Effects of recorded maternal voice on anthropometric parameters and heart rate in premature infants: A pilot randomised controlled trial.

PURPOSE: To explore the benefits of a recorded maternal voice intervention on weight, recumbent length, head circumference, and heart rate of preterm infants in the neonatal intensive care unit. METHODS: A pilot randomised controlled trial was conducted in this study. Preterm infants in the neonatal intensive care unit (N = 109) were recruited and randomly assigned to an intervention or control group. Both groups received routine nursing care, while preterm infants in the intervention group received a recorded maternal voice program of 20 min, twice daily for 21 days. Preterm infants' daily weight, recumbent length, head circumference, and heart rate were collected during the 21-day intervention. Participants' heart rate in the intervention group was also recorded once a day pre-during-after the recorded maternal voice program. RESULTS: Preterm infants in the intervention group showed a significant increase in weight (-75.94, 95% CI -108.04, -43.85, P < 0.001), recumbent length (-0.54, 95% CI -0.76, -0.32, P < 0.001), and head circumference (-0.37, 95%CI -0.56, -0.18, P < 0.001) compared with the control group. Preterm infants in the intervention group also showed significant changes in heart rate pre-during-after the recorded maternal voice program. However, no significant differences were found in the heart rate scores between the two groups. DISCUSSION: The changes in heart rate pre-during-after the intervention may help explain participants' more significant increase in weight, recumbent length, and head circumference. PRACTICE IMPLICATIONS: The recorded maternal voice intervention could be incorporated into clinical practice to promote growth and development in preterm infants in the neonatal intensive care unit. STUDY REGISTRATION: Australian New Zealand Clinical Trials Register, https://www.anzctr.org.au/; (registration number: ACTRN12622000019707).

Family-Integrated Neonatal Music Therapy: A Descriptive Pilot Study of Parental Perceptions on Music Therapy Participation and Long-Term Influences.

Purpose: Following a family-integrated music therapy (MT) approach, describe parental perceptions on the use of music with maternal voice to soothe and connect with the infant and the long-term influence of this approach on parents' integration of music postdischarge. Design: In this descriptive, observational within-subjects pilot cohort study, board-certified music therapists instructed and recorded mothers in singing selected songs of kin. Infants received the recorded sessions weekly from enrollment to discharge. Parents were surveyed at 1- and 6-year postdischarge. Sample: Medically stable preterm infants (n = 12) and their English-speaking parents (n = 17). Main Outcome Variable: Parent perceptions on participation and long-term influence on family integration of music during hospitalization and postdischarge. Results: Parents reported knowledge of soothing and interacting with their children as the highest benefit of MT. They also perceived the effects of an easier transition home, enhanced learning and child development, and personal benefits of positive mood and enhanced relaxation.

Effects of maternal voice on pain and mother-Infant bonding in premature infants in Taiwan: A randomized controlled trial.

PURPOSE: This study aimed to examine the effectiveness of maternal voice in alleviating premature infants' pain during the heel sticks and facilitating mother-infant bonding during hospitalization. DESIGN AND METHODS: A randomized controlled trial with a parallel group design was conducted in which 64 premature infant-mother dyads were randomly assigned to an intervention group or a control group. Voice recordings of the mother reading a children's book were created and subsequently played for the infant during a heel stick procedure once daily for 3 consecutive days. The primary outcomes were heart rate, respiratory rate, oxygen saturation, and pain response assessed using the Neonatal Infants Pain Scale before, during, and after the procedure. The secondary outcome was mother-infant bonding evaluated using the Mother-Infant Bonding Inventory on the seventh postnatal day. Data were analyzed using generalized estimation equations. RESULTS: The two groups did not significantly differ in length of gestation, sex, weight, or other demographic characteristics. At 1 min after the procedure, the intervention group had a lower heart rate (p < 0.001) and Neonatal Infants Pain Scale score (p < 0.001) than the control group did. CONCLUSIONS: The maternal voice intervention slowed the heart rate and alleviated the pain response of the hospitalized premature infants. PRACTICE IMPLICATIONS: This intervention has clinical potential to provide mothers with an opportunity to care for their infants and infants with an opportunity to be soothed during health care, thus enhancing the infant-mother connection. The clinical trial registration number is NCT04158206.

Effect of recorded maternal voice on emergence agitation in children undergoing bilateral ophthalmic surgery: A randomised controlled trial.

AIM: This study was designed to investigate whether the playing-back of the recorded maternal voice through the headphones to children undergoing bilateral ophthalmic surgery has clinical effects on the incidence of emergence agitation, and the anaesthesia recovery course. METHODS: In this prospective, blinded and randomised study, 127 children, aged 2-8 years and undergoing bilateral ophthalmic surgery were randomly allocated to one of the two groups: group T (treatment group, listening to recorded mother's voice via headphones) or group C (control group, wearing headphones without auditory stimuli). The primary outcome was the incidence of emergence agitation, and the secondary outcomes were the awakening time, and the post-anaesthesia care unit (PACU) stay time. RESULTS: Children in the group of listening recorded mother's voice exhibited significantly low incidence of emergence agitation compared with those in the control group (32.8 vs. 55.6%; odds ratio (95% confidence interval): 0.39(0.19-0.80); P = 0.010). The awakening time was shorter in group T as compared to that in group C (22.9 (10.4) vs. 27.3 (13.7); P = 0.048). As results, the group T had significantly less PACU stay time with early discharge than the group C did (29.7 (12.1) vs. 34.8 (14.1); P = 0.031). CONCLUSIONS: Recorded mother's voice is an efficient method to reduce emergence agitation in children undergoing bilateral ophthalmic surgery with sevoflurane anaesthesia. Also, patients woke faster and PACU stay time was shorter in the mother's voice group as compared with the control group.

Effect of recorded maternal voice, breast milk odor, and incubator cover on pain and comfort during peripheral cannulation in preterm infants.

PURPOSE: This study was conducted to assess the effect of recorded maternal voice, breast milk odor, and incubator cover on the pain and comfort of preterm infants during peripheral cannulation. METHODS: This study was a randomized controlled trial. The sample of the study included 136 preterm infants who met the case selection criteria. The infants were randomly assigned to different groups. DATA COLLECTION TOOL: In the study, a recorded maternal voice was played to the maternal voice group. The breast milk odor group was exposed to the odor of breast milk. The incubator cover group was covered by using an incubator cover before, during, and after the peripheral cannulation procedure on the infants in the experimental group. RESULT: While no difference was observed between the groups before the peripheral cannulation procedure in terms of the total Premature Infant Pain Profile (PIPP) scores, a significant difference existed between the PIPP scores during and after the procedure. This difference was due to the incubator cover group. CONCLUSION: Breast milk odor, recorded maternal voice, and incubator cover in preterm infants are recommended as simple, safe, and supportive stimuli that facilitate positive effects during painful procedures.

Randomised study showed that recorded maternal voices reduced pain in preterm infants undergoing heel lance procedures in a neonatal intensive care unit.

AIM: Alleviating pain in neonates should be the goal of all caregivers. We evaluated whether recorded maternal voices were safe and effective in limiting pain in preterm infants undergoing heel lance procedures in the neonatal intensive care unit of an Italian children's hospital. METHODS: This prospective, controlled study took place from December 2013 to December 2015. We enrolled 40 preterm infants, born at a 26-34 weeks of gestation, at a corrected gestational age 29-36 weeks and randomised them to listen or not listen to a recording of their mother's voice during a painful, routine heel lance for blood collection. Changes in the infants' Premature Infant Pain Profile, heart rate, oxygen saturation and blood pressure during the procedure were compared by analysis of variance. Possible side effects, of apnoea, bradycardia, seizures and vomiting, were also recorded. RESULTS: Both groups showed a marked increase in PIPP scores and decrease in oxygen saturation during the procedure, but infants in the treatment group had significantly lower PIPP scores (p = 0.00002) and lower decreases in oxygen saturation (p = 0.0283). No significant side effects were observed. CONCLUSION: Using recorded maternal voices to limit pain in preterm infants undergoing heel lance procedures appeared safe and effective.

Systematic review of maternal voice interventions demonstrates increased stability in preterm infants.

We systematically reviewed how effectively maternal voice interventions supported the clinical outcomes and development of preterm infants. A total of 512 preterm infants were included in 15 studies with different designs, from January 2000 to July 2015. Live and recorded maternal voice interventions were associated with the physiologic and behavioural stabilisation of preterm infants, with fewer cardiorespiratory events, but the evidence was insufficient to evaluate the long-term effects. Well-defined determinants and clear setting conditions are needed for such interventions. CONCLUSION: Further research that investigates the long-term efficacy and effects of live maternal voices on preterm infant development is needed.

The effect of playing music and mother's voice to children on sedation level and requirement during pediatric magnetic resonance imaging.

BACKGROUND: Magnetic resonance imaging examinations frequently cause anxiety and fear in children. The objective of this study was to investigate the effects of listening to music sound, the mother's voice, and sound isolation on the depth of sedation and need for sedatives in pediatric patients who would undergo MRI. METHODS: Ninety pediatric patients aged 3 to 12 years who were planned for imaging in the MRI unit were randomly assigned to isolation group (Group I), musical sound group (Group II), and mother's voice group (Group III). We evaluated patients' anxiety and sedation levels via the Observer's Assessment of Alertness/Sedation (OAA/S) RESULTS: Heart rate, oxygen saturation, OAA/S, and Ramsey scores during the procedure were not significantly different among the groups (p>0.05). The mean amount of propofol and total propofol consumption was statistically lower in the mother's voice group than in the isolation and music sound groups (p<0.001). Mean propofol amount and total propofol consumption were not significantly different in isolation and music sound groups (p>0.05). No difference was found between the groups regarding the time it took for the patients' Modified Aldrete score to reach 9 (p>0.05). CONCLUSIONS: In pediatric patients, listening to the mother's voice during MRI decreased the total sedative requirement consumed without increasing the depth of sedation.

Maternal Voice and Tactile Stimulation Modulate Oxytocin in Mothers of Hospitalized Preterm Infants: A Randomized Crossover Trial.

Prematurity is a major risk factor for perinatal stress and neonatal complications leading to systemic inflammation and abnormal mother-infant interactions. Oxytocin (OT) is a neuropeptide regulating the inflammatory response and promoting mother-infant bonding. The release of this hormone might be influenced by either vocal or tactile stimulation. The main objective of the current randomized, crossover, clinical trial was to assess the salivary OT/cortisol balance in mothers following the exposure of their baby born preterm to two types of sensorial interventions: maternal voice without or with contingent tactile stimulation provided by the mother to her infant. Among the 26 mothers enrolled, maternal voice intervention alone had no effect on OT and cortisol levels in the mothers, but when associated with tactile stimulation, it induced a significant increase in maternal saliva oxytocin (38.26 ± 30.26 pg/mL before vs 53.91 ± 48.84 pg/mL after, p = 0.02), particularly in the mothers who delivered a female neonate. Maternal voice intervention induced a significant reduction in cortisol and an increase in OT levels in mothers when the maternal voice with a tactile stimulation intervention was performed first. In conclusion, exposure to the maternal voice with a contingent tactile stimulation was associated with subtle changes in the maternal hormonal balance between OT and cortisol. These findings need to be confirmed in a larger sample size and may ultimately guide caregivers in providing the best intervention to reduce parental stress following preterm delivery.

Oxytocin Levels Increase and Anxiety Decreases in Mothers Who Sing and Talk to Their Premature Infants during a Painful Procedure.

(1) Background: Preterm infants spend their first weeks of life in the hospital partially separated from their parents and subjected to frequent potentially painful clinical procedures. Previous research has found that early vocal contact reduces infant pain perception while simultaneously increasing oxytocin (OXT) levels. The current study aims to assess the effect of maternal singing and speaking on mothers. (2) Methods: During a painful procedure over two days, twenty preterm infants were randomly exposed to their mother's live voice (speaking or singing). Maternal OXT levels were measured twice: before and after singing, as well as before and after speaking. The anxiety and resilience responses of mothers were studied before and after the two-day interventions, regardless of the speaking/singing condition. OXT levels in mothers increased in response to both singing and speech. Concurrently, anxiety levels decreased, but no significant effects on maternal resilience were found. (3) Conclusions: OXT could be identified as a key mechanism for anxiety regulation in parents, even in sensitive care situations, such as when their infant is in pain. Active involvement of parents in the care of their preterm infants can have a positive effect on their anxiety as well as potential benefits to their sensitivity and care abilities through OXT.

Maternal Singing but Not Speech Enhances Vagal Activity in Preterm Infants during Hospitalization: Preliminary Results.

BACKGROUND: Early parental interventions in the Neonatal Intensive Care Units (NICUs) have beneficial effects on preterm infants' short and long-term outcomes. The aim of this study was to investigate the effects of Early Vocal Contact (EVC)-singing and speaking-on preterm infants' vagal activity and autonomic nervous system (ANS) maturation. METHODS: In this multi-center randomized clinical trial, twenty-four stable preterm infants, born at 25-32 weeks gestational age, were randomized to either the EVC group or control group, where mothers did not interact with the babies but observed their behavior. Heart Rate Variability (HRV) was acquired before intervention (pre-condition), during vocal contact, and after it (post condition). RESULTS: No significant effect of the vocal contact, singing and speaking, was found in HRV when the intervention group was compared to the control group. However, a significant difference between the singing and the pre and post conditions, respectively, preceding and following the singing intervention, was found in the Low and High Frequency power nu, and in the low/high frequency features (p = 0.037). By contrast, no significant effect of the speaking was found. CONCLUSIONS: Maternal singing, but not speaking, enhances preterm infants' vagal activity in the short-term, thus improving the ANS stability. Future analyses will investigate the effect of enhanced vagal activity on short and long-term developmental outcomes of preterm infants in the NICU.

Comparative evaluation of the effectiveness of two innovative methods in the management of anxiety in a dental office: a randomized controlled trial.

Background: The first dental experience is vital in molding a child's attitude towards dentistry and dental outcomes. The cooperation of a child during dental treatment is essential to render successful and high-quality treatment. Dental anxiety is common in children undergoing dental treatment. The success of pediatric dental treatments and patient comfort depends on controlling the levels of patient anxiety in clinical settings. This study aimed to compare the effectiveness of the recorded maternal voice and virtual cognitive tool (Roogies application) in the management of pediatric dental patients. Methods: The study was carried out with children aged of 4-7 years [n = 80, (40 male and 40 female)], without any past dental history, and were randomly allocated into two groups. After informed consent was obtained, the entire procedure was explained to the parents. Anxiety was assessed pre-, during, and post-treatment by measuring pulse rate, and recording Venham Picture Test (VPT) scores. Group A [n = 40; 20 boys and 20 girls)] was provided with a headphone that played a recorded maternal voice. Group B [n = 40; 20 boys and 20 girls)] was administered the virtual cognitive tool. After conditioning the children, oral prophylaxis was performed for both groups. A comparative evaluation was conducted for each treatment session. Results: The intra-group comparison of VPT scores and heart rate for patients assigned to the recorded maternal voice showed a statistically significant difference in dental anxiety (P-value ≤ 0.001). Conclusion: This study demonstrated that a reduction in dental anxiety with the help of recorded maternal voice forms an important component of non-pharmacological behavior management. Alternatively, the use of a virtual cognitive tool as an anxiety-reducing technique can also be advocated.

Parental Perception of Vocal Contact with Preterm Infants: Communicative Musicality in the Neonatal Intensive Care Unit.

In this study, we evaluate mothers' subjective experience of speaking and singing to their infants while they are in their incubators. We also discuss the relevance of the theoretical framework of Communicative Musicality for identifying the underlying mechanisms that may help explain its beneficial effects, both for parents and infants. Nineteen mothers talked and sung to their stable preterm infants in the incubators, for 5 min each, in three sessions over a period of 6 days. After each session, mothers were asked to assess in a self-report questionnaire the ease and the effectiveness of addressing their infants by speaking and singing and their prior musical experience. Perceived ease and effectiveness in communication were found to increase progressively from one session to the next. Mothers rated the speech to be increasingly more effective. This intuitive mean of interaction between parents and infants could be encouraged and supported by the nurses and the medical staff. Furthermore, individual musical experience affects perceived ease of communicating vocally with infants after a premature birth and should thus be encouraged during pregnancy.

The effect of maternal voice for procedural pain in paediatric intensive care unit: A randomised controlled trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of the maternal voice in reducing pain during painful procedures in children between one and three years old receiving treatment in paediatric intensive care unit. DESIGN AND METHODS: This research was designed as a randomised controlled experimental study. Sixty children were randomised into two groups, the maternal-voice group and the controls. The children in the maternal-voice group listened to the maternal voice during the procedure. Although questionnaire forms were used to determine the descriptive characteristics of infants, the Face, Legs, Activity, Cry, Consolability (FLACC) pain assessment scale was used to evaluate pain level. Heart rate and oxygen saturation were also measured. RESULTS: There were significant differences in the pain, heart rate and oxygen saturation levels between the maternal-voice and control groups. Pain levels and heart rates of the children in the experimental group during and after the painful procedures were much lower, and their oxygen saturations were higher than those of the children in the control group. PRACTIC IMPLICATIONS: Distraction methods, such as listening to the maternal voice, should be used as a nursing intervention to reduce pain and decrease heart rate and increaseoxygen saturation in children during painful procedures in the paediatric intensive care unit. The maternal voice is recommended as a helpful option in cases when a pain control method is required. Future research needs to explore different interventional practices.

Memory Traces Formed in Utero-Newborns' Autonomic and Neuronal Responses to Prenatal Stimuli and the Maternal Voice.

In our pilot study, we exposed third-trimester fetuses, from week 34 of gestation onwards, twice daily to a maternal spoken nursery rhyme. Two and five weeks after birth, 34 newborns, who were either familiarized with rhyme stimulation in utero or stimulation naïve, were (re-)exposed to the familiar, as well as to a novel and unfamiliar, rhyme, both spoken with the maternal and an unfamiliar female voice. For the stimulation-naïve group, both rhymes were unfamiliar. During stimulus presentation, heart rate activity and high-density electroencephalography were collected and newborns' responses during familiar and unfamiliar stimulation were analyzed. All newborns demonstrated stronger speech-brain coupling at 1 Hz during the presentation of the maternal voice vs. the unfamiliar female voice. Rhyme familiarity originating from prenatal exposure had no effect on speech-brain coupling in experimentally stimulated newborns. Furthermore, only stimulation-naïve newborns demonstrated an increase in heart rate during the presentation of the unfamiliar female voice. The results indicate prenatal familiarization to auditory speech and point to the specific significance of the maternal voice already in two- to five-week-old newborns.

Sleep, Little Baby: The Calming Effects of Prenatal Speech Exposure on Newborns' Sleep and Heartrate.

In a pilot study, 34 fetuses were stimulated daily with a maternal spoken nursery rhyme from week 34 of gestation onward and re-exposed two and five weeks after birth to this familiar, as well as to an unfamiliar rhyme, both spoken with the maternal and an unfamiliar female voice. During auditory stimulation, newborns were continuously monitored with polysomnography using video-monitored hdEEG. Afterward, changes in sleep-wake-state proportions during familiar and unfamiliar voice stimulation were analyzed. Our preliminary results demonstrate a general calming effect of auditory stimulation exclusively in infants who were prenatally "familiarized" with a spoken nursery rhyme, as evidenced by less waking states, more time spent in quiet (deep) sleep, and lower heartrates. A stimulation naïve group, on the other hand, demonstrated no such effects. Stimulus-specific effects related to the familiarity of the prenatally replayed voice or rhyme were not evident in newborns. Together, these results suggest "fetal learning" at a basic level and point to a familiarization with auditory stimuli prior to birth, which is evident in the first weeks of life in behavioral states and heartrate physiology of the newborn.

Positive effects of low intensity recorded maternal voice on physiologic reactions in premature infants.

OBJECTIVE: To evaluate the effect of low intensity recorded maternal voice on the physiologic reactions of healthy premature infants in the neonatal intensive care unit (NICU). METHODS: Physiologic responses of 20 healthy preterm infants in the NICU of Shariati Hospital, Tehran, were obtained during a 15min intervention including three 5min periods (no-sound control, audio recorded playback of mother's voice, no-sound post-voice). The intervention was presented three times a day for three consecutive days. During each intervention, oxygen saturation (%, OSPR), heart rate (HR), and respiratory rate (RR) were recorded at 1min intervals over the 15min and then averaged over each 5min period, resulting in 3 averages for each variable for each intervention. RESULTS: Repeated Measures Analysis of Variance were employed to examine each variable separately. Over the three days, comparison of oxygen saturation over each of the three periods (before, during voice, after) revealed an increase in oxygen saturation during the voice period, compared to the pre-voice period, which persisted over the post-voice period; there were no differences between the voice and post-voice periods. Analyses of the HR and RR data showed a decrease in both variables during the voice period compared to the pre-voice period which persisted over the post-voice period. Again, there were no differences between the voice and post-voice periods. CONCLUSION: Exposure to low intensity recorded maternal voice has positive effects on the preterm infants 'physiologic responses.

Antenatal Training with Music and Maternal Talk Concurrently May Reduce Autistic-Like Behaviors at around 3 Years of Age.

Antenatal training through music and maternal talk to the unborn fetus is a topic of general interest for parents-to-be in China, but we still lack a comprehensive assessment of their effects on the development of autistic-like behaviors during early childhood. During 2014-2016, 34,749 parents of children around the age of 3 years who were enrolled at kindergarten in the Longhua district of Shenzhen participated in this study. Self-administered questionnaires regarding demographics, antenatal music training, and maternal talk to the fetus during pregnancy were completed by the children's primary caregivers. Autistic-like behaviors were assessed using the Autism Behavioral Checklist. Tobit regression analyses revealed that antenatal music training and maternal talk to the fetus was associated with a reduction in autistic-like behaviors in children, with a dose-dependent relationship. Furthermore, factorial analysis of covariance indicated a significant interaction effect between antenatal music training and maternal talk to the fetus on the autistic-like behaviors and found that children who often experienced antenatal music training and maternal talk concurrently had the lowest risk of autistic-like behaviors, while children who were never exposed to maternal talk and only sometimes experienced antenatal music training had the highest risk. Our results suggest that antenatal training through both music and maternal talk to the unborn fetus might reduce the risk of children's autistic-like behaviors at around 3 years of age.

Early exposure to maternal voice: effects on preterm infants development.

BACKGROUND: Preterm infants complete their development in Neonatal Intensive Care Unit being exposed to environmental stimuli that lead to the early maturation of the sensory systems. It is known that the fetus perceives sounds and reacts to them with movements since the 26th-28th week of gestational age. Maternal voice represents a source of sensory stimulation for the fetus. AIMS: To investigate the effect of the exposure to maternal voice, administered by bone conduction, on preterm infants autonomic and neurobehavioral development. STUDY DESIGN: Longitudinal, explorative, case control study. SUBJECTS: 71 preterm infants with birth weight <1500g, born adequate for gestational age OUTCOME MEASURES: vital and neurobehavioral parameters at term, neurofunctional assessment at 3 and 6months of corrected age. RESULTS: Infants in the treatment group had lower heart rate values and a higher proportion of stable skin color at each study point as compared to the control group. The scores in the visual attention performance and in the quality of the general movements at term were better in the treatment group than in the control one. Neurofunctional assessment score at 3months of corrected age was higher in the treatment group whereas no difference between the two groups was detected at 6months of corrected age. CONCLUSIONS: Early exposure to maternal voice exerts a beneficial effect on preterm infants autonomic and neurobehavioral development.

A pacifier-activated music player with mother's voice improves oral feeding in preterm infants.

OBJECTIVES: We conducted a randomized trial to test the hypothesis that mother's voice played through a pacifier-activated music player (PAM) during nonnutritive sucking would improve the development of sucking ability and promote more effective oral feeding in preterm infants. METHODS: Preterm infants between 34 0/7 and 35 6/7 weeks' postmenstrual age, including those with brain injury, who were taking at least half their feedings enterally and less than half orally, were randomly assigned to receive 5 daily 15-minute sessions of either PAM with mother's recorded voice or no PAM, along with routine nonnutritive sucking and maternal care in both groups. Assignment was masked to the clinical team. RESULTS: Ninety-four infants (46 and 48 in the PAM intervention and control groups, respectively) completed the study. The intervention group had significantly increased oral feeding rate (2.0 vs. 0.9 mL/min, P < .001), oral volume intake (91.1 vs. 48.1 mL/kg/d, P = .001), oral feeds/day (6.5 vs. 4.0, P < .001), and faster time-to-full oral feedings (31 vs. 38 d, P = .04) compared with controls. Weight gain and cortisol levels during the 5-day protocol were not different between groups. Average hospital stays were 20% shorter in the PAM group, but the difference was not significant (P = .07). CONCLUSIONS: A PAM using mother's voice improves oral feeding skills in preterm infants without adverse effects on hormonal stress or growth.