Nathalie:
Hey Jen, how are you this morning?
Jen:
Oh, I'm good. I've been up since 6:00 AM getting things done and just remembered that I was entire need of taking my supplements. I've got my hand full.
Nathalie:
Oh, so let's talk about the morning rush because like, Hey everyone, I'm late and I'm a mom and I think the morning rush and being late has literally been the story of my life. I don't know about you, Jen, but when is a morning ever perfect? Not rushed? Everything goes as planned.
Jen:
I don't think it's humanly possible. I don't either.
Jen:
Yeah. And I always think that I'm going to, I'll make appointments first thing in the morning. Like, oh, I'm going to have this appointment now and I'm going to be there early and everything's going to go well. And then it's last minute, it's like 7 45 and I'm racing out of the door and I'm just, nothing ever goes as planned it seems like. And you can wake up really, really early like I do, and it still doesn't
Nathalie:
Work. And I remember when my kids were super young, I didn't have a choice about waking up really early because my kids were the kinds of kids who bounced out of bed. I don't know about you, but in terms of the awakening of you, they were literally, it's almost like they were caffeinated when they woke up. And so they were screaming for me at ungodly hours of the morning and they're like, mom, mom, mom. And it's like, wait, wait, wait. My brain needs time to wake up. I do not wake up at five 30 in the morning thinking as my first thought. Oh my gosh. Oh my gosh. Oh my gosh. I'm so excited about this day. And yet, you know what I mean? They wake up and their first thought is like, mom,
Jen:
Yeah. We have a running joke in our family about Bower. It's his chant is what we call it. It's Mom, are you up? Are you up, mom, are you up? Are you up? And I was in Morocco a few years ago and the bells would ring to signal prayer and I was like, oh my gosh, chant and Mom, are you up? Are you up? Mom, are you up?
Nathalie:
It just doesn't stop, right? No, it doesn't.
Nathalie:
It's so funny because this morning I'm late for you because Leo calls me and he's having problems with accommodations at school yet again. And for some reason he feels like he needs to share this with me at six in the morning because that's, I don't know, mom, mom.
Jen:
Well, I think it's very sweet that he wants to share it with you. You're the person that he's going to call, and I do think that is sweet, but you probably don't want that disruption right
Nathalie:
Now. So it's just like, so I work, and so I have meetings lined up from early in the morning and then I have patients and stuff like that. And my son is amazing, and he's not actually asking me for help. He's not calling to say, mom, fix this for me. Because after his lifetime I've been like, hun, you're going to have to advocate for yourself. And there are many ways of advocating for yourself. I understand that physically you can't be in someone's face, right to advocate, but there are ways to advocate. So he's not even asking me that. He's literally saying, I need to share how hard things are, which as a parent, what more could you ask for, right? It's just the timing of it. Sometimes it's just like when they're little and right before you have to hand them over to another caretaker is when they decide to either share something important, pitch a fit, or they forgot to tell you something that's going to change the rest of the day. You know what I mean?
Jen:
Absolutely, absolutely.
Nathalie:
Anyway, so this is what I'm grateful for. I told you I like tea with my mind.
Jen:
I was going to say, I thought about that. I was like, why do we have to call it coffee talk? We can call it tea talk.
Nathalie:
So normally it's tea, but I have to say in the rush of morning sometimes when my morning doesn't go as planned and I'm late to talk to you, the Keurig is a lifesaver. Well, because it goes, you push a button and 45 seconds later you have a steaming cup of caffeine. Perfect.
Jen:
Yeah, exactly. Exactly. Well, cheers to
Nathalie:
Cheers to coffee this morning.
Nathalie:
Yeah, thanks. And oh my gosh. And also just cheers to every parent who's ever felt the rush of the morning. And it doesn't get better whether it's a 2-year-old or a 20-year-old.
Jen:
No, it doesn't. It kind of leads us to the topic of today because I know that my 20 years of parenting have been fraught with issues throughout the night. And so the morning rush is even harder, I feel like for a lot of us because we've had to get up throughout the night. You don't ever get away from when I hear my friend say, oh, my baby's sleeping through the night. And I'm thinking, oh my gosh, my baby's never slept through the night and it's been 20 years and you're getting up for school. I'm getting up to get up at five 30 because it takes so long. So once the school age starts, then you're waking up, you've got to get up at five 30, you've got to get the whole morning process going, and of course you're rushing and you've had three or four times a night that you've woken up because you've got to readjust or help your child in one way or another. And this is the sleep deprivation that happens with parents and then the kids who need it. So I wanted to talk about this. We brought this last week definitely, and getting into why is sleep so important and why do we have these issues with kids with CP and what can we do about it?
Nathalie:
Oh yeah. And just so you know, Jen, so you're describing one part, which is where a child is waking up all night long. For some parents, the child won't go to sleep. For others it's awakening early and then not going back to sleep. And it's this question you ask yourself when you see the pediatrician or the CP specialist, it's like, don't just ask me about my kids' sleep. Ask me about my sleep too, right? Because the two are totally linked, and I think a lot of people forget that. And at every stage of a child's life, the problem changes a little bit, but it's always there. And sometimes it's just different in cp, like night terrors, nightmares are different.
You always have to worry about is this due to pain? And that for various reasons, and I mean it's harder sometimes for children with CP to express pain, not just if they feel it, but how much they actually feel. And it's hard for parents to tell if a child's in pain or not, or is this aggravation? Is this another thing? And I think it's a lot of stuff. Plus there's the trauma. Let's not forget of the birth. We talked about that. But you spend possibly the first, I don't know, year at least if not more of your child's life, not sleeping. Because even if they sleep, you're worried that they're going to stop breathing. And so sleep is like, oh my gosh. What was it like for you when Bower was little?
Jen:
It was, it wasn't easy. His sleep from very, very early on was incredibly disruptive. He had terrible gerd, terrible reflux, and I felt like we did what we need to do to help with that, with nisson, fundoplication and things like that. But it never quite, I think it's almost like once he got into the habit of waking up a lot throughout the night and needing to be comforted and that kind of thing, that extended on even after we did the medical things that we needed to do to try to help him. Because prior to doing anything medically, he was really struggling because he was in pain, and then we fix it, and then he's got bad habits. And I feel like it was a good five years, those first five years of trying to ensure that he was just going to sleep through the night.
And I'm not sure that I ever really got it. I don't believe that I ever really got that. It wasn't until he got to be about seven when actually the baclofen pump was able to help. Then we started seeing other issues. We started seeing the dystonia kick in and the spasms kick in. And I still have my notes from back then why we ultimately did the baclofen pump, and it was specifically for leg spasms in the middle of the night. And I can tell you what, even to this day when that thing's not on board the way it needs to be on board, they come back. Even Botox, when it wears off, they come back. It's taken me almost 20 years to learn these things about him. But yeah, early on it was horrible. It was miserable. But even still recently, the past few months, and actually five years, I'd say since 2018, I go back to 18, we've had major sleep issues. And I think how does that in the past few weeks we've finally solved it, which I'm really excited about.
Nathalie:
Really? Yeah.
Jen:
Yeah. I know.
Nathalie:
Well, I want to hear about that, but what was it doing to you? Because I can tell you, you mentioned one thing you said, I read back and I wrote what I wrote. One of the things about sleep so, so important is that it's when memory consolidates itself. And by that I just mean you can't make long-term memories unless you get sleep. It's this crazy thing. There are entire parts of your brain that are responsible for that long-term memory that when you're sleep deprived don't, don't function. I used to joke that women would never have other kids if we actually remembered what it was like at the beginning. But fortunately, we're so exhausted we can't make memories. Right. There's a physiological reason for that. Fantastic. That's a really cute joke though. Politically incorrect and stuff like that. But nonetheless, it is true that you can't form memory. So you were talking about that. So to me, that's a sign that you were probably pretty aware of that sleep deprivation.
Jen:
I think I have been acutely aware of the sleep deprivation. I've also been acutely aware of my inability to remember anything. So I do think that I frequently say I really struggle with memory, and I'm sure that's, that's a big part of the reason I have my nap time. If I do take my nap, it's amazing how when I do get to sleep, I can sleep like a rock. But yeah, it is definitely taken its toll. And I feel like I'm starting to catch up with Bower boarding these days. And I have four nights a week now that I can actually sleep through the night. So that's something very new for me.
Nathalie:
But what's happened since you can sleep through the night?
Jen:
Well, I mean, I sleep like a rock, but I wake up right at six. I mean a little bit before that usually. And I pop up and it's pretty remarkable. And sometimes I wake up and I'm like, wait a minute, I'll think he's still here. And wait, is he still asleep? He couldn't have slept through the night. That's the first thing I'm thinking about. And then I realized, wait a minute, he's not here. So it's still a big adjustment.
Nathalie:
Sorry. Yeah. So you mentioned something helped with him that you finally had it solved
so you mentioned a little bit earlier, and I told you I was going to come back to it, you said, but in the last short period of time you think you've got this.
Jen:
So we've really been playing around with the medications. I would say this, and there's a lot of, we have incredibly good sleep hygiene around here, so I don't feel like our family has behavioral issues that are contributing to Bower's sleep issues. We have the same routine and all of that kind of stuff. So it has been more medical management of his sleep issues. And so recently I actually was at the academy and we had a phenomenal speaker do a sleep presentation and trying to basically talk, it was for parents. And she did just a great presentation. And I talked to her a little bit after about what we were currently doing. And she was like, this medication really is not for helping him sleep. It's more for dystonia. And so we talked a little bit about it. I went back to his physiatrist who, his spasticity, and we had a long conversation about it and we changed up some of his medications or just one of his medications.
And also we're in the process of weaning him off melatonin, which he had been on for way, way, way too long. And so far I've had him, we started this two weeks ago, and he's appropriately waking up now. And when I say that he's always sort of appropriately woken up, but it's been much more dramatic and painful for him. The combination of we've increased the pump through the night and then we've taken away one of the medications for dystonia and then we've added a medication to help him fall asleep and at the same time reducing the melatonin and he'll be waned off of that by the end of next week. And that was an interesting thing that I had learned about melatonin is if you've been on it for a really long time, you can't just stop it.
So we're taking a very slow role to get off of that. And so by the end of next week, he'll be off the melatonin. But there's certain things that wake him up, mom, if you're thirsty or if he needs repositioning through the night. So I do have to do that. But for him, one of the things that had been happening as well was reflux. So reflux would happen then he would have painful dystonia as a response. So he'd have the painful reflux and it would hurt. And when things hurt, then you have dystonia. So that combination was happening all the time and it was horrible to him. And he wouldn't necessarily wake up. He would scream out in pain, we'd be able to go in, give him a little bit of water, reposition him, and then he'd sleep for a little bit and then it would happen again. So we've also addressed the reflux trying to getting all of these things on board. And so far so good. We've had two weeks where it's very appropriate waking up for just needing to be turned over or a sip of water or if he's had an accident. So yeah, it's,
Nathalie:
The thing is Bower is able to actually tell you that he's uncomfortable. Where a lot of the families I work with have a problem is their children are too young. Some of them don't even express themselves yet. And it's that fear of, am I missing something? And the other thing you're describing is the utter complexity of it, what you haven't quite alluded to, but is actually buried underneath there is the fact that this is constantly changing. And every time you think you've got it, it'll work for a while, and then something changes because your child grows. And so many people focus on CP that they forget to say, well, this is an evolving human being. This is a growing human being. And sometimes it's not just about the cp, it's about the fact that you have a child who is developing and growing other kids and who is going through hormonal changes and life changes and all sorts of other things. And just because that child may not be able to care for themselves the way another child their age is, doesn't mean that they're a baby. They're no longer a baby. And so it's really interesting because things keep changing. And just like for any parent, every time you think you've got the routine down and you're there, something changes. And for me, the first thing that changes is sleep. And with that, it's my patience with everything and my outlook on life. So I tend to be an overly energetic and positive person to the point where some people are really annoyed by it. And when I'm sleep deprived, I become, it's not depressed, but I become like, oh, I can't do this. I can't possibly do this. Even though the rational part of my brain is saying, Hey, you have gone through the dark tunnel so many times, even when you don't see the light and you make it through, we know this. We know we can make it through, but at the same time, when you're sleep deprived, you're just like, I don't know. I don't know if I can.
Jen:
Yeah, I know on my end it's a distraction. It's the more sleep deprived I am, the more I feel like I have attention deficit disorder or I can't focus on anything. I'll do one thing and I'll move on to another. Before I finished what was just happening. And I know when I haven't had a good night's sleep that that's what's going on. And
Nathalie:
Oh, yeah, on top of it. And when you haven't had a good night's sleep and Bower also hasn't had a good night's sleep, that combination is like, but what you talked about is complexity though. And I was thinking about all the adjustments you talked about. You talked about reflux. So reflux, like GERD isn't just his food coming up, it's his food coming up, and it's painful. Painful. In fact, we found at one point last year, we didn't realize that it was GERD that was kind of triggering a lot of these things. And it wasn't until one morning he was crying and just crying. And when he was doing it, he opened his mouth wide enough that I could look in it. And there were two giant sores in his. Oh my gosh. And I was so horrified. I called his neurologist immediately. I was like, Anne, you have to come over. She came to the house. I was in tears. I was like, that's amazing. Amazing human being. And I was like, I can't believe this has been going on, that he's got sores back there. And that I didn't see it. And we didn't realize that this was gerd. We were thinking that it was dystonia all of the time, and that every time he was waking up, it was just dystonia. But we weren't thinking about gerd. And it wasn't until he was crying bad enough that I saw in the back of his mouth that that's what was going on. And then we went and got him into the GI Doc. But I was horrified. I was absolutely horrified.
Nathalie:
I get why you're horrified. It's your child and he's in pain. But at the same time, and I'm not trying to place blame on pediatricians or anything else because I am one, so just so you know, but one of the things we know is in children, GERD is something that happens. And the thing is esophagitis. So inflammation of the esophagus of the whole thing can happen. And stomach ulcers. So stomach ulcers, and we know we have to treat h pylori, the bacterium that can cause that thrives on acid and that can cause these terrible ulcers. We know that in any other kid, this could happen.
And the thing is, I think this is the danger. We know that there's some complexity that is entirely due to the cp, and this is our constant battle as parents. But we can't forget that all of pediatrics, everything, we know the giant books that tell us about all the things that happen to any child. I mean, they don't have to be typical to any child. They're also going to be there and we have to look for them. And there's a tendency, I know for me, and I've seen it sometimes in the people who care for my son to think this is because of his cp, right? But it's like, no, no, no, actually there are a hundred reasons why this is not because of his cp and just because he is a developing boy and it's not all the cp. And if we focus only on that, and some of the stuff you were talking about, the dystonia and stuff and the meds, the meds are a nightmare because we know the more meds there are, the more likely it is that there's a side effect from those meds.
Jen:
And that's also one of the interesting things about what we're trying right now is we're really trying to eliminate the hangover so that what we're using is helping him sleep and get through the night without having that extra side effect. That's why we got rid of one of the medications that was just for the dystonia, and then we we're trying to get rid of another one as well. There's basic key whether we should do that one or not.
Nathalie:
I know, but you just said two things, right? You talked about the melatonin getting off of it, another medicine and getting off of it. But sometimes in a kid who's complex, any medical complex kid, not just cp, the thing is asking yourself periodically like a tuneup, how much do I actually need? How much does he or she actually need? And having someone you trust to look at the whole picture, not just at the cp, but at the whole picture and say, okay, out of all these things, have we tried to see which of these are still necessary and which we could maybe remove? Is there a better one? And then there's the painstaking time that you have to do to take one off to put another one on. And also, I'm
Jen:
Sorry to interrupt you, but one of things that I've kind of learned is the time that you need to be on it to see if it's helpful. So it's not just taking things away, but it's also once they're on board, keeping it on board long enough to see if it works
Nathalie:
And adjusting it, right?
Jen:
Yeah. So it definitely, it is painstaking.
Nathalie:
It is. But sleep is worth it, right?
Jen:
Sleep is, sleep is worth it. Yeah. Sleep is worth it. And there is no magic bullet. Well,
Nathalie:
So you've talked about one end though. So I've been fortunate not in the fact that things are going perfectly or anything else, but that Leo's on a different end than Bauer. And there are many reasons for that. But for me, just so you know, a lot of the concerns had to do with as much me as him, that anxiety that I had of when he wakes up is this pain. And so when he would wake up, and I am a highly educated pediatrician, I know all about nightmares and night terrors, but there was always that if he's waking up, screaming is this pain? And when you're dealing with a 2-year-old or a 3-year-old, you can't tell, I'm sorry, but because it can be my stomach hurts, ow, ow, ow or mom, but it's crying, it's terror. It's this distress that overwhelms my rational thinking.
And all I can do is hold him and try to breathe to say, okay, think through this rationally, ask the right questions that he possibly could answer. And then you get to the fact that maybe there was a T-Rex involved. But then there's another aspect to sleep that a lot of people don't talk about and a lot because of stigma and it's not pain, but it's behavioral health. And I just want to mention it here because a lot of people don't want to talk about the fact that when you have yourself or your kids problems with anxiety and depression, they affect sleep.
Jen:
Absolutely.
Nathalie:
And it's not about necessarily treating spasticity or dystonia or reflux. It's about treating something that has a real chemical basis to it that should be treated. And so anxiety, and we've talked about it, you and I at the A-C-P-D-M, I think about anxiety being one of the most prevalent problems in CP and anxiety can start really, really young. You think is a 2-year-old, two young to be anxious? Nope. It turns out no. And is anxiety or an untreated anxiety disorder going to affect their sleep? Absolutely.
Jen:
Well, wouldn't anxiety increase all these other issues and wouldn't anxiety to the distance
Nathalie:
Anxiety and depression and
Jen:
Reflux for that matter?
When I'm anxious, I've got reflux
Nathalie:
Well, there's that and there's pain, right?
Jen:
Yeah.
Nathalie:
So I remember when Leo had to go through a full spinal fusion, I was really lucky because he had an amazing doctor. I don't know if you know Nathan at Nationwide.
Jen:
He's awesome. Very well. And he's been on this podcast.
Nathalie:
Oh, okay. So Nathan, amazing boy, doctor, Can I just tell you? Because he gets boys and he's a boy's boy or whatever it is. He's a man's man. I don't know how to say it. But he gets a lot of the issues that adolescent males have or adolescents who identify as males even. He just gets it. And what's really interesting is, so I talked to him, I'm like, Nathan, you know what? Leo's going to go through an unbelievably painful procedure and pain and sleep, as you know we've talked about are huge issues. And I was like, the one thing I want to do before we go into this surgery is make sure that when he has pain, it's not due to lack of sleep or to a mood disorder because we know that anxiety and depression are going to worsen it. So I said, talk to him and tell me if you think that just as an adjustment period before his surgery and maybe a little bit afterwards, we couldn't start treating some of Leo's anxiety issues. And I thought Leo was going to hate it, but Nathan explains things so well. He explained things so well in a way that a young man could understand. I say young man, Leo was 15 or 16, and we treated that. We started treating it and within about, and it's to your point, you have to give it time. Well, mood SSRIs take a while to act. And that's why I started about, I think it was six weeks before, but already at four weeks, even at a really low dose, Leo started noticing things. He started noticing that his anxiety, it wasn't as big of a burden all the time, his moods started stabilizing. And I never realized how much his moods and his anxiety were affecting his sleep until that was starting to be treated. And I was like, oh my gosh, we are not having problems up with what's going to happen, what's going to happen? And we are not having as much problems sometimes going to sleep. I was like, why didn't I think of this before?
Jen:
Yeah.
Nathalie:
And so he helped and it really helped with the surgery. He had less pain and he was off of medications. Now we have protocols, I don't know if you know this, but scoliosis has surgery and CP has been amazing because they have safety protocols and they have pain protocols to get you off to minimize the risk of infection and to make sure that you get off of pain management as soon as possible, like unnecessary pain management. It's revolutionized. I think all the centers that have adopted those guidelines, you want to go to one of them Totally. Because when I saw what it does to have these guidelines and to abide by them and how it helped Leo just return to his normal sleep, which made my life better, and just treating that anxiety over time had a big impact on both our sleep quality. So it doesn't keep the mornings from being anxious.
Jen:
When I agree with you, you have to plan a ton more time than everyone else because everything is slower. I don't know about you, but it seems sometimes that everything moves through sludge and you're just looking at the clock thinking to be somewhere at a certain time and you just have to look at your child and think, you are not on my internal clock. And I just need to bring it. Down. And I know for me, I like to wake up before Bower. I like to get up and have a little bit of coffee and then go in and try to get him up and get him ready and take the time and not be, mom, are you up? Are you not? Have that happen to me and be able to be like, oh, you're up. It's time. Let's get you ready for, let's get you ready for school. Let's get you ready for the day, or whatever it is. And that's always my perfect scenario. But that does mean that I have to regulate myself and get up much earlier and have that time to, so I'm not racing. So maybe I feel like I'm a, I don't know. I like I learned that early on, but that's been a routine of mine as best I can for all these years, just to try to beat him to the clock, I guess, and get up before him and get myself prepared and get myself prepared for the day so that I can manage what's going to happen. And even if he had a really bad night.
Nathalie:
So if you were going to tell parents listening, what's two pointers about sleep and a kid with CP that you think are really important?
Jen:
Gosh, I am hardly an expert in this because we've struggled in it for so long. And I think sleep hygiene is a really important thing, keeping those routines, because that's one thing you can control and I think control what you can control and whether it's for yourself and for your child, going to bed at the same time and trying to wake up at the same time. Having that consistency. I know that when we maintain that consistency, things might be a little bit better and we function a little bit better. So that would be one thing. And really, I know it's hard, it really is, especially if you've got other kids too, and other responsibilities, but really trying to keep that routine and that consistency as best you can. And the other thing is really have a doctor that you trust. Because looking at all of these things, in our case, it is so complex, and I've got four different people weighing in on what are the different issues.
We've got neurology, gastroenterology, physiatry, and then the general PCP, and that's the team that's kind of working on this. And so knowing, trying to coordinate all of that and having somebody you trust who can think through all of that and bringing it up with everybody because everybody's got a different take. And then trying to consolidate what that take is. But I do think it's important to bring it up with everybody and say, this is a big issue in our lives. So those would be my two tips I think. What about you? What would you say as both a mom and a pediatrician? Yeah,
Nathalie:
So you've done as a mom, honestly, those are the things that I would've said to, I think, let me put the pediatrician on for a sec, because I think the two things, so I go back to the a p because the American Academy of Pediatrics a P is really where pediatricians go for everything. I think that the two things I would say is make sure you expect your doctor to ask the right questions of you and your child. So I would say there's three questions they should always ask about sleep beyond, how's your sleep? What does your child have problems falling asleep, staying asleep, or going to sleep? They should ask, is this affecting you and your family? And would you like some help? Right? And not forgetting that it's not always cp. So that's why I think you shouldn't just expect a neurologist or a physical medicine and rehabilitation doc to ask those.
You should ask. You should expect your pediatrician. And so if they don't, it's not because they don't care, it's because they've got a short amount of time. So it's up to you to advocate and say, Hey, ask me about my sleep. So I would say that that one tip is if someone doesn't ask you those things, say, Hey, ask me about my sleep and my child's sleep. And the second is never ever forget the importance of mental health because it affects everything. It affects your immune system, it affects your sleep, it affects pain, it affects how you recover from everything. And as a parent of a kid with cp, everyone's like, oh, you've got to be resilient. You've got to be resilient. And it's like freaking shush. How easy is it to be resilient? When I'm sleep deprived, I don't have the capacity to be resilient sometimes. So make sure that you ask me those questions about mental health. If my pediatrician doesn't ask my child and me about that, then it's also up to me to say, ask me about how I'm doing. Ask me about my mental health. Ask me about my child's mental health.
I know that people are probably thinking I place too much importance on this, that the mind isn't everything, but the mind is a lot.
Jen:
I think that's an incredibly important point. And it kind of leads me to an idea for our next coffee talk. What about talking about, I'm just thinking about the mind and SSRIs and medications and things. What about talking about dopamine?
Nathalie:
Dopamine. I'm just looking because I love dopamine for many reasons. Talk about it some way. I can talk about it as a mom too, not just as a doctor, because dopamine is a cool neurotransmitter. And yeah, that would be super fun.
Jen:
I would learn so much from you about that. And it's something that comes a lot from a CP perspective, from a mental health perspective, all of it. I think it'd be really fun to talk about. So maybe that'll be our next topic.
Nathalie:
We can talk about that. I mean, there's something about the name dopamine, right? It's like dope. Yes, I know. I'm such a dork, right? I told you I was a geek. Back to our first conversation, am total geek, and we'll find the names of neurotransmitters. Really cool.
Jen:
I love it. I love it. All right. Well, Natalie, I have loved our coffee talk this morning, and I hope that everybody enjoys and knows that from this you can go and knows how to advocate for yourself and for your child when it comes to sleep. And I will see you next
Speaker 1 (45:23):
Time. Take care.