4
Anthropometric Risk Criteria

This chapter provides information about anthropometric characteristics of women, infants, and children that are used to place them in Priorities I through III in the WIC program (biochemical and other medical risk criteria in Priorities I through III are in Chapter 5). It begins with a consideration of the use of reference anthropometric measures. Then, it covers anthropometric criteria used for pregnant or postpartum women, followed by risk criteria used for infants and children. For each risk criterion, available information is provided about the prevalence of the condition in the population eligible for participation in the WIC program, use of each criterion as an indicator of risk and a predictor of benefit, and cutoff points in use in WIC programs nationwide. A summary of anthropometric risk criteria used by state WIC agencies appears in Table 4-1.

Use of Anthropometric Measures In The WIC Program

The major uses of anthropometric measures in the WIC program are twofold: (1) to screen women, infants, and children with nutrition risks for certification to participate in the program and (2) to assess their responses to interventions over time. Their use to assess individuals has several implications for interpreting results and choosing cutoff points.

First, a woman or child's position relative to the reference standard for the anthropometric measure being evaluated, whether it is expressed as a percentile or a z-score, represents a statement of the probability that the individual is part of the healthy distribution (also called specificity). It is not a statement about the probability that the mother or child is unhealthy. The farther away a



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--> 4 Anthropometric Risk Criteria This chapter provides information about anthropometric characteristics of women, infants, and children that are used to place them in Priorities I through III in the WIC program (biochemical and other medical risk criteria in Priorities I through III are in Chapter 5). It begins with a consideration of the use of reference anthropometric measures. Then, it covers anthropometric criteria used for pregnant or postpartum women, followed by risk criteria used for infants and children. For each risk criterion, available information is provided about the prevalence of the condition in the population eligible for participation in the WIC program, use of each criterion as an indicator of risk and a predictor of benefit, and cutoff points in use in WIC programs nationwide. A summary of anthropometric risk criteria used by state WIC agencies appears in Table 4-1. Use of Anthropometric Measures In The WIC Program The major uses of anthropometric measures in the WIC program are twofold: (1) to screen women, infants, and children with nutrition risks for certification to participate in the program and (2) to assess their responses to interventions over time. Their use to assess individuals has several implications for interpreting results and choosing cutoff points. First, a woman or child's position relative to the reference standard for the anthropometric measure being evaluated, whether it is expressed as a percentile or a z-score, represents a statement of the probability that the individual is part of the healthy distribution (also called specificity). It is not a statement about the probability that the mother or child is unhealthy. The farther away a

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--> TABLE 4-1 Summary of Anthropometric Risk Criteria in the WIC Program and Use by States   States Using             Postpartum Women   Pregnant Women Lactating Nonlactating Infants Children Women Prepregnancy underweight 54 18 15 — — Low maternal weight gain 53 — — — — Maternal weight loss during pregnancy 33 — — — — Prepregnancy overweight 53 17 12 — — High gestational weight gain 37 38 15 — — Maternal short statue 0 1 1 — — Postpartum underweight — 43 43 — — Postpartum overweight — 42 39 — — Infants and Children Low birth weight — — — 53 8 Small for gestational age — — — 10 — Short statute — — — 48 50 Underweight — — — 53 52 Low head circumference — — — 7 — Large for gestational age — — — 14 — Overweight — — — 53 49 Failure to thrive — — — 30 27 NOTE: Dashes indicate criterion was not used for that subgroup. SOURCE: Adapted from USDA (1994). measurement is from the central part of the distribution of healthy individuals, the greater the likelihood that it indicates health and nutrition disorders. As described in Chapter 3, yield for a given cutoff point increases with prevalence. If the assessed population were exactly the same as the healthy reference population, then one would expect, for example, that 5 percent of children would have heights at or below the 5th percentile. If a screened population has

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--> an excess of children with height-for-age below a cutoff point (e.g., 10 percent below the 5th percentile), one could assume that at least the difference (10 minus 5 equals 5 percent) represents short stature resulting from environmental causes, including diet. Most anthropometric measurements that are below the 5th or the 10th percentile or above the 95th percentile are considered abnormal. These statistical cutoffs define the central 85 or 90 percent of the reference distribution as the normality range. For some anthropometric measures, such as maternal weight gain, recommended cutoffs reflect an even smaller portion of the distribution. These cutoffs do not truly define the normal range from a health or nutrition point of view; rather, they are used as a guide to facilitate clinical assessment (IOM, 1990). It is impossible to find a cutoff that has both the highest sensitivity and the highest yield (Rasmussen and Habicht, 1989), as discussed in Chapter 3. When interventions have no adverse effects, the choice of cutoff points for defining risk depends mainly on the available resources and the priorities to be addressed. However, if factors causing decreased nutrition status tend to affect all mothers or children in the population, all individuals can be assumed to be malnourished (Keller, 1988; Yip, 1993), and selection of a specific cutoff point may be irrelevant. Experience shows that in populations with high prevalences of both short stature and underweight children, major causes of such abnormalities are usually health and nutrition. Likewise, low maternal prepregnancy weight or weight gain in pregnancy may result from a variety of factors, but populations with high prevalences of both are often malnourished. Although anthropometry has widely been used as a measure of or proxy for various conditions related to health and nutrition, abnormal anthropometric measures themselves do not provide specific etiologic information. For example, a child may be abnormally short because of infection, inadequate food intake, psychological disorders, endocrine or metabolic diseases, or simply normal variation in a population. Finally, although most anthropometric criteria are able to predict some present or future risk, they may not be indicative of a possible response to or benefit from participating in the WIC program. Indicators of risk and indicators of benefit are not always identical. As discussed in Chapter 3, for the best use of WIC program resources, one should use benefit indicators and cutoff points to target services to those individuals who are likely to benefit. For most anthropometric criteria, a positive response can be viewed as a benefit from participation in the WIC program. All the anthropometric measurements covered in this chapter are practical and can be obtained with reliability in the WIC program setting with adequate training of personnel, periodic quality assurance reviews, and use of appropriate equipment that is calibrated regularly.

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--> Maternal Anthropometric Risk Criteria A summary of anthropometric risk criteria as predictors of risk and benefit for pregnant and postpartum women appears in Table 4-2. Prepregnancy Underweight Prepregnancy underweight is defined as a prepregnant weight below a certain cutoff point based on reference data of desirable weights for nonpregnant women of the same height. Weight alone is not a very sensitive measure of maternal body size: at the same weight, a tall woman may be underweight, while a short woman, overweight (IOM, 1990). Thus, weight-for-height status is a better way of assessing women for poor health and nutritional status, although still crude and indirect. The lower a woman's weight-for-height, the more likely it is that she is undernourished (IOM, 1990). Maternal prepregnancy weight-for-height is usually defined in one of two ways: (1) weight below a designated percentage of a reference standard or (2) body mass index (BMI = kg/m2) below a specified cutoff. Although reference standards for women have not been validated specifically in relation to reproduction, prepregnancy underweight has been defined as less than 90 percent of the 1959 Metropolitan Life Insurance weight value for a given height TABLE 4-2 Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Pregnant and Postpartum Women Postpartum Women   Pregnant Women Lactating Nonlactating Risk Criterion Risk Benefit Risk Benefit Risk Benefit Prepregnancy underweight ✓ ✓ ? ? ? ? Low maternal weight gain ✓ ✓ ✓ ✓ ? ? Maternal weight loss during pregnancy ✓ ✓         Prepregnancy overweight ✓ ✓ ? ? ? ? High gestational weight gain ✓ ✓ ? ? ✓ ✓ Maternal short stature ✓ 0 ? ? ? ? Postpartum underweight     ✓ ✓ ? ? Postpartum overweight     ✓ ✓ ✓ ✓ Abnormal postpartum weight change ? ? ? ? ? ? NOTE: ✓ = predictive of risk or benefit; ? = evidence unclear; 0 = evidence but no effect; blank = not applicable to that group.

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--> (ideal body weight, or IBW), which is equivalent to a BMI of less than 19.8 (IOM, 1990). This definition has been widely adopted in the United States (e.g., ACOG, 1993; Wilcox and Marks, 1995) and is used in this chapter unless otherwise noted. Prevalence of and Factors Associated with Prepregnancy Underweight Underweight may be associated with poverty, substandard living conditions, inadequate food intake, chronic or infectious diseases, or conditions that induce malabsorption of nutrients (IOM, 1990). Using the above cutoff value, 20 percent of the low-income women included in the 1990 Pregnancy Nutrition Surveillance System (PNSS) data set were underweight, and 6 percent of these PNSS women were classified as being very underweight (BMI < 18.0) (Wilcox and Marks, 1995). The percentage of underweight women decreased as age increased, with the highest prevalence of underweight observed among Asian women (Wilcox and Marks, 1995). White adolescents, in particular, may routinely attempt to limit their body weights by restricting their dietary intakes and exercising excessively (Larson, 1991). Substance abuse is also associated with low prepregnancy weight-for-height (Johnson et al., 1994). However, some women may be healthy and well nourished, but simply lean. In a study of about 600 WIC program participants in California who were followed through two consecutive pregnancies, the most important factor predicting a low prepregnancy weight-for-height at the beginning of the second pregnancy was low prepregnancy weight in the first pregnancy (Caan et al., 1987). As household size increased, the risk of prepregnancy underweight decreased. Maternal age was inversely associated with prepregnancy underweight, and black race was associated with increased risk, but these findings did not quite reach statistical significance (p < .07 and p < .09, respectively). Prepregnancy Underweight as an Indicator of Nutrition and Health Risk Compared with women with normal weight-for-height, women with low prepregnancy weight-for-height are at higher risk for low-birth-weight (LBW) infants (Brown and Schloesser, 1990; Elkblad and Grenman, 1992; IOM, 1990; Nandi and Nelson, 1992; WHO, 1995), retarded fetal growth (Abrams, 1991; Elkblad and Grenman, 1992; Kramer, 1987a, b), and perinatal mortality (Hogberg et al., 1990; IOM, 1990). Some studies have found that prepregnancy underweight is associated with a higher incidence of various pregnancy complications, such as antepartum hemorrhage, premature rupture of membranes, anemia, endometritis (IOM, 1992b), and cesarean delivery (Elkblad and Grenman, 1992), but the small number of studies examining this question limits the ability to draw inferences.

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--> The relationship between maternal underweight and preterm delivery (delivery before 37 weeks' gestation) is controversial, with some reports concluding that the relationship is strong and others finding no significant association (Berkowitz and Papiernik, 1993). The committee could find no studies assessing whether prepregnancy underweight is associated with increased risk for poor lactational performance or poor health during the postpartum period. This is a complicated question to address, because it is also necessary to consider the potential mediating influence of gestational weight gain. Prepregnancy Underweight as an Indicator of Nutrition and Health Benefit Data from several food supplementation trials have demonstrated that intervention to improve nutrition can increase birth weight in underweight women (Edozien et al., 1979; IOM, 1990). Two evaluations of the Missouri WIC program separately examined the impact of WIC program participation in underweight women. Schramm (1986) reported that participants who were at least 15 percent underweight before pregnancy had significantly lower Medicaid paid claims for newborn medical services than did nonparticipants. However, using another sample of Missouri WIC participants, Stockbauer (1987) reported that WIC program participation was not associated with significantly lower rates of LBW in women who began pregnancy at least 10 percent underweight. Neither of these studies adjusted for gestational weight gain. Providing WIC program benefits to underweight women is likely to reduce the rate of LBW even if only a subset of underweight women respond, because prepregnancy underweight is a prevalent condition among low-income American women. In the study by Caan and colleagues (1987), receiving WIC program benefits after the first pregnancy was associated with a decreased risk of maternal underweight, but this finding was not statistically significant. Results of recent studies suggest that maternal underweight may be associated with poor fetal growth because of poor plasma volume expansion early in pregnancy (Rosso et al., 1992) or because of interaction among low prepregnancy weight, psychosocial stress, and cigarette smoking (Cliver et al., 1992). With improved understanding of the complex mechanisms by which maternal underweight influences fetal growth, it may become possible to target those underweight women who will readily benefit from WIC program participation. The committee identified no data addressing the efficacy of maternal prepregnancy underweight as a nutrition risk indicator for either breastfeeding or postpartum nonlactating women. Since gestational weight gain may change a woman's weight category after delivery, postpartum weight-for-height is a more relevant indicator of maternal nutritional status for lactating or postpartum women.

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--> Use of Prepregnancy Underweight as a Nutrition Risk Criterion in the WIC Setting Table 4-1 summarizes the extent to which prepregnancy underweight is used as a nutrition risk criterion by the WIC program. The ideal weight-for-height cutoffs ranged from 85 to 95 percent. Recommendations for Prepregnancy Underweight The risk of prepregnancy underweight is well documented for pregnant women but not for postpartum women. There is both empirical evidence and a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of maternal prepregnancy underweight as a nutrition risk criterion for pregnant women by the WIC program, with a cutoff value of 90 percent of IBW or a BMI less than 19.8. The committee recommends discontinuation of the use of maternal prepregnancy underweight as a nutrition risk criterion for postpartum women by the WIC program. The committee recommends research to determine the cutoffs for underweight that would produce the highest yield for reproductive outcomes and to improve the ability to distinguish healthy, well-nourished, slender women from women who are underweight because of poor nutrition or other factors that could be ameliorated through WIC program participation. The committee also recommends studies to examine interventions aimed at improving maternal health, lactation performance, or other postpartum outcomes for women who had low prepregnancy weight-for-height. Low Maternal Weight Gain Low maternal weight gain is often defined in relation to the lower limits of the Institute of Medicine's (IOM) BMI-specific total weight gain recommendations: less than 12.5 kg for women who begin pregnancy with a low BMI (< 19.8), less than 11.5 kg for women with a normal BMI (19.8–26.0), and less than 7 kg for those with a high BMI (> 26.0 to 29.0) or obese BMI (> 29.0) (IOM, 1990). Because total gain is not known until delivery, weight gain during the second and third trimesters is substituted. The IOM (1990) recommended cutoffs of less than 0.45 kg/month in obese women and less than 0.9 kg/month in nonobese women. These recommendations, as well as ''provisional" weight gain grids, were provided with the acknowledgment that validated data on which to provide confident recommendations were not available. A slightly lower than recommended gain is not necessarily a problem, provided that weight gain appears to progress toward the BMI-specific target (IOM, 1990). Before intervening, further evaluation is recommended to rule out measurement

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--> error, assess health and nutrition status, and consider other possible explanations for the low gain. Little is known about the prevalence of a low maternal weight gain assessed during gestation, but approximately 39 percent of the women included in the 1990 PNSS had a total gain that was less than the lower limit recommended for their prepregnant BMI category (Wilcox and Marks, 1995). Prevalence of and Factors Associated with Low Maternal Weight Gain The published literature consistently shows that maternal weight gain is highly variable. A low gestational weight gain occurs most commonly among women with a high prepregnancy BMI, especially those who are obese (IOM, 1990). This lower gain may reflect intentional weight restriction on the part of the mother, but low rates of weight gain also occur in settings in which all women were encouraged to gain weight (Taffel et al., 1993). Conversely, many other obese women experience high rates of gestational weight gain. Among married mothers delivering live singleton infants who participated in the 1980 National Natality Survey, a total maternal weight gain of less than 6.8 kg was associated with maternal short stature, cigarette smoking, black race, Hispanic ethnicity, low levels of maternal education, and high maternal BMI (IOM, 1990; Kleinman, 1990). Southeast Asian background, young maternal age (within 2 years of menarche), multiparity, unmarried status, and low-income have also been associated with an increased risk of low total maternal weight gain in U.S. women (IOM, 1990). Physical activity, work outside the home, stress, or moderate alcohol use appear to have little effect on gestational weight gain in U.S. women (IOM, 1990), but data are limited. The 1990 PNSS reported that Asian and American-Indian women were the ethnic/racial groups most likely to have a low total gestational weight gain, but maternal age was not a risk factor for a low weight gain (Wilcox and Marks, 1995). The use of illegal drugs, especially cocaine, is associated with low maternal weight gain (Petitti and Coleman, 1990). The literature does not give a clear answer as to whether cigarette smokers tend to gain less weight than nonsmokers during pregnancy (Johnston, 1991). Data are not available to assess whether older age (> 35 years) affects weight gain beyond the contributions of increased parity or BMI. One report on the determinants of weight gain in a small group of black adolescents concluded that delayed enrollment in the WIC program (late in pregnancy) and consumption of less than three snacks per day were significant predictors of a slow gestational weight gain (Stevens-Simon and McAnarney, 1992). Recent results from a multiethnic cohort study of about 10,000 pregnancies concluded that maternal height, hypertension, cesarean delivery, and fetal size

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--> were positively associated with the maternal weight gain in each of the three trimesters. However, association with weight gain differed by trimester for prepregnancy body size, age, parity, smoking status, race/ethnicity, and diabetes mellitus (Abrams et al., 1995). The most important predictors of weight gain were maternal age and Asian race or ethnicity in the first trimester; prepregnant body mass, parity, and height in the second trimester; and hypertension, age, and parity in the third trimester. Low Maternal Weight Gain as an Indicator of Nutrition and Health Risk The IOM (1990) concluded that low maternal weight gain during the second and third trimester is a determinant of fetal growth, and that low maternal gain is associated with smaller average birth weights and an increased risk of delivering an infant with fetal growth restriction. Studies published since that report confirm this finding (Hickey et al., 1993; Parker and Abrams, 1992; Scholl et al., 1990a). In the recently conducted World Health organization (WHO) collaborative meta-analysis of studies from populations around the world, low maternal weight gain or low maternal attained weight at 20, 28, or 36 weeks' gestation was associated with increased risk of fetal growth restriction or an infant small for gestational age (SGA). Odds ratios were especially high for women with low prepregnancy weights (WHO, 1995). Attained weights at 20, 28, and 36 weeks predicted LBW and SGA with reasonable sensitivity (at least 35 percent) and odds ratios of about 2.5 (WHO, 1995). However, two studies of presumably well-nourished clinic populations reported that low total maternal weekly weight gain (Dawes and Grudzinskas, 1991a) or deviation from an "optimal curve" (Theron and Thompson, 1993) had relatively low specificity and yields as predictors of SGA. Low yields are not surprising given that fetal growth is multifactorial, and total maternal weight gain by healthy pregnant women with good pregnancy outcome is highly variable (Abrams and Parker, 1990). The relationship between low maternal weight gain and small fetal size is modified by maternal prepregnancy BMI. At high BMIs, a low maternal weight gain has less impact. However, there is also evidence that a low maternal weight gain (< 6.8 kg) is associated with an increased risk of delivering infants who are SGA (Parker and Abrams, 1992). Thus, low rates of gestational weight gain remain a concern, even among obese women. Overall, women with both a low gestational weight gain and a low prepregnancy BMI are at highest risk for delivering a low-birth-weight infant. Studies of preterm delivery usually express total weight gain as a rate of weight gain (total gain/gestational age) to adjust for gestation. Although several studies suggested that a low weekly rate of maternal weight gain throughout pregnancy is associated with early spontaneous delivery, the data could be

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--> considered only suggestive, especially given difficulties in accurately determining gestational age (IOM, 1990). Studies published in the 1990s tend to support a relationship between low rate of maternal weight gain and preterm birth (Hickey et al., 1995; Kramer et al., 1992; Siega-Riz et al., 1994; Wen et al., 1990; WHO, 1995). Effects of the specific pattern of maternal weight gain on fetal size or preterm delivery are under study. Some investigators provide evidence that a low maternal weight gain early in pregnancy is significantly related to low-birth-weight infants (Scholl et al., 1990a) and infants who are SGA (Abrams and Newman, 1991); others do not agree (Dawes and Grudzinskas, 1991b; Petitti et al., 1991). A recent study of almost 3,000 white women concluded that, after controlling for total maternal weight gain and other factors, a low gestational weight gain during the second trimester was associated with decreased birth weight (Abrams and Selvin, 1995). At least three studies suggest that a low rate of maternal weight gain late, but not early, in pregnancy is associated with spontaneous preterm delivery (Abrams et al., 1989; Hediger et al., 1989; Hickey et al., 1995). Some studies have also found associations of a low maternal weight gain with neonatal complications. A study of low-income, black adolescents reported that a slow rate of maternal weight gain (< 0.23 kg per week) was associated with longer infant hospital stays, more admissions to the neonatal intensive care units, and more antibiotic treatments (Stevens-Simon and McAnarney, 1992). Fetal or infant mortality appears to be higher in women with low rates of weight gain (Hogberg et al., 1990), and the relationship is particularly strong in women with low prepregnancy weights-for-height (IOM, 1992b; Johnson, 1991). It is postulated that nutrition during pregnancy may play a role in the development of long-term health conditions in the offspring during childhood or adulthood. In support of this, Godfrey and co-workers (1994) found that a low maternal triceps skinfold thickness at 15 weeks of gestation and a low weight gain from 15 to 35 weeks of gestation were associated with higher blood pressure in the offspring at about 11 years of age. This is an area of active investigation. Maternal weight gain may relate to other health outcomes in pregnancy or postpartum, but few data have been published. A Finnish study reported that women with low gestational weight gain (< 5 kg) had fewer deliveries requiring surgery and a shorter second stage of labor (Elkblad and Grenman, 1992). Little is known about the effects of low rates of gestational weight gain on spontaneous abortion, congenital malformations, maternal complications, or the long-term health of the mothers. Gestational weight gain does not appear to be associated with the volume or composition of breast milk for women residing in industrialized countries (Dewey et al., 1991a; IOM, 1990). However, a recent study of well-nourished lactating Danish women reported that women who gained more than 17 kg produced milk with a much higher fat concentration

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--> than did women with a low (< 11 kg) prenatal weight gain (Michaelson et al., 1994). Low Maternal Weight Gain as an Indicator of Nutrition and Health Benefit Studies to examine whether low maternal weight gain is a useful indicator of nutrition and health benefit are hindered by problems in study methodology, difficulties in estimating dietary intake accurately, and low statistical power (IOM, 1990). The great variability among women in such characteristics as energy requirements, physical activity, body size, and health practices also complicates understanding of the relationship. Most experimentally designed studies have been conducted in developing countries and have demonstrated that dietary supplementation can improve infant birth weight, especially in women with the poorest nutritional status (IOM, 1990). However, relatively few experimental nutrition supplementation trials have specifically examined effects of such supplementation on maternal weight gain. Although the results of those studies tend to show that supplementation improves both maternal weight gain and infant birth weight, results have been inconclusive. Furthermore, the link between energy supplements and gestational weight gain is weaker among women in industrialized countries, presumably because of lesser degrees of malnutrition before and during pregnancy. Observational studies have reported on the relationship between dietary intake and maternal weight gain, with conflicting results (IOM, 1990). Gestational weight gain, but not dietary intake, was strongly associated with birth weight in a study of 529 primarily white, middle-class women (Aaronson and Macnee, 1989). No statistically significant relationships between dietary intake and birth weight were detected in a recent study of black inner-city women (the relationship between diet and weight gain was not reported) (Johnson et al., 1994). In pregnant adolescents, Scholl and colleagues (1991) reported a significant association between energy intake early in pregnancy and total weight gain. They also reported a relationship between gestational weight gain and infant birth weight, but the relationship between energy intake and birth weight was not significant. Kramer (1993) reported only slight effects of protein and energy intake on maternal weight gain. However, Susser's review of data from the Dutch famine and supplementation trials concluded that dietary influences on birth weight appear to bypass gestational weight gain (Susser, 1991). Of the three WIC program evaluations that have reported on the program's impact on maternal weight gain, two suggest a positive effect. The first National WIC Evaluation (Edozien et al., 1979) showed associations between food supplementation of more than 3 months and increases in both maternal weight

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