​Dit is nie vreemd nie; as pediaters sien ons dit baie gereeld; 2-4% van kinders onder die ouderdom van 5 jaar kry koorskonvulsies; die piektyd vir aankoms is tussen ouderdom 12 en 18 maande. Daar is 2 tipes : eenvoudige koorskonvulsies en komplekse koorskonvulsies. Eenvoudige koorskonvulsies is van korte duur (<10min), betrek die hele liggaam (veralgemeen), vind net een keer plaas tydens die koorssiekte-episode en die herstel na afloop van die konvulsie is spoedig. Komplekse koorskonvulsies neem lank om te stop (>15min) en/of betrek net een deel van die liggaam en/of vind herhalend plaas tydens die koorssiekte-episode.

Hoekom kry kinders dit? Hierdie kinders het 'n geneties-bepaalde temperatuur-konvulsie-drempel wat 'n neiging het tot spontane elektriese ontlading in die brein weens hoë koors. Dit vind tipies plaas saam met 'n virale boonste lugweg-infeksie - en veral weens menslike herpes-virus 6 (roseola = "babamasels").

Het jy geweet? Die meeste kinders met eenvoudige koorskonvulsies hoef nie in die hospitaal toegelaat te word nie, veral as hulle bekend is om eenvoudige koorskonvulsies te kry. Die meeste kinders hoef ook nie 'n lumbale punksie (om te toets vir breinvliesontsteking) te ondergaan nie.

Is koorskonvulsies skadelik? Nee. Dit veroorsaak nie breinskade nie en beïnvloed ook nie die latere kognitiewe vermoëns (intellek) of gedrag van kinders nie.

Kan dit weer gebeur? Ja, tot 33% van kinders met koorskonvulsies kry dit weer in die toekoms. Risikofaktore vir herhalende koorskonvulsies sluit in : ouderdom onder 12 maande ten tyde van die eerste koorskonvulsie, 'n laer koors by hospitaal-aankoms (na 'n koorskonvulsie by die huis), 'n kort tydperk tussen aankoms van die koors en die aankoms van die konvulsie, 'n familie-agtergrond van koorskonvulsies of epilepsie en gereelde koorssiektes. As jou kind vir 2 jaar nie weer 'n koorskonvulsie gehad het nie, is dit onwaarskynlik dat hy of sy dit weer sal beleef.

Beteken dit my kind gaan in die toekoms epilepsie (konvulsies sonder koors) kry? Onwaarskynlik. Alhoewel kinders met koorskonvulsies 'n hoër risiko het in vergelyking met kinders wat nie koorskonvulsies kry nie, is die kanse steeds skraal : slegs 1-2% van kinders met eenvoudige koorskonvulsies (die mees algemene tipe) gaan aan om epilepsie te ontwikkel. Kinders met die volgende risikofaktore het 'n groter (5-10%) kans om latere epilepsie te ontwikkel : ouderdom ouer as 3 jaar ten tyde van die eerste koorskonvulsie, komplekse koorskonvulsies, veelvuldige koorskonvulsies-herhalings, koorskonvulsies in 'n kind met neuro-ontwikkelings-agterstande en 'n familie-agtergrond van epilepsie.

Moet daar verdere toetse gedoen word? Gewoonlik is dit nie nodig met eenvoudige koorskonvulsies nie. Kinders met komplekse koorskonvulsies word op 'n individuele basis beoordeel vir die doen van, onder andere, 'n breingolftoets (EEG) en MR-skandering van die brein.

Wat kan ek by die huis doen? Draai jou kind op sy of haar sy en bel die ambulans; moenie iets in die mond sit nie. Vir kinders wat geneig is tot verlengde koorskonvulsies, is daar wel die opsie van tuisbehandeling met medikasie, alhoewel dit nie in Suid Afrika in 'n gerieflike vorm (neussproei of rektale gel) soos oorsee beskikbaar is nie. Alhoewel elke ouer sekerlik so vroeg moontlik na die aankoms van 'n koors koorsmedisyne sal gee, is daar nie op papier bewyse dat dit noodwendig die aankoms van 'n koorskonvulsie verhoed nie.

​Kan chroniese epilepsie-behandeling koorskonvulsies voorkom? Moontlik, maar... Huidige aanbevelings is steeds dat daaglikse behandeling met anti-epileptiese medisyne nie die potensiële newe-effekte werd is vir kinders met herhalende eenvoudige koorskonvulsies nie. Kinders met komplekse koorskonvulsies mag moontlik meer voordeel trek uit voorkomende anti-epileptiese behandeling, maar elke geval word op 'n individuele basis beoordeel daarvoor, veral met inligting ingewin met die uitvoer van bogenoemde spesiale ondersoeke.

'n Gedeelde na-uurse rooster tussen onafhanklike dokters in privaat praktyk skep uitdagings met die oorhandiging van pasiente tussen die betrokke dokters. Ouers kan ongelukkig wees beide :

1. As die pediater-aandiens op 'n spesifieke aand nie hulle kind die volgende oggend oorgee aan hulle gereelde pediater vir verdere hantering nie. Om dit nie aan te bied aan die ouer nie toon 'n gebrek aan respek vir ouer-keuse en mede-kollegas se praktyke.
2. As die pediater-aandiens op 'n spesifieke aand hulle kind die volgende oggend oorgee aan hulle gereelde pediater vir verdere hantering, sonder om dit met hulle te bespreek. Dit mag dan voorkom asof die pediater-aandiens nie belangstel om hulle kind verder te wil hanteer nie. Die teendeel is egter waar : die pasientjie word oorhandig aan sy of haar gereelde pediater uit respek vir die kollega. Maar hoe dan gemaak as dit nie is wat die ouer verkies nie? Klagtes is al by die hospitaal-bestuur ingedien aangesien sekere ouers voel dat hulle graag sou wou hê dat die pediater-aandiens die volgende oggend moet voortgaan met die hantering van hulle kind met die huidige toelating en dat hulle nie aan 'n ander (selfs gereelde) pediater oorgegee moet word nie.

Ouer-keuse is tops. Laat die ouer toe om te besluit. 

I believe that Nexiam (and other proton pump inhibitors) are being overprescribed in private practice. It might have become a fashion drug, being conveniently packaged in the small doses used in young infants. Recent medical literature does not support this phenomenon of widespread non-restrictive prescribing of proton pump inhibitors for infants with gastroesophageal reflux. This is mirrored in the current recommendations from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). In fact, we might be doing more harm than good.

Why the fuss? Decreasing the stomach acid might have consequences : 1. Increased risk of infection : intestinal infections (especially), upper respiratory tract infections, pneumonia and urinary tract infection. 2. Gastric and small intestinal bacterial overgrowth with a disturbance in the establishment of a healthy microbiota. The role of a healthy microbiota in health and disease, digestion, immunity and allergy prevention is an active field of scientific study at present. 3. Iron, vitamin B12 and magnesium malabsorption with associated deficiencies of these. 4. Negative impact on bone health with a risk of later childhood fractures. Listed other noteworthy potential side-effects of proton pump inhiitors like Nexiam include hepatitis (inflammation of the liver), interstitial nephritis and chronic kidney disease (inflammation of the kidney) and pancreatitis.

"Use of proton pump inhibitors (PPI) is discouraged in infants, except for those with endoscopically documented moderate to severe esophagitis, because of limited efficacy and increased risk for some infectious, metabolic, and nutritional disorders. In a new retrospective database study of over 850,000 children, proton pump inhibitor use prior to one year of age was associated with subsequent fractures during childhood; increased risk was seen with both earlier and prolonged duration of PPI therapy. These findings are consistent with studies in adults showing a link between PPI use and osteoporotic fractures and provide an additional rationale for avoiding or minimizing PPI therapy in infants whenever possible." Uptodate.com, updated August 2019

Why is it prescribed so easily? There is a persistent belief that crying in a young baby might be related to the discomfort caused by acid reflux. Doctors probably feel obliged to try something that might potentially make the crying baby more comfortable. It is difficult to prove or disprove that a baby is or is not troubled by his or her reflux. Young babies are even prescribed Nexiam for "silent reflux" (where you don't see any spitting up, passive flow or vomiting of milk in-between feeds). This situation opens up the door for unnecessary and prolonged proton pump inhibitor medication. Even a diagnostic trial of proton pump inhibitor therapy for a few weeks (to diagnose symptomatic reflux) is not supported by the current ESPGHAN guideline.

"Several randomised trials and a systematic review concluded that proton pump inhibitors are not valuable in infants with irritability or regurgitation, because they do not improve symptoms as compared with placebo". Uptodate.com, updated August 2019

"..., The more difficult subgroup of patients is the group of infants presenting with fussiness, crying and arching with or without spitting but who otherwise are thriving. In this population. there is often intense pressure by families to start anti-reflux therapies or pursue diagnostic testing because of the perceived severity of symptoms. In the absence of warning signs, diagnostic testing and/or therapies including acid suppression are not needed if there is no impact of the symptoms on feeding, growth or acquisition of developmental milestones." ESPGHAN guideline, 2018

Most babies will have reflux in the first few months of life at least. Many settle by four months; up to 12 months is still considered normal. With regular feeding neutralizing stomach acid, non-acid reflux episodes are common (especially shortly after feeding) and not bothersome to a baby.

Is Infant Gaviscon an alternative? No. It is intended for short term (days) use only. The chronic use of antacids like Gaviscon is not recommended due to adverse effects again on bone health (hypophosphatemic rickets) and aluminium toxicity in children with kidney disease. What about other medications? Motilium (prokinetic) : not recommended. Erythromycin (prokinetic antibiotic) : not recommended. Zantac (histamine antagonist) : could be beneficial with endoscopically(camera)-confirmed ulcerative esophagitis and gastritis, but is not available. Ulsanic : no clear benefit as yet. We should not be prescribing these medications easily.

What are the recommended conservative measures one should rather try? 1. Don't be overly concerned. Gastroesophageal reflux is normal and resolves in 98% of infants with gastroesophageal reflux before 12 months of age. Warning signs of pathological or an abnormal level of reflux are : failure to gain weight, blood-stained vomit, regular chest infections and episodes of choking/struggling to breathe related to an episode of reflux. 2. Feed smaller volumes more regularly. 3. Thicken baby's expressed breastmilk or formula with rice cereal or oat cereal or, if only on formula, try an anti-reflux (AR) formula, like NAN AR 1 or Novalac AR 1. 4. It could be a manifestation of protein allergy. For breastfed babies, mom could attempt a 2-4 week trial of dairy exclusion. For formula-fed babies, an extensively hydrolysed formula like Pepticate could be tried. 5. If someone smokes at home, stop smoking. Passive smoke inhalation promotes reflux in your baby.
​
References :

1. Gastroesophageal reflux in infants. Uptodate.com
2. Optimizing the use of medications and other therapies in infant gastroesophageal reflux. Ciciora SL, Woodley FW. Pediatric Drugs 2018; 20: 523-537.

Babies are drinking too much milk in the 6 to 18 month window period. This period is critical in establishing healthy eating behaviour. Too much milk not only deprives the body of nutrients it needs from solid foodstuffs, it also leads to iron deficiency and contributes to chronic or recurrent constipation. Riekie Van der Vyfer, a local dietician based at Quenet's Family Pharmacy, gives some tips to help getting baby off the bottle (and breast).  

Die 2019 griepinspuiting is beskikbaar vir toediening. Maar is dit regtig nodig? Ek glo dit is. Ons het in 2018 merkbaar baie kinders toegelaat in die hospitaal met verskillende vorms van griep - 'n goeie persentasie hiervan sekerlik verhoedbaar met immunisasie. Dit was verbasend in watter vorme die griepvirussiekte gemanifesteer het en hoe laat in die jaar ons steeds gevalle gesien het. Baie kinders het voorgedoen met koors en braking en opgeëindig met onnodige lumbale punksies om breinvliesontsteking uit te skakel. Party kinders was deurmekaar; 'n paar kinders kon vir 'n paar dae nie loop nie weens spierinflammasie. Ander kinders het voorgedoen met kroep, brongitis en longontsteking. Meeste gevalle in andersins gesonde kinders. Buiten die siekte self, kan baie kinders van onnodige (en dikwels pynlike) toetse gespaar word deur die griepinspuiting te kry vanaf April elke jaar.

Die formele indikasies vir die jaarlikse griepinspuiting is :
- Alle kinders onder 5 jaar en veral alle kinders onder 2 jaar. Definitief aangedui as jou kleintjie in dagsorg of kleuterskool is.
- Alle kinders (en volwassenes) met 'n hoër risiko vir gekompliseerde griepsiekte : 
Pasiente met asma
Pasiente met aangebore/verworwe harttoestande
Pasiente met aangebore/verworwe immuuntekorte (insluitend kinders op chemoterapie vir kanker)
Pasiente met suikersiekte
Pasiente met brein- en spinaalkoordabnormaliteite, soos serebrale verlamming, epilepsie of spierswakheid
Pasiente met niersiekte
Pasiente met aangebore metaboliese steurnisse
- Alle swanger vrouens
- Alle gesondheidswerkers (dokters en verpleegpersoneel)
- Alle oppassers van kinders in dagsorg
- Alle mense ouer as 65
- Alle mense in versorgingseenhede of ouetehuise

Praktiese dinge :
Die griepinspuiting kan toegedien word vanaf 6 maande.
Die griepinspuiting kan gegee word vanaf April tot aan die einde van die winter.
Kinders onder 3 jaar (36 maande) kry 'n halwe volwasse dosis; kinders ouer as 3 jaar kry 'n volwasse dosis.
Kinders jonger as 8 jaar wat die griepinspuiting vir die eerste keer ontvang, moet 'n tweede dosering van die griepinspuiting 4 weke na die eerste dosering kry. In die daaropvolgende jare, kry hulle net 'n enkele dosering.
Dis goedkoop!

If your little one has been diagnosed with non-specific vulvo-vaginitis (inflammation of the inner lining of the female genital area), adhering to these measures are recommended to treat and prevent an episode of vulvovaginitis in prepubertal girls. 
General hygiene measures :

• Regular handwashing.
• No picking of the nose.
• Wipe front-to-back after bowel movements. If she has trouble remembering : let her sit backwards on the toilet, facing the toilet.
  

Clothing measures :

• Pajamas : Nightgowns are better by allowing air to circulate.
• Avoid tight fitting clothing (tights, leotards, leggings). Skirts and loose-fitting pants are better by allowing air to circulate.
• Cotton underpants
• Do not use fabric softeners for underwear and swimsuits.
• Avoid letting children sit in wet swimsuits for long periods of time after swimming.
• Double rinse underwear after washing, to avoid residual irritants.

 Specific care of the genital area :

• Daily warm bathing. Allow her to soak in clean water (no soap) for 10-15 minutes.
• Do not use bubble bath/ perfumed soap.
• Wash regions other than the genital area just before taking the child out of the tub – limit use of any soap on genital areas.
• Rinse well and gently pat dry.
• Air dry genital area with hair dryer on the cool setting.

Lonette De Vries, a registered occupational therapist in Robertson, has been kind enough to suggest a few developmental exercises you can do with your baby in the first few months of life. Have fun!

1. Make family mealtime a priority. Have a routine meal together as a family at least once a day - dinner is most practical. 
2. Avoid distractions during mealtime. No TV.
3. Maintain a calm and pleasant attitude during mealtime.
4. Encourage the appetite during the day : have shorter and more frequent meals : limit meal duration to 20-30 minutes and have 4-6 meals or snacks per day with water in-between meals. No milk/juice/sweetened beverages between meals - use these rather as a reward after meals.
5. Systematically introduce new foods and don't give up easily - try new foodstuffs up to 8-15 times before giving up.
6. Give age-appropriate foods.
7. Encourage self-feeding.
8. Accept age-appropriate mess. 

As recommended by the World Health Organization.
Comments :
1. Thaw ready-to-eat frozen food in the fridge or microwave - don't thaw at room temperature.

Yes, it is available in Worcester. A few drops of your baby's blood can be collected onto a blood card in the first few days of life (best on the day of discharge) to screen for a number of metabolic and other inherited diseases (see below for the complete list). As a screening test, the aim is to identify newborns that require further, definitive testing. The benefits include early diagnosis and potential treatment of these relatively rare (1 in 4000 babies affected), but potentially serious and lifelong, conditions. They can be quite difficult to diagnose (if one waits for symptoms and signs to appear) and by the time they are, some of the complications may be irreversible. It is strongly recommended to have the screening test done if there is a family background of one of these conditions. Why isn't everyone having the test for their baby? It is relatively expensive (currently up to allmost R1600) and your medical aid probably won't cover the cost.
Conditions screened for with the newborn screening test :

Amino acid disorders : Citrullinemia type 1, classic phenylketonuria, homocystinuria, maple syrup urine disease, tyrosinemia type 1.
Organic acid disorders : 3-hydroxy-3-methylglutaric aciduria, 3-methylcrotonyl-CoA carboxylase deficiency, glutaric acidemia type 1, holocarboxylase synthase deficiency, isovaleric acidemia, methylmalonic acidemia (cobalamin disorders), methylmalonic acidemia (methylmalonyl-CoA mutase), propionic acidemia, beta-ketothiolase deficiency.
Disorders of fatty acid oxidation : carnitine uptake defect/ carnitine transport defect, medium-chain acyl-CoA dehydrogenase deficiency, very long-chain acyl-CoA dehydrogenase deficiency.
Disorders of carbohydrate metabolism : classic galactosemia.
Endocrine disorders : congenital adrenal hyperplasia, primary congenital hypothyroidism.
Other disorders : biotinidase deficiency, cystic fibrosis.
More information :
Newborn screening in South Africa
Newborn screening in the USA

Is it important? Yes. Iron deficiency is common and may have lasting adverse effects on your child’s cognitive abilities. It has also been associated with headaches and the development of ADHD (attention deficit hyperactivity disorder) and strokes in children.
What can we do to decrease the prevalence of iron deficiency? At delivery, your baby’s umbilical cord should only be clamped after 60 seconds, if safe to do so for mom and baby. If your baby is at high risk for the development of iron deficiency, he or she needs to be supplemented with iron from 2 weeks after birth. This is especially important for babies of mothers who had iron deficiency during the course of their pregnancy, premature or low birth weight (<2.5kg) babies,  and babies who lost blood before (in the womb), during or after delivery. If breastfeeding exclusively, your baby needs to be supplemented with iron from 6 months of age. When starting with supplemental feeds @ 4-6 months, start with an iron-enriched baby cereal and do not wait until after 7 months to start with pureed meats. Delay giving unmodified cow’s milk until after 12 months of age, as its intake before this time can lead to poor iron absorption and silent bleeding in your baby’s gut, with chronic blood loss aggravating the iron deficiency. Toddlers older than a year of age should not be drinking more than 400-500ml of unmodified cow’s milk per day; if they are and cannot be weaned from doing so in the short term, they should be supplemented with iron. Routine iron supplementation is also recommended if your child (between the age of one and five years) is eating less than 3 portions of iron-rich foodstuffs per day (<85g meat per day). Liver, prune juice, spinach and iron-fortified cereal are some of the less well-known iron-rich foodstuffs. Meat not only contains good amounts of iron, but also inherent factors that promote the absorption of iron from other (non-meat) iron-rich foods. Food elements having a negative effect on the absorption of iron, include tea, coffee and calcium (beware excessive amounts of dairy in the diet). Tea may decrease iron absorption by 90%. Ascorbic acid (vitamin C) promotes the absorption of iron : it is a good idea to give a (diluted) vitamin C-enriched juice with (iron-rich) meals. Children should be dewormed at least every 6 months in the first 5 years of life – the worms attach to the inside of the gut, leading to significant blood loss over time if the amount of worms are enough.

Human breastmilk is the optimal form of nutrition for a baby in the first few months of life.
Short term gastro-intestinal benefits include :
- Enhanced stomach emptying (better for reflux)
- Increased gut motility (rare for a breastfed baby to become constipated)
- Natural acquisition of beneficial gut micro-organisms (Bifidobacteria, Lactobacillus) through human milk oligosaccharides to establish a healthy gut microbiome, which plays a role in metabolism, immunity and allergy prevention.
- Decreases the incidence of necrotising enterocolitis (serious gut infection) in premature babies
Breastmilk contains many antimicrobial substances, preventing and decreasing the severity of illness during and for a period after breastfeeding :
- Gastro-enteritis (diarrhoea)
- Respiratory tract infections (up to the first year of life)
- Acute and recurrent otitis media (middle ear infection) (up to the first 2 years of life)
Long term benefits :
- Post-natal flavour learning.
​Eating vegetables during breastfeeding will increase the chance that your baby will eat them too.
- Allergy prevention
- Auto-immune disease prevention
(type 1 diabetes mellitus and inflammatory bowel disease)
- Decreased risk of cancer (decreases leukemia risk by 20%)
- Decreased risk of type 2 diabetes mellitus
- Improved vision and hearing
- Better bonding between mom and baby
Potential long term benefits (not convincingly proven yet):
- Decreased risk of becoming obese (overweight)
- Improved neuro-development (better IQ)
- Less childhood behavioural problems

Breastmilk can be frozen (in a sterilized bottle). If special containers for this purpose aren’t available, you may express into a normal (sterilized) bottle, covering it with plastic or foil to prevent contamination.
How to thaw : swirl bottle with frozen expressed breast milk under running, warm water. Don’t thaw at room temperature : it takes too long, spoiling may occur. Never heat in a microwave. Never refreeze once thawed.
How long can expressed breast milk be stored?
- Fridge ice compartment : 2 weeks
- Freezer : 3 months.

Wash hands and all feeding utensils well.
Boil all feeding items for 5 minutes. Close cleaned, dry bottles until used.
Boil fresh water for 5 minutes; allow to cool down to lukewarm before pouring into bottle.
Prepare one feed at a time. Only use the scoop provided with the formula - scoop sizes vary between brands. Read the label carefully to see the recommended volume of the feed according to your baby's age and/or weight and the amount of water to be mixed with a scoop of formula powder. Level each scoop with the back of a clean, dry knife.
If formula needs to be warmed, it should be done with a bottle warmer or by placing the bottle in a container of warm water. Do not warm in a microwave (creation of hotspots with the risk of causing burns). Do not warm for longer than 15 minutes (certain bacteria may start to proliferate). An appropriate temperature for the formula is between room and body temperature. Test a few drops on the inside of your wrist to check the temperature before you offer it to your baby.
Any infant formula not consumed within 2 hours should be discarded. Leftovers should never be reheated, refrigerated or saved for the next feed.

Routine follow-up visits
Follow-up visits of high risk infants and children with chronic diseases are individualised. Routine follow-up of your healthy baby, infant, toddler or child is recommended at the following ages:
6 Weeks
3–4 Months
6 Months (especially for first-time parents)
9 Months
12–15 Months
18–24 Months
Yearly after age 2 
The idea behind routine follow-up visits is to see the children when they are well and capable of being screened for developmental problems. Time is spent on the little things. Advice on nutrition, supplementation, prevention of common childhood problems and immunization is provided. A quick systemic examination is performed and all measurements are assessed. Time to bring in the little list of questions you have compiled over the last few months!

Jaundice
If your baby is jaundiced, be sure to know when your paediatrician would like you to have the jaundice test to be repeated. In general, if the jaundice test was done on the day of discharge from hospital, it is recommended to have it repeated within the next 48 hours. It is also recommended to repeat testing if your baby is still jaundiced after 2 weeks.
Feeding And General Baby Care
If you experience any feeding difficulties or if you have any questions regarding routine care of your baby, please contact Sr Anelle Greyling on 083 564 6722 for feeding advice and support.
Regular Weighing Of Your Baby
It is recommended that you have your baby weighed regularly in the first few weeks – weekly initially for the first 2–4 weeks and then biweekly thereafter.
Routine Follow-Up
If Dr Stander attended to your baby after his or her birth in hospital, you will be contacted to arrange a follow-up visit at the practice within 5 days of discharge from hospital, as well as an appointment for a routine check-up at 6 weeks, usually arranged for the same day you have a check-up with your obstetrician.
Baby Immunizations
Routine immunizations are done at 6 weeks, 10 weeks and 14 weeks in the first few months of your baby’s life. This is irrespective of whether your baby was born prematurely or at term. The practice will arrange for your baby’s immunizations at our in-house immunization clinic, Kleinding Kliniek.
Hearing Test
It is recommended to have your baby’s hearing tested after birth. The hearing test can be arranged with the following audiologists in Worcester :
Elda Van Dijk 082 331 8889 (66 Fairbairn Street)
Ula Rabie 023 347 4176 (30 Russell Street)
Helmien Van Rooyen 072 179 8486
If you have any further questions or experience any problem not addressed above, be sure to give the practice a call – we will gladly assist you.
Office hours 08h00-16h30 023 342 2333
After hours 079 294 3199