she is less successful.
    When she weighed them, the first of my sons stepped on the scale for the first time, having been weighed on the “kitchen scales” the previous times (and this was in a pedi’s room anyway as the Tipat Chalav ones were occupied). I hadn’t been paying much attention to their weights, it wasn’t a worry, and then she turned to the computer to log in his data and asked me “does he eat at all?” Turns out he had weighed in at only 100g more than at his previous appt 6 months earlier.
    It took me all of ten minutes to persuade her to reweigh him on the kitchen scales, she kept insisting that even if there was a difference, it wouldn’t be much. Of course once the reweighing WAS done, she had to concede that there was almost 500g (!!!!) difference between the two measurements, and that my son had put on a reasonable amount of weight.

    Thinking of all this, I think they’re due another visit (they’re nearly 3.5, and we never did go back to retake the communication test, although they definitely do communicate), I should ring up to see when this nurse has her summer vacation so I can make an appointment for then…

  13. I’m an RD so our Tipat Chalav nurse usually questions me about nutrition. “What do I tell mothers whose kids are eating/not eating/eating this or that?” “Is this and this and that OK?” Sheesh. :o) When it comes to food I usually feel as though I’m the one who came to counsel her. :o) On development issues she’s usually very relaxed, as I believe she should be. It’s so imprecise after all. And a baby/toddler might be doing something at home but not perform the same in Tipat Chalav (because maybe they dislike the memory of getting vaccinated there, or because there’s some distraction) so really, take it all with a grain of salt.

  14. I’ve enjoyed reading all your stories. What Victoria said is always true–listen to your instincts If you think something isn’t right continue to investigate.

  15. I’ve been pretty satisfied with our TC experiences but I really wish they’d use weight-to-length/height charts instead of weight-to-age and length-to-age charts.

    My 3 year old was pretty consistent for weight to length but under for weight to age and length to age.

    When the nurse told me he’s too short for his age, I asked her if she wants me to hang him by his ankles from the laundry line every day to stretch him.

    I mean, really….

  16. Ima in February says:

    I’m 7-8 weeks pregnant with my first, and I’m curious about the prenatal care that some of you are mentioning. What does it involve? Should I go for it? I’m ambivalent about my OB-GYN… he’s very experienced and is a three minute walk from my home (a bit plus!), and he speaks great English, but he seems kind of negative. My appts with him (including birth control and yearly exams the past two years) are always really brief… I always kind of expect him to check more, ask me a bunch of questions, but he never does. He’s never even weighed me! (I ask as many questions as I want, though.) I’m toying with the idea of switching, but I’m not sure that a different doctor would be different… from what I’ve heard, for example, Israeli doctors tend not to do pap smears or breast exams unless you specifically request them (definitely the case with this doctor), so maybe his “efficiency” is just an Israeli thing.

    Hmm… I think maybe the point of this long-winded comment is that I’d appreciate a post about what to expect with Israeli prenatal care!

  17. Ima in February — it took me until this year to learn that in Israel only breast surgeons do breast exams! You can schedule one through your kupah. You can also ask your ob/gyn to give you a referral for a breast ultrasound, which is done at the kupah.

    Paps should be done once every three years after you’ve had three normal exams in a row. You should insist on it being done at your postnatal checkup.

    Israeli doctors rely heavily on ultrasound rather than internal exams during pregnancy. Having only had babies here, I don’t have anything to compare it to. Unless there’s a problem, there doesn’t seem to be a reason to do anything more invasive.

    As far as tipat halav — I hated (ok, hate is strong — I seriously disliked) our first nurse. I then spent a year trying to schedule appts. conveniently when she WAS NOT there! We got a great nurse after that, and then she left and was replaced by an even better nurse whom we LOVE. She’s pro BF, pro babywearing, pro baby led weaning, etc. — and she didn’t balk when I said I hadn’t given him vitamin D or iron, but that he ate dried fruits (cooked) and got some sunlight each day!

    We are at the Tipat Halav in Jerusalem on R’ Yehuda in Baka.

  18. Ima in February says:

    Melissa, thanks for the reply… it sounds like my doctor is pretty normal. I’ve had two ultrasounds already, while women I know in the US don’t have any until about week 10 at least. I’m not crazy about early ultrasounds but at least I know that it’s not just my doctor! -Maya

  19. Nurse Yachne says:

    Tipat Chalav nurses vary in their educational backgrounds and experience. Some are super qualified witha an RN and academic background, others, ESPECIALLY the older ones, may be only LPNs. Things have improved a lot and their approach has been updated in many places. In general, the worse the neighborhood, the better the Tipat Chalav, because they get more enrichment courses and better back-up.

  20. Shoshana says:

    Weight, blood pressure, and even your blood sugar/urine tests are all dealt with by tipat halav or the nurses for your kupah (depending on location) and not at all from your dr office. You are expected to open a tik with them during 2nd trimester already for all that sort of monitoring.

    Doctors here seem to only be really involved in your pregnancy care if you are a high risk patient – and then they are paying attention to everything. But if things go smoothly, they don’t regard it as any sort of ‘illness’ requiring medical attention – the same way childbirth is managed by midwives unless something is going wrong.

    shoshana

  21. Nurse Yachne says:

    Nicely put, Shoshana! Bay the way, Tipat Chalav also ensures that nobody is excluded from basic pre- and post-natal care at an affordable price, and that there is no shortage of caregivers and no long wait for basic care. That is something to be proud of.

    Also, bear in mind that the language-culture gap may cause Anglos to be disproportionately offended. My experience with Tipat Chalav before and after Israeli acculturation and 2 1/2 years in an Israeli nursing school gave me an alternate perspective on Tipat Chalav nurses.

    Nevertheless, when we did clinical work in nursing school, ALL my classmates with children, Israelis and vatikim, were surprised at how much better the nurses in the deprived neighborhoods where we dtudied were than the nurses from the more upscale neighborhoods and yishuvim in which we lived. It’s a lot better now.

  22. Interesting comments. Nurse Yachne, thanks for sharing that interesting fact about the nurses in poorer areas, and about Anglos’ views on nursing care.
    The government tried to restrict the number of ultrasounds but mothers were up in arms. Israel has the highest rate of neo-natal testing in the world, we seem to really want perfect babies.
    Am planning a post on Israeli pre-natal care, great idea.

  23. I’ve only ever had kids in Israel, so I don’t have much to compare it to, but I am really impressed with our Tipat Halav (btw, Nes Ziona has been far superior to Tel Aviv, where our first was born).
    Our nurses are both incredibly professional and knowledgeable. The doctor we just saw there was the most pro-breastfeeding health care professional I have ever encountered so far. He was really encouraging.

  24. Missnursing says:

    All I can say, is that when my fourth (and last…) had her “sgirat tik” checkup a few months ago, I muttered under my breath as I left, “Barukh sheptarani”…

  25. Nurse Yachne sent me more comments by email, I’ve published them here. http://www.amotherinisrael.com/insiders-view-tipat-chalav
    Missnursing and Lauren, thanks for your visit. I was much happier to be done with gan parties and parent meetings (school was easier).

  26. Ima in February,
    Israeli doctors do tend to be short

    He will tell you, or ask him whether you should be also going to the nurse at the clinic for follow-ups to.

    Unfortunately, it seems that you need to find out yourself what tests you need to have done and make sure he is sending you for them.

    In ultra orthodox areas, or if they see a relgious person, they do not always inform mothers of everything available.

    re: pre-natal testing, there are some tests that are done in Israel that are not necessary and potentially dangerous. but apart from that, ultrasounds are generally not recognized as dangerous and can be helpful

    MII I think the expression, “prefect baby” is problematic. Most people do not do ultrasounds in order to have only a perfect baby. The first one confirms that the baby is indeed in the womb and not ectopic.
    Other detailed US checks can give Drs info that can prepare them for treatment either in-utero, or immediately after birth, i.e. a couple of people I know knew that their child would be born with a blocked intestine, and had operations to correct this condition immeditely after birth, or someone else I know whose child had heart surgery straight after birth.

    • Keren, you’re correct. “Perfect” is an overstatement. I am not sure that ultrasounds are so harmless, and Israel does many more than in other countries. Remember that we pay for all of this testing through our taxes.

  27. As an ND, I have found tipat chalav nurses to be woefully undereducated medically if not totally uneducated. When my daughter gave birth I [and most other mothers in the vicinity] told her to stay as far away from them as possible, or barring that not to listen to a word they say without checking it out with me or her pediatrician.

    I still remember them telling me to feed a child in active heart failure cooking oil with Materna in a bottle to fatten her up a bit as she was thin at that time [duh!!] — I left and did not return for 5 years, until I had to give said child whatever shots she had not outgrown the need for after she had started school.

    But that was a few years ago. My oldest daughter, who is a young new mother, is very tall and very skinny and her hubby is even skinnier — and wouldn’t you know it, her baby is not fat. They started to give her a hard time about Mr. baby’s weight but as soon as they saw that she had more education in health/medicine than they seem to they backed off.

    If your baby is not fat enough to be a sumo wrestler they will give you a hard time and their feeding advice is best ignored if you value your child’s good health. The main thing you should be watching is your child’s personal growth curve — as long as they stay on it, don’t let anyone bully you. It doesn’t matter if your child is short, tall, thin, chunky, whatever — normal, healthy children come in different shapes and sizes and as long as they are getting a healthy, varied diet [after they start eating food, obviously] and are not showing any signs of ill health they should be left alone.

  28. Wise or not, we decided to stop taking our obviously healthy baby to tipat halav because it upset me so much each time. I was not approaching post-partum depression in any way, but every single appointment made me so angry that it wasn’t worth it.

    That being said, I frequently hear about other’s positive experiences. Just haven’t been able to replicate them.

    ~ Maya

  29. Just a question for experienced Israeli moms- is there a rule one should go to Tipat Chlav? Do you have to go at the specific times they recommend? What happens if you delay for a while?
    Thanks!

  30. Thanks!
    My daughter always hits the average line, so I haven’t had too many bad experiences to share about…one or two. Mostly they have been relatively normal towards me- a well-baby checkup without the expensive fees that American docs charge.

  31. Tipat Chalav is good for vaccinations and measurements, and that’s about it – in my opinion. I have had a few issues with them:

    1) One nurse gave my son MMRV, and only told me that she was giving him MMR. We were on the fence about the varicella vaccine, and were going to push it off, or possibly skip it entirely. I found out that he had been vaccinated when I was checking something else in his pinkas chisunim. Gee, thanks. My friend told me that this had happened to her, too, with her second child, but both she and I chalked it up to her not paying enough attention/ being up to date. I guess not – it’s the same Tipat Chalav.

    2) Another nurse told me that she wanted my son to get checked out, because “she doesn’t know why he’s not talking” – i.e., she’s not sure what to do with a child who, at a year and a half, isn’t talking. Not only that, he says words, then stops saying them, and starts saying other words. And that confuses her. Um, lady, his father only spoke at age three – and skipped the stages, speaking in full sentences right away. Plus, he understands everything, is very social, and is very stubborn. If you don’t know what to do about it, fine. I think he’s just fine, but I will ask my doctor – not yours – anyways, just to be sure. (Doctor also said it’s fine, and told me to do what I was planning on doing anyways: Revisit the issue (and the doctor) after his second birthday. Yay, me. I think the way the doctors do.)

    3) The third nurse told me (there are only three in my clinic) that my son had gone down in percentile at 8.5 months and I should fill his stomach with chicken so that he’ll gain weight. She didn’t ask for the background before giving me this amazing advice: a) Child has two tall, slender parents, both of whom kept to the lower percentiles during childhood, and each of which, at one point, was underweight. b) Child is still nursing. Most Israeli children quit nursing long before 8.5 months. c) Child just switched nursing schedules. d) Child is sick of nursing, because it is boring. Parents insist on child nursing, and then eating solid foods (whatever they are eating, usually). Child does not need chicken every day, nor does anyone else, for that matter. Nurse then wanted child to come back in two months to be weighed. Nurse was also upset that we did not give the iron supplement every day, even though child always ended up spitting it – and his breastmilk – up.

    A professional would have asked for the background, which, obviously, warrants a different answer. It also should be said that in cases 2 and 3, we did not listen to the nurse. In case 1, I am going to give it to them over the head next time we go back, around his birthday. Giving immunizations to a child without their parents’ consent (barring obvious exceptions) is not okay.

    • The nurse should tell you what vaccines you are getting. Varicella needs a booster so keep that in mind, you will have to make a decision about it. As for #2, that is her job. To catch possible problems and recommend getting them checked out. Obviously you know your child better than she does. Children do drop in percentile at this age, especially breastfed ones who are slimmer on the WHO charts.

  32. groan. they drive me crazy. i come out of there with my head spinning from all the advice that gets thrown at me. today my visiting parents took my baby in for a shot, without me, and reported that the nurse said he needs to be on solids and drinking water because he’s not growing. that is utter BS. he is six months today, and when i do give him food to taste, he’s not particularly interested. the previous nurse he saw weighed him in his clothes and didn’t extend his leg to measure him. while i’m not ecstatic that the pediatrician is very terse and well-baby checkups are short, i trust his measurements more. one nurse (anglo) looked at me disapprovingly when i said i was going back to work full time and giving a nonzero amount of formula. tipat chalav (jerusalem, machane yehuda) ruins my mood for the whole day; i just use them for the shots.

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