Are you considering adopting or fostering a baby who was exposed to opioids prenatally? We talk with Dr. Robin Gurwitch, a faculty member in the Duke University Department of Psychiatry and Behavioral Sciences and the Center for Child and Family Health. Her research focuses on improving the outcomes and increasing resilience in children who have experienced trauma, including prenatal exposure.
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Welcome, everyone to Creating a Family talk about adoption and foster care. I'm Dawn Davenport. I am the host of this show, as well as the director of the nonprofit CreatingaFamily.org. Today we're going to be talking about surviving the first six months with a baby with prenatal opioid exposure. We'll be talking with Dr. Robin Gurwitch. She is a faculty member in the Duke University Department of Psychiatry and Behavioral Science, and the Center for Child and Family Health. Her research focuses on improving the outcomes and increasing resilience in children who have experienced trauma, including prenatal exposure. Welcome Dr. Gurwitch. I look forward to talking with you.
Thank you so much for having me, Dawn.
All right. We work with families who are foster adoptive and kinship families. And many of the children they are adopting or fostering or parenting, kinship parenting have experienced prenatal opioid exposure. So let's start by talking about first what drugs are included in the category of opioids or opiates. I'm going to refer we're going to opiate and opioids. But we will be referring to both as opioids they mean the same and I think generally, people now refer more to opioids. So anyway, what, what what drugs fall into that category?
I think when we think when we think about opioids, we think about Oxycontin. We think about a heroin, and all the derivatives that come from either. So if if someone is using opioids during their pregnancy, the baby the fetus actually becomes dependent. Just like the user becomes dependent. There's not a little man standing at the top of the of the uterus saying no bad things can't enter here. So it all flows through. So when those babies are born, they actually have to go through a medical withdrawal that is supervised by medical professionals to get the baby sort of detoxed and off of the opioids. But I think it's really important to recognize that while it would be wonderful for us to sit here and say, Okay, this baby's only been exposed to opioids. And this baby's only been exposed to non opioids like alcohol or cocaine or amphetamines is a real problem, or methamphetamines. The world's not that clean. And so when you have a baby that's exposed to opioids, you can probably be fairly certain there's other substances that have been used, particularly alcohol.
And alcohol causes some of the greatest long term impacts much greater interestingly, of course, and sadly, than even even opioids. So yes, and you're right in, you know, there's new research coming out on marijuana, and all of these, so many of our children are multi exposed. Yeah,
right. So think that is going to be the much more common. And the hard thing is if someone is addicted to something like OxyContin, so maybe they got a prescription or maybe that's what led to their abuse, their addiction. Oftentimes that's related to alcohol, because that's not really an illegal substance. I didn't do anything illegally. I had prescriptions for this. And alcohol doesn't. It's not breaking the law of drinking. But that combination really does a number on developing babies.
Yeah. Okay, so let's some of the drugs, you've mentioned them heroin, and then some of the synthetic opioids such as fentanyl, which is becoming increasingly more common, and then pain relievers, even the legal ones as you've mentioned, oxycodone, which brand name Oxycontin, hydrocodone brand name, pocket, and then things like codeine, morphine, and then others. What about some of the medical treatments that are used for substance abuse disorders such as methadone and Suboxone?
So when when someone moves to methadone, the best thing is that that is generally monitored by a physician. So the dosing of the methadone is really geared to what does that woman's body need to help continue to detox from the opioids? So yes, that still gets into the system and into the baby. But there's somebody that is monitoring this So when the baby's born, they may still need to go through that detox with that methadone, because that's still there, and the body is going to want want that. But it will be so much safer because somebody has been following. Here's the amount that this woman has been getting. This is what we know, this is what the baby's getting. So is it great? No, it'd be better if that wasn't used at all. But at least from the very beginning of that methadone treatment, there are there are medical professionals onboard monitoring every step of the way. Yeah, and no, one other
thing. It's usually in fact, if it's being used as prescribed, it's a steady dosage. And so we don't see the wide fluctuations, where they're not seeking a high per se, so they're not. Yeah, so for all those reasons, I think it's disappointing and sad for parents, and they're like, we thought that, but it is it we thought that the baby would be fine because the mom was on methadone, but in fact, it is probably preferable. So because the mom is in treatment, so if nothing else, yeah, that is good.
All right, so somebody's getting because we also know that prenatal care if I'm addicted to substances, that often takes a hit I don't, I'm not really able to think about going for prenatal visits and taking prenatal vitamins. And what if they test me for something while I when I go for prenatal checkups? So methadone, at least, again, is being medically monitored, and the likelihood that that woman is able to be getting some prenatal care to check other parts of her pregnancy health is is higher than if she were just using on her own like heroin. Okay, excellent.
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So if we think about terminology, the baby didn't have any choice in this matter at all. They're not going out and seeking this. So they're really born dependent on the substance, the when the baby comes out, the body truly is craving that need for that, that substance. And so their body is really dependent on having that to keep them in their new sort of steady state. They're not the babies that looking for a high the baby's not looking for other needs, but their body goes through true withdrawal. So you will get more jitteriness and more trembles and and tremors I'm sorry, as they go through that withdrawal from opioids. And again, it's because their body is saying I need to have this. I need to have this. And so it really is critical that a medical professional is helping that bought that baby detox, it's neonatal abstinence syndrome there they they truly need it and we have to help them so that they do not need it anymore. They don't need to, to have that substance in order to have their other chemical balances corrected. So
what are the symptoms of neonatal abstinence syndrome? You often sometimes see that in ALS is the abbreviation. You mentioned tremors. What are some of the other if you assuming the baby has not been tested, and we're going to talk a minute about how often it is that babies have a drug screen But assuming the baby isn't if you just look at a baby at birth, can you tell if they have, if they're having if they have neonatal abstinence syndrome, ie being if they are dependent upon the substance, the mom the opioid, the mom
is like a really great question. Because if you notice that the baby in your care is having tremors is very jittery is having problems with just suck, swallow, breathe, swallow, breathe with eating, or having some real sleep issues. Don't assume oh my gosh, this is opioids. Because you see some of that also, in babies that have been exposed to other substances. One requires a true medical detox, the other does not. And those those features will generally diminish with time. Either way, they're really tough babies, right? They cry at a, you know, the sometimes looking at their cries, they're crying at a higher rate and a higher frequency. So imagine colic, multiply it by about six and have it last for a while. Anybody that's been around a colicky baby knows how stressful that is, because you're desperately trying to figure out how to soothe. And these babies are very difficult to comfort. And, and I really want to say people that have opened their hearts and their homes to these babies are just wonderful families to give this baby the best start in life that he or she can have. But if you see anything you're worried about, ask, don't assume oh, my gosh, this must be opioids, I've got to go get him get this baby detoxed because it may be from something else. So that's again, while you want to have a very close relationship, not only with your physician, but also with as much as possible with it's the babies in child welfare with the caseworker who may have more information about what kinds of things happen prenatally with if it's a kinship, foster placement. What information do you know from family members that may help give your physician a better guess of what's happening? And certainly, as you mentioned, testing at birth can really help give us an idea of what may be coming down the road.
Yeah, exactly. We're going to so the symptoms that you've mentioned are tremors, difficulty and soothing. A more frequent crying and a higher pitch crying, difficulty with feeding the feeding with a newborn is suck, swallow, breathe, suck, swallow, breathe. That's how babies do it. And, and that's a, I'm having trouble saying it. So you can imagine a baby while doing it. And if that's the case, and I mean, plenty of babies struggle at the very beginning. They're brand new boys hearts, you know, they're getting used to everything. But a child with prenatal exposure to opioids may have a greater difficulty. So any other any other symptoms? I think I've said all the ones that I think
those are the big ones, those those are honestly the big ones. And, again, it'd be great if babies came with these wonderful manuals, but they don't anything that as parents that you are at least the least bit concerned about. Ask, I will tell you, you know, I, I remember my daughter was very, very, she has very, very, very pale skin. And when she was a newborn, I could see the blue running through all I mean, it was just, I was freaked out. And I didn't know what to do. I went to my pediatrician and she was able to put my mind at risk and just very fair. And so you're seeing that. So just because you're concerned doesn't necessarily mean it's a problem, but it'll put your mind at ease. If you're worried. That's what pediatricians and family practice Doc's are there for and pas to help us give babies no matter what the best start they can. They're part of the team, right? Yeah, parents as well. Oh, absolutely. Yeah. Given parents first and where do we go from there? Right.
Yeah, right. Amen. So I think a lot of times adoptive and foster and kinship parents assume that the baby or the mom are automatically going to be drug screened. Is that the case? Ah,
no. And honestly, there's great disparities. Yep. That are present with who does and who doesn't? You're more likely to be screened. If you're dropping delivery, you're more likely to be screened. If you have no prenatal care, you're more likely to be screened. If you have no insurance.
I suspect you're more likely to be screened, I'll have not seen this research. But I suspect you're more likely to be screened if you're poor and a person of color.
Absolutely. Because if you're poor and a person of color, you're more likely to not have high insurance.
So people who are educated and white and have employment, IE and have insurance as a result, but less likely to protest. But
honestly, opioids don't care there and don't pull opportunity equal SES, it is across the board. And because things like OxyContin and oxycodone, those, those generally start with prescriptions. So I went to my doctor to get this generally for pain. So you may have people that were involved with medical care for injuries or other things that started that addiction. So I wish I could tell you that we had a practice in this country, no matter what when you came in, and how you came in, you were screened, so we knew what was going on for babies. But that doesn't happen. That does not happen.
So what impacts the severity of the withdrawal symptoms in an infant. And I'd like to start with a misconception that, I think a lot of, again, adoptive Foster and perhaps kin families experience and that is, if a baby is not born, dependent, it does not have neonatal abstinence syndrome, the assumption is the baby has no impact, when in fact, it could well be that the mom used throughout her pregnancy, but for whatever reason, did not use substances in the last couple of months or weeks of a pregnancy. And in essence, what's happened is the baby went through withdrawal in utero. So the baby has already gone through the withdrawal, and you're not seeing it. So timing of the last consumption of the of the last drug or in this case, opioid is significant. So what are some other effects? And I
think that's a really important point. So timing is an issue, how much was being used as an issue, genetic factors, that sort of that black box that we really don't know, who are more susceptible than others can make a difference. But if the baby is not showing signs, again, it is. I mean, we all go there, we all hope, for the very best. And so we think this isn't a problem. My this baby didn't have any of those issues. So we're good. But even if I screen, there's so many substances, alcohol, which is really used a lot with those opioids doesn't come up even on a screen, or even
if he does not come up, and it's it's the worst. So for long term, even though not short term, but but for long term. Certainly,
yes. So we really do have to recognize that babies that can be born and you're really lucky you dodged the bullet about neonatal abstinence syndrome, and we breathe a sigh. But I think it's still important to remember that that's not all.
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it's going to be treated at the hospital. So they're not going to send the baby home and expect a foster parent to withdraw a baby from opioids. So you may not be able to take the baby straight home at birth. So the baby may have to stay in the NICU for a bit until the drugs are well out, and the baby has completed treatment. So and that's hard because you want to, you want to, you've got your the room set up, you've got everybody excited to meet this baby, and you can't take them right home. And so plan on some days in the hospital, again, that will depend on the physician and what they're planning. But I think that's one I think, also to recognize that even when you do go home, there may be it's not going to be okay, we're past the abstinence. So everything will be fine, you may still have some challenges with that little baby as they come home. So not a one day
they're fine. And we don't have to worry about it. It's a process.
It truly is. It truly is. You know, I've
heard of hospitals, if the baby normally they try to wean the baby off, they often will give small amounts of a different drug to try to help with the withdrawal symptoms. And I have heard of hospitals, sending babies home. I don't know with foster parents, but certainly with adoptive parents, it when they're down to the they're titrating it down. So I have heard, but they're going to teach you everything you need to know.
Yes. And they wouldn't do it at the very beginning. Yes. Because they have to figure out how does that titration how does that drawdown work? And they would probably not say okay, here's some things to try. See if this works, we may have to go up or down. But yes, you're right. So as they are toward the end, they may very well say, Yep, the baby's good to go. Because by now, they know this is this is the dose that we think this is what you can do. And we're going to teach you everything you need to do to feel comfortable. But they have to get it started.
How involved can parents be adoptive? And let's assume that the birth parents have given full permission. And so it's we don't have that problem. How involved will the NICU allow parents to be in the care and nurturing and bonding?
Oh, my goodness, thank you for that question. Yeah, we all know that the best thing for babies is being able to form that initial attachment, right? So being able to come in checking out with with the hospital, how do they manage for coming in for those visits for skin to skin contact, that sort of kangaroo care where the baby can can be on your chest and listening to your heartbeat and have that beautiful touch that you offer? Because those factors are so important to even if you're going in and you're just singing and talking to that baby so they are hearing your voice their their hearing that soothing comfort. So checking with your physician, the hospital that they're born at? How does it work? Some hospitals actually have opportunities for parents to stay with while the babies in the hospitals so hospitals do things differently. And depending on where the baby is born, check and see what is your what is your procedure because the medical staff also knows how critically important parents are to the overall well being and development of the babies. So they want you there when you can be there to offer those intangibles, the touches and the voice and the even the crooning and feeding when possible. So parents, please consider yourself an equal part of the baby's team. Right you are as important as the nursing staff and the physicians and everybody else. It is a it is a team that helps babies and we want to give them the right start. And without you being part of that active team. I think the baby the I think the chance for resilience goes up substantially Really, when you're there from the get go,
and so does your confidence, which helps as well. Yes, yes. Yes. Yeah. Okay, so now the baby has which has been discharged from the hospital, perhaps oftentimes without any additional medication. But perhaps with medication. That's a little Yep. And so you have the baby home, you are thrilled because you're tired of being at the hospital, you're been waiting for this. So what are you may be thrilled, but you bet, what you may be struggling with soothing the baby, because we know that these babies, their nervous systems are strong, high, and they are sometimes hard to soothe. So what are some ways that parents can soothe a baby who is, you know, is crying more, as you said, pelvic time six, you know, which sounds
so soothing babies, I wish there were a magic formula. Babies all have their own personalities too. So you may try a few different things. Um, some babies, particularly babies with prenatal exposure, really do benefit from swaddling. So swaddling newborns can be very helpful for soothing it gives that sort of comfort and security, we often recommend that instead of swaddling, with their arms down in the blanket, you know, when you swaddled babies, to leave their hands up so the baby can access their hands can sometimes help for soothing babies, some babies do better, and sort of a football hold other babies do better with a traditional sort of in your, the crook of your arm hold. So I wish I could say, Gosh, all babies would do best if you did this. But so some of it and I'm telling you, even if you didn't have this history, talk to any parents out there, they'll tell you that. So trial and error and maybe baby one suit better this way and baby to calm better that way. Sometimes we find that babies can get overstimulated when they're eating. God in His glory figured out that the breast to the to the caregivers face was a great distance. And that's where baby's eyes can sort of focus. So when you're bottle feeding, that seems great. But for some babies that are easily overstimulated, looking at your face while they're trying to suck, swallow, breathe is way too much. So sometimes we talked to parents, while it seems disconnected, actually turning your baby facing sort of a blank wall, feeding them so they can just focus on the suck, swallow, breathe, and then turning them around to have that eye contact, turning them around, have that attachment to you, after they've been able to eat for some babies that helps and and parents think oh my gosh, that seems so horrible that I'm so disconnected, but they still feel you. It's just too much to look at your face. So turning them away for a moment and then turning them back. So they still see your face, but they have that time for six while and breathe for some babies that can help with it.
Also, it also makes sense then, if you've got a noisy household to seek a calmer, which is hard to do. I know when you've got other children or animals, you know, it's this is and babies eat frequently. So this is hard to do but, but to try to lose the first couple of weeks, get help so that that you can feed the baby, uninterrupted,
uninterrupted sort of a quiet place. And for you think about how you're going to stay calm. It may be that you have soft music playing because it calms you too. Because remember, babies pick up on your anxiety and your worry. So if you can calm if you can, while you're feeding that baby practice your relaxation breathing. So when you say calm that calm translates to the baby babies are really good at picking up on your anxiety and your stress. So a setting where you're calm will help the baby be calm. There are wonderful, you can find them online, you can find them in videos, some really simple infant massage strokes for newborns can be helpful with everything from just digestion to bonding. So some simple strokes for infant massage. And what we have found that babies get so excited that when they hear parents sort of rubbing some oil on their hands so they hear that that sound of the hands rubbing they get so excited because they know something wonderful is getting ready to come. So sometimes for babies, that can be a really soothing and helpful strategy, it also helps parents calm when I'm doing some small strokes on my baby. I feel calmer, too.
Yeah, that's such a good point. And I love that you're bringing up that the parental care, because usually not always, but you may be new to parenting. But if not, you may be new to parenting a child who has been prenatally exposed to opioids. So regardless, there's there's a lot of tension in the air. And so things that you can do, to calm yourself and take care of yourself, at the same time acknowledging that sleep is a challenge. So Oh, yes. And does prenatal exposure in general and opioid exposure in specific, does that influence the ability of a baby to be able to start sleeping longer and sleeping through the night? Do we see that these kids struggle more with sleep issues as well?
Some of these babies absolutely do have a harder time with sleep. And so as soon as you can now in babies cry, there's a lot of discussion about let babies cried out. No, we do not let newborns cry out anything. Because that's also how babies are learning about the world around them, that when I cry, my caregiver comes and my needs are met. So that is not a cry it out when they're in that newborn period. They need to be attended to when they do get upset, to help, soothe and calm and help them regulate. But if you can get into a habit, not a habit of routine that helps and that not only helps newborns, that's going to help your your toddler that's going to help your preschooler your school age and your teenager, the more routine and structure you have the better. So if you are bathing baby, in the evening, then keep it in the evening. If you are feeding in a certain spot in the beginning, sometimes that can help. So the more structured you can be, the better. And definitely when that baby sleeps, because it may be in little spurts. Rest. That's not where you need to now go ride your peloton or work out to music. You're going to need your sleep too. So grab it when you can.
So, yes, and that goes for all parents of newborns. Yeah, yes. So any additional tips for dealing with and helping a baby who was exposed to opioids? I think one thing to point out is this doesn't last, this initial period where the child is recovering off of having been born dependent, doesn't last terribly long. And first of all means how about how long would you predict that this baby is going to sound and be less would stand out from the crowd as far as
well, first of all, this baby probably will look like every other newborn baby out there. Unless there was a lot of alcohol exposure. But you can count on probably less than a few months, less than a couple of months before babies start just getting into that routine. So I think that's that's so important for families to know that this isn't going to be till they go off to college. This is really sort of short term a few months before you get into that routine before the baby gets used to the to their new routine, their new home can be so helpful. And and some of it comes because you're becoming more competent parents. You can differentiate that cry of distress and the cry of hunger. You'll learn that in your new baby. All be all parents can pick out there, there were studies done. Lots and lots of babies crying. Parents can pick out their baby from all the other crying babies out there they can they know which baby cry is theirs, you will learn that and because you learn your baby, you'll be able to respond to your baby's needs. So again, you've already done the most important thing you've given the baby a stable, loving place to develop and grow and feel loved. So
what yeah, we're just protective factors so anyone can do
absolutely. So have faith in yourself. You will you are again, you're just as important to this baby's health well being in development as anybody else on that baby's team.
I want to pause for a moment to thank one of our partners who support that allows us to bring you this show. They are children's house International. Children's House International is a hay accredited international adoption agency currently placing kids from 14 countries they placed with families throughout the US. children's house also provides consulting for international surrogacy. So now we've got the baby home and a couple of months have gone by. She's beginning to kind of get into the flow of life. She's becoming more regular. She's figured out this sucking business. She's maybe not sleeping through the night, but she's doing better. She's getting better. Yeah, you're getting some sleep? Yes. Are there is the baby out of the woods? Are there are there any long term impacts that parents should be cognizant might happen from a child who is born, who is exposed to opioids in pregnancy,
you're always going to be a little bit worried and waiting for the other shoe to drop, that that's just part of parenting, I think all parents tell you. But I think as the babies grow and develop, you do want to be mindful, are they meeting their developmental milestones on time, if not taught to your doctor, because there are programs in every state in the country for babies that may be behind. And certainly prenatal exposure to drugs and alcohol, including opiates puts a baby at higher risk for some of those developmental issues, whether it is motor skills or language skills, or just how that brain is helping make decisions that sort of executive functioning. And so there are higher risks, it's not a guarantee, it's not a if this happened, then this definitely will. But it is a higher risk, higher risk for perchance, learning disabilities. And again, Don, I can't stress this enough, it is unlikely that those opioids was the only substance on board during pregnancy. And because you may not know anything else, there, those other substances definitely are putting babies like alcohol at a higher risk for learning disabilities, for higher risk for executive functioning problems, sort of how their brain works. So as they're going through school, to as they growing up and meeting those milestones, getting into kindergarten, if you're worried at all, check with someone. Checklist, there's no such thing as a dumb question. And it will make you feel so much more confident in your parenting skills that you are following this, you're checking in. So to say, Gosh, once they've been once the neonatal abstinence syndrome is gone. I don't have to worry about anything. I wish I could tell you that were the case. But we know that that's not always the case.
And I think another point is that, I hear this so often, parents who knew are suspected that their baby, a child had been prenatally exposed to alcohol or drugs. And then, but once the child is, say, three or four, they they stop thinking in terms of, of any of the impacts. And so if they see something, and they don't, they don't tie it back. And the reason, and quite frankly, many of these symptoms that we're talking about executive function in particular, often you're not going to see that until second or third grade. Because at that point, that's when we're expecting the brain to kind of kick in and, and start making thinking on a higher level. They call them higher level thinking skills for a reason. So parents, and the reason this is important, is because another major protective factor is getting services to our children, absolutely, that they don't feel they don't have to go through the feeling of of failing, and, and there's something wrong, that they're that they're being supported, and they're being accommodated. And so, all the more reason to just constantly that in a loving home are your biggest protective factors. And sometimes
parents are sort of worried about how much do I disclose, right? How do I tell if my child is having some difficulties? Do I say well, when when she was born or when he you know, when when his mother was pregnant? And so they worry about sort of labeling the child with that history. And and it's really one of those issues that parents wrestle with and I'll give you my opinion that it is better, the more information those that care for your Baby have whether it is the teacher, whether it is the physician, whoever it is to understand, then the child gets the services they need. And they're not seen as he's being oppositional. Or she's just not trying hard enough, I began to look at, what can she do? Not won't, what Won't she do? And if I have that information, then I'm going to think about what are the best accommodations that can help the child meet their full potential, which could be limitless, if we make sure that the child gets the services that he or she needs? So rather than thinking, Oh, I'm going to have them think poorly, it will actually probably change the perception that what can I do to help from that professional, whether it's an education or daycare, or medicine? How can I help rather than how do I say, Oh, this child is XYZ, and it's all negative adjectives?
Yeah, I agree. And I will just throw out one other thing that I think is a myth. And because I hear it a lot, if your baby is not born dependent, does not have neonatal abstinence syndrome. But you know, our society have strong suspicion that the mom used opioids or other drugs or alcohol during her pregnancy, the fact that the baby is not born dependent does not influence how impacted long term the baby will be, it does help in the baby, the short term, the baby won't have to go through withdrawal. But in the long term, it doesn't mean anything one way or the other. It simply means that the baby the perhaps a mom have
to write though it only means the baby doesn't have to withdraw from something as well. It's all it
means, which is good. But but but it does not mean that you don't need to be on the lookout for developmental or learning issues.
Yeah, and it's one of those things that sometimes we don't even know that that was a potential, we know, maybe they came out of a home that had a lot of domestic violence. So we may not even know that there was alcohol or drug use there. But that domestic violence, exposure puts the baby at higher risk, right. So again, part of our jobs as parents is to be that protector and that champion for the child. So no matter what, we will have that role for Everett, my goodness, my daughter is 31 years old, and I still call her if I see the weather is going to be bad and where she lives 1000s of miles away from me because I'm her mother. So I don't
probably rolls her eyes, just I'm sure
she. But again, that I have simply assist the decision to have a child and it doesn't matter whether you have them as your biological or your kinship or foster or adoptive. But the decision to have a child is monumentous. It means deciding for ever to have your heart walking around outside of your body. That is what parenting is all about. So yes, you may have dodged this issue. But that doesn't mean there may not be other things that come along. And the best thing we can do, besides developing that secure attachment with our child, is to make sure that we are are giving the child every opportunity to be their best self. And so we're constantly we're always looking we're always checking. That's our job. That's our job. Those are our hearts walking around, right.
Oh, what a perfect note to end. Thank you so much Dr. Robin gurwitch. I couldn't agree with you more on everything you said. Thank you so much, and to our audience. See you again next week. I look forward to talking with you then as well.
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