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Original Article | Dermatol Pract Concept. 2023;13(3):e2023190 1
Vitamin D Levels in Children During Winter
and the Relationship Between Sunscreen and
SunProtection Behaviors
Burcu Tugrul1, Hatice Gamze Demirdag2, Aysin Hanli Sahin3
1 Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey
2 Private Practice, Dermatology Clinic, Ankara, Turkey
3 Health Science University, Ankara Oncology Training and Research Hospital, Department of Pediatrics, Ankara, Turkey
Key words: vitamin D, sunscreens, sun protection, vitamin D deficiency, vitamin D status in children
Citation: Tugrul B, Demirdag HG, Hanli Sahin A. Vitamin D Levels in Children During Winter and the Relationship Between Sunscreen
andSun Protection Behaviors. Dermatol Pract Concept. 2023;13(3):e2023190. DOI: https://doi.org/10.5826/dpc.1303a190
Accepted: March 4, 2023; Published: July 2023
Copyright: ©2023 Tugrul et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Hatice Gamze Demirdag, Private Practice, Dermatology Clinic, Ankara, Turkey.
E-mail address: demirdaggamze@gmail.com
The parents patients in this manuscript have given written informed consent to the publication of their case details.
Introduction: Sunlight is the major source of vitamin D, thus, the use of sunscreens could result in
vitamin D insufficiency or deficiency.
Objectives: Our study aimed to assess serum vitamin D levels in healthy children aged 0-18 years in
the winter season and determine the association between sunscreen use and sun protection behaviors
on vitamin D status.
Methods: The demographic data, clothing style, skin type, history of sunburn, history of visiting sea-
side towns in summer, sun protection behaviors including sunscreen use, wearing sunglasses and hats,
and further detailed information about sunscreen use were recorded. Vitamin D status was assessed by
measuring blood levels of total 25(OH)D during winter.
ABSTRACT
2 Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
Introduction
The prevalence of vitamin D deficiency and insufficiency
among different pediatric age groups was evaluated by sev-
eral studies and high percentages of hypovitaminosis D were
reported worldwide [1-3]. Exposure of the skin to sunlight is
the major source of vitamin D. Only some food including oily
fish such as salmon, swordfish, tuna, cod liver oil, and sun-
dried mushrooms naturally contain adequate vitaminD[3].
Vitamin D-fortified milk and orange juice provide another
food source for vitamin D [5]. The main reason for vitaminD
deficiency is inadequate exposure to sunlight [1-6].
When the human skin is exposed to sunlight, most of this
UVB radiation is absorbed in the epidermis and most vitamin
D is produced in the living cells in the epidermis [7,8]. Sun-
light exposure-induced vitamin D synthesis is influenced by
many important variables including the season of the year,
time of day, latitude, altitude, air pollution, skin color, age,
area of skin exposed, clothing habits, sunscreen use, sunlight
passing through glass and plastic, and aging [8,9].
Sun protection is widely recommended from childhood
to prevent both melanoma and non-melanoma skin cancer
as ultraviolet radiation (UVR) causes sunburn and UVR is
defined as a carcinogen. Sunscreens were designed to absorb
solar UVB radiation. Concerns have been expressed about
the negative effects of limiting UVB exposure on vitamin D
status because vitamin D production is associated with direct
sunlight exposure [7,10]. The role that sunscreens play in
reducing vitamin D synthesis is still unclear [1]. Although
experimental studies suggest a theoretical risk that sunscreen
use may affect vitamin D, there are no randomized controlled
trials or longitudinal studies reporting that sunscreens sig-
nificantly suppress cutaneous vitamin D synthesis [9,11].
There are only limited real-life studies evaluating the re-
lationship between sunscreen use and serum levels of vitamin
D in children in the recent literature. Less is known about
the association between other recommended sun protection
behaviors (such as wearing a hat and sunglasses) and vitamin
D levels.
Objectives
Our study aimed to assess serum vitamin D levels in healthy
children aged 0-18 years in the winter season and determine
the association between sunscreen use and sun protection be-
haviors on vitamin D status.
Methods
The study was conducted in dermatology and pediatrics out-
patient clinics between December 2021 and March 2022 in a
Training and Research Hospital in Ankara. The study period
was chosen as winter, with minimum ultraviolet exposure in the
middle region of Türkiye, taking into account the differences in
serum levels of vitamin D that may be shown by the season
and sun exposure. Institutional review board protocol approval
was obtained from the hospital ethics and scientific committee
(Approval date: 08.07.2021, Decision number: 2021-07/1273),
and written informed consent was obtained from the parents
of all the children. This research was conducted in compliance
with the principles of the Declaration of Helsinki.
The participants in this study were randomly selected
from Caucasian children who were admitted to pediatric
outpatient clinics for routine examinations. Healthy children
aged 0-18 years, both girls and boys, were enrolled in the
study. Adolescence is the life stage between childhood and
adulthood, between the ages of 10 and 19 years; our study
groups are classified according to age groups as children aged
under 10 years, and adolescents as age 10 years and older.
The demographic data, clothing style, history of sunburn,
history of visiting seaside towns to swim in summer, and sun
protection behaviors including sunscreen use and wearing
sunglasses and hats were obtained from each parent and child
through face-to-face interviews. Detailed information about
Results: Three hundred seventy-six children (172 boys and 204 girls) with a mean age of 128.38±56.39
months were enrolled. The mean serum level of 25(OH)D was 15.32±8.64 ng/mL. The mean values
of vitamin D were associated with age, sex, traditional clothing style, having a sunburn history, and
sunscreen use (P < 0.05). Adolescents and girls had vitamin D deficiency and inadequacy more than
younger children and boys (P < 0.05). Sunscreen use in the adequacy group was lower than in the
inadequacy and deficiency groups (P = 0.001). There was no significant difference between vitaminD
status according to the sunscreen details (sun protection factor, product source, season, and body
areas) (P > 0.05).
Conclusions: Sunscreen use appears to reduce vitamin D levels measured in winter. Children, especially
girls and adolescents, should be exposed to sufficient sunlight to maintain normal serum vitamin
Dlevels. Vitamin D supplementation should be given to children, especially during winter.
Original Article | Dermatol Pract Concept. 2023;13(3):e2023190 3
sunscreen use, whether sunscreen products were bought
from pharmacies or supermarkets, sun protection factor
(SPF) levels (SPF ≤ 30 or SPF 50), applying sunscreen to the
face and/or body, and applying sunscreen in the summertime,
sunny days or all seasons were also recorded. The weight and
height of the participants were assessed using a standard pro-
tocol, and body mass index (BMI) was calculated as weight
(kg)/height (m)2. The clothing style of participants who wore
long sleeves and pants/skirts all year was expressed as tradi-
tional clothing. The children’s skin color was classified us-
ing the Fitzpatrick skin phototype classification, which was
based on the skin’s response to ultraviolet light [12].
Vitamin D status is assessed by measuring blood levels of
total 25(OH)D. Serum levels of 25(OH)D were measured us-
ing a Roche Cobas E601 Modular Diagnostic System. Data
were recorded from the laboratory results in the hospital data
system. We used the widely used cut-off points as suggested
by Munns et al [13]. According to their criteria, vitamin D de-
ficiency was defined as a serum 25(OH)D level of <12 ng/mL
(<30 nmol/L) and insufficiency as a 25(OH)D level between
12 and 20 ng/mL (30-50 nmol/L). Twenty-five(OH)D levels
>20 ng/mL (50 nmol/L) were accepted as adequate.
The exclusion criteria were intake of vitamin D supple-
ments during the previous year, risk factors for the develop-
ment of vitamin D deficiency, known metabolic bone disease,
diseases or medicines known to affect vitamin D or calcium
metabolism, acute diseases during the past two months, and
chronic health conditions, e.g., diabetes mellitus, obesity. Ad-
ditionally, children with excessively high and toxic levels of
25(OH)D were excluded.
Statistical Analysis
Statistical analysis was performed using the Statistical Pack-
age for the Social Sciences (SPSS) for Windows version 20.0
software package. Descriptive statistics are presented as
numbers and percentages for categorical variables, and mean
± standard deviation and minimum-maximum values for
numerical variables. In the analysis of numerical data, com-
pliance with normal distribution was examined using the
Kolmogorov-Smirnov test, and because all numerical vari-
ables did not show normal distribution, the Mann-Whitney
U test was used in the comparison of two independent
groups, and the Kruskal-Wallis H test was used in the com-
parisons of more than two groups. Analyses of categorical
variables were performed using the Chi-square test. P values
less than 0.05 were considered statistically significant.
Results
After 44 children who were under supplement treatment
were excluded, the study group consisted of 376 children
(172 boys and 204 girls) with a mean age of 128.38 ± 56.39
months and median age of 132 (min 9-max 216) months.
The mean serum level of 25(OH)D was 15.32 ± 8.64 ng/mL.
The mean BMI of the children was 19.22 ± 10.99 kg/m2 and
the median was 18.66 kg/m2. The percentages of data and
comparisons of demographic data and mean values of vita-
min D are presented in Table 1. The most seen skin type was
Fitzpatrick type 4 with 50%. Fitzpatrick skin types 1 and 6
were not found in the study group. Some 12.5% of children
had a history of sunburn, and 4.8% wore traditional cloth-
ing. Nearly 60% of the children regularly visited a seaside
town in summer, 64.4% of children wore a hat under the
sun, and 31.1% wore sunglasses. More than half of the chil-
dren (58.5%) did not use sunscreens. The mean values of
vitamin D were low in children aged over 10 years old, girls,
those who wore traditional clothing, had a sunburn history,
and sunscreen users (P < 0.05).
Table 2 presents the details of sunscreen use in the group
that used sunscreen; 55% of the group preferred sunscreens
with SPF ≤30. Sunscreen products were bought almost
equally from both pharmacies and supermarkets. Of the
children who used sunscreen, half used sunscreens only in
summer and nearly 95% of children applied sunscreen both
to the face and body. There was no significant difference
between the details of sunscreen use and vitamin D levels
(P > 0.05).
Vitamin D deficiency was recorded in 33.5% (N = 126)
of the children and inadequacy was in 46% (N = 173).
Seventy-seven (20.5%) patients had adequate levels of
vitamin D. There was a significant difference among age
groups and sex in terms of adequacy of vitamin D (P = 0.003
and P < 0.001, respectively). Adolescents and girls had vi-
tamin D deficiency and inadequacy more than younger
children and boys. There was a statistically significant differ-
ence in terms of vitamin D levels according to sunscreen use
(P = 0.001). The rate of sunscreen use in the adequacy group
was lower than in the inadequacy and deficiency groups.
There was no significant difference between vitamin D de-
ficiency/inadequacy/adequacy groups according to the sun-
screen SPF, product source, in which season sunscreen was
used, and areas of the body it was used (P > 0.05) (Table 3).
Conclusions
The present study evaluated the relationship between vita-
min D status and sun protection behaviors and sunscreen
use in a Turkish pediatric series. It revealed that 79.5% of
the patients had deficient and inadequate levels of vitamin D.
Adolescents, girls, and sunscreen users had lower serum lev-
els of vitamin D causing deficiency and inadequacy. History
of sunburn and traditional clothing had only a lowering
4 Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
Table 1. Demographic data and vitamin D levels in the study group (N = 376).
N (%) Vitamin D Mean±SD P value
Age, years
<10
>=10
153 (40.7)
223 (59.3)
17.49±10.58
13.93±6.54 <0.001
Gender
Male
Female
172 (45.7)
204 (54.3)
16.64±8.27
14.32±8.73 0.001
Skin type
Type 2
Type 3
Type 4
Type 5
29 (7.7)
119 (31.6)
188 (50.0)
40 (10.6)
15.47±5.14
15.75±10.43
15.26±8.19
14.80±6.18
0.772
Clothing style
Veiled
Normal
18 (4.8)
358 (95.2)
11.53±5.30
15.58±8.68 0.023
History of sunburn
Yes
No
47 (12.5)
329 (87.5)
12.95±5.95
15.73±8.85 0.020
History of visiting seaside in summer regularly
Yes
No
224 (59.6)
152 (40.4)
15.06±7.36
15.86±10.13 0.792
Wearing a hat
Yes
No
242 (64.4)
134 (35.6)
15.06±7.11
15.97±10.76 0.864
Wearing sunglasses
Yes
No
117 (31.1)
259 (68.9)
14.58±6.85
15.74±9.25 0.484
Sunscreen usage
Yes
No
156 (41.5)
220 (58.5)
14.13±6.54
16.27±9.70 0.030
SD = standard deviation.
Table 2. The details of sunscreen usage in the group using sunscreen (N =156) and vitamin D levels.
N (%) Vitamin D Mean±SD P value
Sunscreen SPF
SPF 30/less than 30
SPF 50
86 (55.1)
70 (44.9)
14.37 ± 6.23
13.84 ± 6.95 0.625
Usage season
Only summer
Sunny days
All seasons
84 (53.8)
35 (22.4)
37 (23.7)
13.51 ± 6.14
14.01 ± 5.48
15.67 ± 8.10
0.337
Product source
Market
Pharmacy
79 (50.6)
77 (49.4)
13.67 ± 6.22
14.61± 6.96 0.385
Areas used
Only face
Face and body
8 (5.1)
148 (94.9)
17.48 ± 7.53
13.95 ± 6.47 0.149
SD = standard deviation; SPF = sun protection factor.
Table 3. Vitamin D deciency, inadequacy, and adequacy according to demographic characteristics,
sun protection behaviors and sunscreen details.
Deciency <12
(N =126) N (%)
Inadequacy 12-
20 (N=173) N (%)
Adequacy
>20 (N=77) N
(%) P value
Age, years
<10
>=10
42 (27.5)
84 (37.7)
67 (43.8)
106 (47.5)
44 (28.8)
33 (14.8) 0.003
Gender
Male
Female
50 (29.1)
76 (37.3)
71 (41.3)
102 (50)
51 (29.7)
26 (12.7) <0.001
Skin type
Type 2
Type 3
Type 4
Type 5
8 (27.6)
36 (30.3)
67 (35.6)
15 (37.5)
17 (58.6)
57 (47.9)
81 (43.1)
18 (45)
4 (13.8)
26 (21.8)
40 (21.3)
7 (17.5)
0.737
Clothing style
Veiled
Normal
9 (50)
117 (32.7)
7 (38.9)
166 (46.4)
2 (11.1)
75 (20.9) 0.279
History of sunburn
Yes
No
19 (40.4)
107 (32.5)
24 (51.1)
149 (45.3)
4 (8.5)
73 (22.2) 0.090
History of visiting seaside in summer regularly
Yes
No
72 (32.1)
54 (35.5)
112 (50)
61 (40.1)
40 (17.9)
37 (24.3) 0.130
Wearing a hat
Yes
No
81 (33.5)
45 (33.6)
110 (45.5)
63 (47)
51 (21.1)
26 (19.4) 0.921
Wearing sunglasses
Yes
No
42 (35.9)
84 (32.4)
51 (43.6)
122 (47.1)
24 (20.5)
53 (20.5) 0.777
Sunscreen usage
Yes
No
53 (34)
73 (33.2)
85 (54.5)
88 (40)
18 (11.5)
59 (26.8) 0.001
Sunscreen details in suncreen usage group (n=156)
Deciency <12
(N=53) N (%)
Inadequacy 12-
20 (N=85) N (%)
Adequacy
>20 (N=18) N
(%) P value
Sunscreen SPF
SPF 30/less than 30
SPF 50
27 (31.4)
26 (37.1)
49 (57)
36 (51.4)
10 (11.6)
8 (11.4) 0.743
Usage season
Only summer
Sunny days
All seasons
32 (38.1)
10 (28.6)
11 (29.7)
44 (52.4)
22 (62.9)
19 (51.4)
8 (9.5)
3 (8.6)
7 (18.9)
0.432
Product source
Market
Pharmacy
27 (34.2)
26 (33.8)
47 (59.5)
38 (49.4)
5 (6.3)
13 (16.9) 0.105
Areas used
Only face
Face and body
1 (12.5)
52 (35.1)
5 (62.5)
80 (54.1)
2 (25)
16 (10.8) 0.277
SPF = sun protection factor.
6 Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
Conflictingly, Pulungan et al [27] found no significant differ-
ence between vitamin D insufficient and vitamin D sufficient
children related to types of clothing, among whom all girls
wore hijabs (long sleeves, long skirts, and headscarves).
Vitamin D levels were lower in children with a sun-
burn history; however, no significant difference was found
between vitamin D deficiency, inadequacy, and adequacy
among children with a sunburn history. Having sunburn pre-
viously may direct to more sun protection behaviors, there-
fore, vitamin D levels may decrease. Linos et al found that
sunscreen was more frequently used in subjects who were
more likely to get sunburn [29].
To protect against UVR, almost all medical associations
and societies recommend seeking shade during midday hours
and wearing protective clothing, a hat with a wide brim, and
sunglasses, besides using broad-spectrum sunscreens [29,30].
Although there was no relationship between vitamin D lev-
els and wearing a hat and sunglasses, sunscreen users had
lower levels of serum vitamin D. Wearing a sunhat or using
sunscreen was not associated with lower vitamin D status in
some studies [10,29]. In Hansen et al study, seeking shade
and wearing protective clothing were significantly associated
with lower vitamin D status in adults but not in children
[10]. In another study, Danish school children who used hats
rarely/never had 12.1 nmol/L higher vitamin D levels com-
pared with school children who always/often used hats [31].
There is no clear relationship between vitamin D concentra-
tions and sun exposure guidelines because, in real life, there
is no certainty if children pay attention to sun protection [6].
Sunscreens limit the absorption of UVB radiation over the
skin and applying sunscreens is encouraged in time to prevent
sunburn, skin aging, and skin cancer development [9,32]. Us-
ing sunscreens and their effect on vitamin D synthesis still
seems to be confusing. Some studies showed that sunscreen
agents caused a defect in the cutaneous synthesis of vitamin
D [33-35]. Sunscreen use on the entire body blocked ultra-
violet-induced vitamin D synthesis, if >19% of total body
surface area was not applied with sunscreen, vitamin D lev-
els increase significantly [35]. Similarly, Holick et al reported
that daily application of sunscreen with SPF 8 on all sun-ex-
posed body areas decreased vitamin D production by the
skin [3]. Individuals with low sun exposure and regular use
of sunscreens had an odds ratio of hypovitaminosis D [21].
Some studies found that sunscreens did not prevent the pro-
duction of sufficient vitamin D. Vitamin D production can be
reduced by the strict use of sunscreens at recommended con-
centrations of 2 mg/cm2; however, their inadequate applica-
tion (<2mg/cm2), mostly done by average users, does not lead
vitamin D deficiency [5,9]. Marks et al [36] concluded that
sufficient exposure to the sun was achieved during the Aus-
tralian summer to allow adequate vitamin D production in
subjects who regularly applied sunscreens. Farrerons etal [37]
effect on mean serum levels of vitamin D but not the ade-
quacy of vitamin D status in children.
The prevalence of vitamin D deficiency observed varied
from 24% to 99% in different studies and regions [14,15]. In
Türkiye, the prevalence of vitamin D deficiency for children
was 39.8% in a meta-analysis review [4]. In this study, vita-
min D deficiency was found similarly at 33.5%. In a study
with children aged 6-9 years, according to values measured
throughout the year, vitamin D deficiency was observed in
5.6% of children and insufficiency in 18.6% [16]. We found
a deficiency in 27.5% and inadequacy in 43.8% of those
aged less than 10 years. The higher rate in our results may be
due to the season. The study was conducted in winter when
most children stay indoors. The average temperature in An-
kara is 1.4°C and the mean duration of sunshine is 3 hours
per day during winter [17]. Researchers found that vitamin
D levels increased in summer [15,18] and decreased in win-
ter [16,19-22]. Outdoor physical activities are also limited in
winter. Thus, vitamin D deficiency continues to be a severe
problem, especially in non-sunny seasons.
Vitamin D deficiency increased with age in our study.
In recent studies, older children and adolescents had lower
median vitamin D levels than younger children, compatible
with our results [6,15,18,22-25]. In the current study, the
prevalence of vitamin D deficiency in adolescents was 65.1%
and insufficiency was 58.1%. By contrast, the prevalence of
low concentrations of 25(OH)D in adolescents was found as
75% in Feketea et al study [6]. In adolescents from Kuwait,
81% and 15% of adolescents were vitamin D deficient or vi-
tamin D insufficient, respectively [24]. Vitamin D deficiency
was highly prevalent (61.6%) in Qatari adolescents aged
11-16 years. Older skin seems to synthesize less vitamin D
than younger skin [23].
The serum levels of vitamin D were significantly lower
among girls compared with boys in our study, in line with
most other studies [14,15,18,19,22-26]. In contrast to these
results, some studies found no significant difference be-
tween the sexes in mean levels of vitamin D [6,16,21,26,27].
Al-Taiar et al. supposed that an indoor lifestyle might be
more common in girls and may exacerbate vitamin D defi-
ciency [24]. Taking into account this sex disparity, improving
vitamin D levels among adolescents should focus on girls by
supporting safe sunlight exposure and/or intake of vitamin
D-rich foods and supplements [24].
We found lower mean vitamin D levels in children who
wore traditional clothing. Vitamin D status was affected by a
covered style of dress that prevented exposure to direct sun-
light [4,10,14]. Vitamin D insufficiency and deficiency were
found more common among Turkish adolescent girls, par-
ticularly those wearing concealing clothing [28]. In Sherief
et al study among healthy Egyptian adolescents, all females
were wearing hijabs and all had vitamin D deficiency [8,14].
Original Article | Dermatol Pract Concept. 2023;13(3):e2023190 7
reported in self-reports of these behaviors in questionnaires
and intervention research [40].
In conclusion, keeping the risk of sunburn and skin can-
cer in mind, children should benefit from the sun adequately
during the winter. Special attention should be given to girls
and adolescents because they have more vitamin D inade-
quacy and deficiency. Vitamin D supplementation should be
given to children, especially during winter. Further studies
including vitamin D measurements from various cities and
all seasons are required to clarify the effects of sun-protective
behaviors on vitamin D levels.
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In this current study, children who used sunscreens had
low adequate vitamin D levels. In the sunscreen users group,
SPF, product source, season, and body areas were not related
to vitamin D status. Mortensen et al [31] found a tendency
towards a negative effect on serum 25(OH)D with the use
of sunscreen having SPF ≥30, which became significant with
parental education or week of measurement. Contrary to
our results, Feketea et al [6] found higher vitamin D levels
in children who used sunscreens than in those who did not.
Pulungan et al [27] showed that more healthy children from
7-12 years of age in the vitamin D sufficient group did not
use sunscreen (59 versus 27, P = 0.02), but this finding was
inconsistent with their multivariate analysis. Several longitu-
dinal studies of sunscreen users and controls showed similar
end-of-summer levels of vitamin D, indicating that infre-
quent sunscreen use or sufficient amounts of UVB passed the
sunscreen barrier and/or unprotected skin parts might also
contribute to this result [30]. The measurement times of vita-
min D levels in winter months may play a role in low vitamin
D levels regardless of the sunscreen use details in this study.
Because it is thought that visiting seaside towns to swim
in summer may affect the sun exposure time, this question
was asked of participants. No relationship was found be-
tween visiting seaside towns and vitamin D levels. Some
studies showed that the duration of time spent under the sun
was longer in children with vitamin D sufficiency [23,27].
Outdoor physical activity and/or total time spent out-
side were not questioned in the present study, which may
affect vitamin D levels. In a study, autumn vitamin D status
in 4–8-year-old Danish children was associated with phys-
ical activity habits [31]. Seasonal changes for vitamin D
levels that allow seasonal comparisons were not researched
in this study. Seeking shade, one of the recommended sun
protection behaviors in guidelines, was not questioned of
the families. Staying in the shade was found to be related to
lower vitamin D status [29]. The sunscreen use details and
sun protection behaviors were evaluated according to the
self-reports of parents. However, validation of self-reported
sun protection habits has been evaluated and confidence was
8 Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
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