[00:00:00] Speaker A: May is PFD and ARFID Awareness month and Feeding Matters will be celebrating and engaging the community with weekly themed content. We'll have expert led, Instagram lives, podcasts, resources and a whole lot more. We're gonna get informed, get deep, get loud and get local about pediatric feeding disorder and avoidant restrictive food intake disorder. So join us on eatingmatters on Instagram.
[00:00:29] Speaker B: Feeding Matters Infant and Child Feeding Questionnaire was developed as an evidence based tool to promote early identification of feeding disorders. Developed by internationally recognized feeding experts, this online questionnaire, available in both English and Spanish, can help you better understand your child's feeding differences and needs. Take it online for free
[email protected] that's questionnaire Feeding Matters. Org or type ICFQ in your search bar. Presented by Feed Matters with host Jacqueline Peterson. Dr. Haley Estrom, feeding Does Matter welcome to Feeding Does Matter. I'm Jacqueline Peterson. I'm here with Dr. Haley Estrom, my co host. And today we are joined by Dr. Will Sharp. Well, I know today that we are mostly talking about the provider landscape, but I thought it would be important to kind of start on just what the research initiatives task force was in general. And Will, you were kind of a leader in that because you also like pushed us to think about like getting curious. And that's what I always love, like you thinking about, you know, what are the biggest questions that we need to ask as a field. So what's been your perspective and kind of the forming of the task force?
[00:01:47] Speaker C: Yeah, I mean, I think talking about well, well, well resourced programs, I think I'm lucky to have a very well resourced program. And so with that said, my perspective is that if it takes as much luck as I've had with the two institutions, Emory and Children's Healthcare Atlanta that supported me, I could only imagine what it would be like to try to stand up these very well resourced centers across the country. And we know that parents and families are not going to be able to have access to them. We are very limited with these multidisciplinary centers and there's a need to support the community more broadly.
[00:02:24] Speaker B: And when you started as chair of the task force, you really had that vision of asking a lot of questions and figuring out where we needed to go with the research. And when we started as a task force a few years ago, Haley, you were our research pillar chair. And since I've passed that title on but have stayed on the task force, what was your kind of insight in the forming of it?
[00:02:46] Speaker D: Well, I was really wanting us to be able to, you know, identify concerns and be able to act on it. I wanted us to have the task force to be able to identify the gaps.
[00:02:58] Speaker B: Yeah.
[00:03:00] Speaker D: And the research and to be able to have projects and do the things that we've been doing. So we're now seeing these things come to fruition. And all of our projects are now in different stages and we're having publications come out and we also have projects ongoing and it's. It's ideal, really. I. I like that we have things in. In different phases in the pipeline and that we. We've had all these partnerships ongoing and that we're also being able to get into these advocacy areas and, you know, engage with community and that we've also been able to have the Fakori Award. Yeah.
And engage with families.
[00:03:48] Speaker B: Yeah, I agree. It's nice to really open up what we've been doing for the past few years and have other people be a part of it and other perspectives be a part of it.
You know, I sometimes feel like our projects that we talk about, the list gets really long. But now it's nice to know that there are other people that are part of that work and the consortium being kind of that first. First go with us and expanding.
So I referenced the Feeding Matters philosophy in another talk, but I thought it would be worth us reviewing the philosophy and getting your guys responses to it. But essentially we put this philosophy together to really give a sense of, from Feeding Matters perspective, what we were seeing in terms of what our families were sharing with us, what our community was sharing with us. And a lot of that was that we believe families need to be the center and the lead of a child's treatment team and can be respected in this way. And I think that's a core value in family centered care. That PFD may impact function in any of the four domains. And so a comprehensive assessment needs to be included in all of those. It may not mean that treatment is the case for all four domains, but at least having that awareness between all domains. And then this third point, I think this is where we get some stickiness to it. But there are no identified best practices for intervention. And that's due to the lack of longitudinal information available in the current research and the heterogeneous nature of the population of children with pfd. And so we just share that. As a result, we think it's important that a family's definition of success be incorporated into the treatment planning and that treatment philosophies may not be equally appropriate for all children and that families should be well informed about all services that exist. I think again, some of that family centered language and bringing that into kind of typical academic language that you hear about treatment. And then finally, we believe multiple perspectives are necessary to create a functional system of care. Any reaction response to the feeding matters philosophy?
[00:05:41] Speaker D: I don't know if there will be one identified best practice for care as.
[00:05:45] Speaker B: Of how heterogeneous the population is.
[00:05:48] Speaker D: Right. I think that there's going to be pathways, you know, to follow to help you identify the best practice for that child.
But I think that part of the problem is that there's a lack of, you know, a lack of common measures being used across, you know, different clinical settings and research.
You know, we're not able to build evidence to identify evidence based practice when we're using different measures, you know.
[00:06:32] Speaker B: Yeah. Talking a different language, using different measures, working in different silos.
It's so interesting on the feeding matter side because you'll hear of a research project happening and I think we do it too, but you'll hear of a research project happening and then you'll hear of another research project happening and then you're like, oh man, they should have just done this together. They're kind of looking at the same thing from a different lens. And I almost think that's a little bit in a bigger scale of what we're trying to do in bringing together the ARFID PFD side.
[00:07:00] Speaker C: Well into Haley's point. I think there probably are some things we know about best practices, but only for certain patient populations. Right. So it may be that we know that kids with really severe feeding problems benefit most from going to a multidisciplinary, intensive type of setting. But that's only talking about a very small subset of kids. And the majority of kids, we're not doing a good job of documenting who they are, what their presenting problem is like and what treatment works for them. So I think we have a very narrow window of understanding of what works best.
[00:07:32] Speaker B: Yeah, right. That leads us right into all of our stuff. So Haley and I shared the study that she did and really looking at who is pushing that research out there and how there are some limitations based on that being from a single disciplines perspective and where some of the gaps are even in the ages of the kids and some of that. And so from your perspective, what we did earlier on in the task force of really looking at what questions do we need to be asking? What, what do you feel was perpetuated in the research Well, I mean, I.
[00:08:04] Speaker C: Think there's gaps of things we don't know or don't don't know as well.
I think that's almost the gaps are more interesting than what we know. Right.
[00:08:14] Speaker B: So we know, I think that's very.
[00:08:15] Speaker C: True, that psychologists are publishing about their treatment that shows that behavioral intervention is an effective way to deal with really severe problem feeding challenges.
And you know, when you have food avoidance and restriction, behavioral intervention is a great way to introduce food. But it doesn't answer like the big questions are about, like, how does the family adopt and support that? How do kids advance their feeding skill? Like, I think once again, we know the most about the most limited number of severe cases.
[00:08:46] Speaker B: So once the task force was formed and we started asking some of these questions, we also used what we heard from Feeding Matters from the community to ask some of these questions as well. And just to touch on that before we even dive into some of the projects that we did on the task force. But a lot of that was we were hearing not only just from families, but also on social media and in open dialogue and emails, et cetera, that families had trouble identifying qualified providers. We've even heard that from healthcare professionals that it was challenging identifying the appropriate course of treatment. I think one thing I continue to hear from families is they don't know who to listen to. They're hearing one thing from one healthcare professional, one thing from another healthcare professional, and how do you know who to trust if they both present as healthcare professionals, how do you know which path to follow?
And then I think on the community and healthcare professional side, we just knew anecdotally that the educational pathways for providers to gain experience and expertise was challenging. And then it was even more challenging to engage with the research, whether that meant doing it or even leveraging it in your care. On the community side, back to that split you kind of talked about originally.
[00:10:03] Speaker C: Well, and you also learned that there was a lack of training too.
[00:10:06] Speaker B: We did. We started looking at like what, what are the qualified providers that are in the field and what, how do we even like map the landscape and what even is a qualified provider in the landscape? And then that allowed us to dive a little bit deeper and then really looking at those intensive programs and how limited they are in terms of the impact they're able to make and how many children they serve versus how many children have PFD broadly and then even further diving deeper into treatment with the longitudinal follow up survey and interview.
So that first survey that we did, talk to us a little bit about that, Will.
[00:10:44] Speaker C: Yeah, so this was our first attempt to get an understanding of what was happening for the majority of children accessing care in the United States. And we, we had an international audience too. But for this first paper we, we narrowed it down to the US landscape of providers. And what we found was that the majority of children accessing care are doing so most often with a single provider, most often being a speech language pathologist or occupational therapist. And they're, they' serving them in an outpatient setting, you know, involving weekly treatment. The majority of the sample was, you know, almost three fourths were SLPs or OTS.
They're delivering care in early outpatient settings. But the interesting part was they're using what, what's referred to as responsiveness or sensory based approaches. And these are approaches that haven't been rigorously evaluated yet in the scientific literature.
And what's more interesting if you loop back to what we were talking about psychologists and followed by medical doctors being the primary people publishing in this area, is that when we went out and just said, broadly, who's serving these kids? Psychologists represented only 4% of the sample, suggesting that we probably have an overrepresentation in the literature compared to what the workforce is now. We could be wrong. We could have missed some psychologists, but I actually don't think we did. I think that's a pretty good representation of how many psychologists and or BCBAs are out there.
And so what this really shows us is that we need to do a better job of evaluating what's actually happening for the majority of kids accessing care in the community.
[00:12:23] Speaker B: Yeah, and I think you mentioned some of these, the other findings, I think a lot of the mental health challenges, as we know, if we're not identifying PFD early enough, that's what becomes the primary driver. And that's a lot of the PFD and ARFID conversation. But with mental health providers being such a limitation. Talk to me about what your insights were when you were reviewing the data.
[00:12:49] Speaker D: Well, I think that for, I mean, psychologists and physicians are contributing a lot of the research because, you know, the research training often comes with receiving a doctoral degree.
So I mean, it's, it's hard, it's hard for clinicians that are practicing at a master's level that don't receive research training to go out and do research. I mean, it's, it's, that's a really hard thing to do if you haven't been shown how to do that as part of your training. I mean, they have to learn a lot to go out and practice clinically. They don't have time to include research training as part of what they're doing. It's just not, it's not part of it, it's not necessary.
So I mean that's one of the things that when I was research pillar chair, like we were thinking about like how can we partner with clinicians? How can we, you know, get out there and help facilitate or create, create avenues to help to get this done or would. What would help to make it happen?
[00:14:12] Speaker C: Yeah, and I think the other, the other big piece here is that we know that access to mental health care providers in general is a major issue in this country. Right?
[00:14:22] Speaker B: Yeah, it's a crisis.
[00:14:23] Speaker C: Yeah, it is a crisis. And so we have limited number of psychologists to begin with. And then if you're going to think about psychologists who then go and specialize or re. Specialize in pfd, that's going to be even more limited. And so we need to understand the workforce better and how do you grow a workforce of this nature? The one thing that is growing is we do know BCBAs are growing leaps and bounds. But once again their experience with assessing and treating PFD is not part of their day to day training. And so yeah, it's. While that's great, the workforce is growing. We need a way to train and support that, that, that group as well.
[00:15:01] Speaker B: Yeah. And understand what the limitations are or what they need to better support this population.
[00:15:08] Speaker C: Yeah.
[00:15:10] Speaker B: You know what would be great?
Yeah, Haley. Well, you've heard Haley talk about how we need a multidisciplinary training grant and program.
[00:15:21] Speaker D: Really it would be called an interdisciplinary training grant because they would be working together and training together.
[00:15:28] Speaker C: It's interesting you say that we, we're piloting what it would be like to train BCBAs, but we're only training them as psychologists. But we didn't involve multidisciplinary. We, we even multi disciplinary. So we basically say you got to have medical screening, you got to make sure that the child's cleared for oral intake and we're ruling out organic factors and you need to know about nutrition because those are key things. And you got to know about feeding skill mainly. But we're saying don't treat these kids that have major feeding skill. Don't treat kids if they have ongoing organic. But. And once you start treating, you should know your nutrition like you. And we're using the MyPlate.gov system as a way to treat, teach them that. I mean, but we will only scratch the surface. This is A pilot. But, but we didn't intentionally involve an md, a dietitian and a skill provider in the training itself because we thought you're, you may not have access to them. So we should see if we can teach you enough to be mindful of what you should be screening for and partnering with. But we don't think you necessarily going to be able to access a multi disparate team like, like we mentioned earlier in the talk.
[00:16:36] Speaker B: So the biggest limitation.
[00:16:37] Speaker C: Yeah, it's a limitation. So we should train on pfd. I agree with you on that. And maybe involve the different providers, but I don't think they should have a deep knowledge of the medical pillar because they should not try to replace the medical pillar, if that makes sense.
[00:16:50] Speaker B: No, yeah, there just needs to be like an awareness of the complexity.
[00:16:54] Speaker D: Yeah, yeah. Not to replace, but to have a knowledge, like a surface knowledge and an appreciation for like, when to refer and like, you know, so a screening level knowledge and when to refer. It should also involve caregivers. Like I, I'm thinking of, you know, like a nice interdisciplinary type of seminar series where you, you know, you bring everyone together and you, you have a seminar like every other Wednesday or every month or something and you know, you have all these people come together and there's a course and you know, this is a funding training grant. Yeah, that kind of situation, that's just.
[00:17:34] Speaker B: Haley's dream that I think that this builds the evidence base for the need of something. It's really what a lot of this is doing in my mind.
[00:17:42] Speaker D: We're building the justification to eventually have this thing.
[00:17:46] Speaker B: So Will, this paper was led largely by you and your team.
Tell us a little bit about the study, the why of it, what came out and the key findings and just more about it.
[00:18:00] Speaker C: Yeah, so this was, this was kind of an organic study. What I mean by that, it kind of just happened.
We were, we were, we're working, we're currently working to try to change some of the payer landscape in terms of supporting treatments for kids with pfd. And one of the questions that came up was how common is treatment for severe cases in intensive multidisciplinary settings? And so we started looking around, we scoured the Internet. We partnered with Feeding Matters, we partnered with another feeding organization that had a database of providers. And we wanted to figure out like how many people are out there and what are they doing?
And we found some really surprising results.
The title of it was Intensive Multisciplinary Feeding Programs in the United States. A report regarding the Treatment landscape. And once again, we're looking at programs that are multidisciplinary. So they had all the four domains. So medical skills, feeding skill, nutrition, and psychosocial. They were providing care across consecutive days. So it was a Monday through a Friday type of admission with multiple meals per day. So you had to be feeding the kid multiple times a day across consecutive days and involved that multidisciplinary team. And what was really shocking to us is we thought there'd be more. I actually thought there'd be more than 16 programs out there.
So that was the first thing that was really surprising. There's only 16 programs now. There were other programs, but they didn't meet inclusion criteria for either they didn't have all the domains or they didn't have the consecutive days, or they only did one meal a day. But something about them that didn't meet inclusion criteria.
[00:19:43] Speaker B: And you saw a lot that closed during COVID too, right? Or their changes that happened during COVID are what kicked them out of the.
[00:19:50] Speaker C: Well, we. Yeah, we saw that. You know, that's another thing. It's very hard to open a multidisciplinary clinic. It requires a lot of institutional support, a lot of resources. And we were finding that programs were closing down either because they couldn't figure out the financial or the operational aspect of running it. The majority of the programs that are open are in the East, Midwest or East, and they tend to cluster up in the Mid Atlantic around where the birthplace we're calling the birthplace of this model of care is the Kennedy Krieger Institute in Baltimore. And why we're calling the birthplace is the oldest running intensive feeding program in the country by decades. It's more than 40 years old.
And so we did find to your earlier question that most programs were at least 10 years or older. So there were very few programs. Of the 16 that open, I think only four to five open in the past five years. So I call these legacy programs and I'd also call them the ones that have figured out how to survive.
And so this is probably a map of survivors, right? I know, like for instance, there was a program in Birmingham, Alabama that was started and run for a few years, but it didn't make it. I could probably name. There's ones in Texas. Many. Yeah. It's also important to note that we didn't try to capture hospital based admissions where you're admitted into the hospital for the treatment. And the reason we didn't do that is personally, as a, as an expert in this field, I think that that's not a tenable way to try to disperse care. I think admitting a kid to the hospital we know is expensive. We know that, like, insurance isn't going to necessarily. I think there's too many barriers for disseminating a model of care that relies on admitting a kid to the hospital for a feeding issue, unless the kid needs a hospital admission. And I don't think that's what the majority of the kids out in the community need.
[00:21:45] Speaker B: And that was just published recently as well. But I think the biggest thing, at least from my perspective that is the read between the lines on a lot of this is, yes, that there aren't a lot of places for children to go. And we know that it's not meeting the capacity and the needs. And then also it just leads to so many questions when you say it's a map of survivors, because I get that that's, like, exactly what it is. It's a map of survivors that, because they had these legacy programs, have been able to sustain through economic changes, changes in insurance, and all of these different things. But for me, the questions are like, okay, so what does that mean for future multidisciplinary care for pfd?
[00:22:28] Speaker C: So let me take you back in a time machine. When I first started in this field, we were so focused on trying to show that treatment, like a behavioral approach works, or this works, or this doesn't work, but we weren't talking about the treatment setting where treatment was occurring. And so one of the things that I try to pivot to was describing where kids were accessing care, just like we did with the landscape paper, talking about their access and care from OTs and SLPs and outpatient clinics. In this paper, I started trying to talk about for kids with really severe feeding concerns, they're receiving care at these multidisciplinary clinics. And then how prevalent is this model of care? And so one of the things we learned is less than 1,000 kids a year. There's less than a thousand slots for these kids to access this care. At these 16 programs, we think that more than a million kids in the United States have PFD or some form of pfd. We took a haircut in the paper many times. We said, okay, we're not going to say that all kids with PFD need to come to these programs. But if we even just took like a 5% of the PFD population, we're looking at 45,000 kids trying to access 1,000 slots, like, if that makes sense. So there's A huge unmet need.
There is some consistency among the programs in terms of how they're delivering care, how long care is. Care tends to be, you know, about eight weeks in length. It tends to involve, you know, three to four meals a day. It tends to involve kids in that early childhood to middle childhood. So three to eight. So there was some consistencies. I don't think we all necessarily are doing exactly the same thing within our practices, but I think there's enough convergence that suggests there is some uniformity about what's happening at these intensive programs.
[00:24:10] Speaker D: What do they do while they're waiting?
[00:24:14] Speaker C: You mean waiting for treatment?
[00:24:16] Speaker B: Because every single program had a wait list and a significant one.
[00:24:19] Speaker C: Right? They did. And, you know, it's interesting, in talking to the different leaders, some programs are doing what I call like a preparation phase where they have kids on their wait list and they're preparing them for the admission. I'm very interested in that, and I would likely want to spearhead that at multiple centers. So preparing them so that they can come into the program and hit the ground running, as opposed to spend the first few weeks just getting comfortable with the therapeutic approach. But I still don't think prepping them that way is going to meet the unmet need that we have.
[00:24:55] Speaker B: No. Yeah. It doesn't change. I think it gets back to understanding what children do best with which treatment, and how are we leveraging what's happening in the community with these more intensive programs and how that everybody's flowing from one to the other and how partnership is happening.
[00:25:18] Speaker C: Yeah, And I think the idea. I think these programs will always be necessary, but I think if we could shrink the overall number of kids that would be in the pipeline to possibly come in, that would be fantastic.
[00:25:28] Speaker B: Yeah.
[00:25:29] Speaker D: Where do you think telehealth plays into? Especially West coast, like, what do you think is happening for all the other 45,000 kids?
[00:25:42] Speaker C: I mean, I think they might be with a community provider, but that's not a good match necessarily for that type of patient with that level of severity.
I think they may be floundering between. You know, and I say floundering, I don't mean that the families are not trying their best. I think.
[00:26:00] Speaker D: Absolutely. Yeah.
[00:26:02] Speaker C: I think they might be landing with a provider who tries to treat it with one of the other domains, like, let's try some medicine, or let's try a hunger provocation, or let's try. And I think the stories we get from parents is that until they land at a place that's seen the most, like intensive cases, it's been a confusing journey for them because they keep on getting the wrong answers from different providers, and nothing seems to be working. So. And I'm not saying these are the only type of programs that will work. What I'm saying is these type of intensive programs work for the most severe kids. And once again, like we started the talk about these, these intensive programs are not meant for the majority of kids with pfd. So that's that balance we're trying to make it. Yeah.
[00:26:43] Speaker B: Yep.
[00:26:43] Speaker C: It's recognizing these programs are important, but they. They're only serving a subset and that the majority of treatment that's occurring community needs to be better understood.
[00:26:52] Speaker B: Yeah, well, and that really dives us into our next question, which is about kind of what these programs are doing and how successful they are for some individuals.
And you really wanted to ask that question of your own program, and so that's why you enlisted Haley and the team to try to look at that. And so I know we're in the middle of the research, but I thought it would be good to touch on that a little bit.
[00:27:16] Speaker C: We.
[00:27:16] Speaker B: Yeah, okay.
[00:27:17] Speaker C: We have a paper of 81 patients who we treated for feeding tube dependence over a decade or between five and 10 years ago. And the furthest we went out with that group was a year. So we knew what happened with them a year later.
And I think in the beginning of this podcast, we noted there's no longitudinal data. That was one of the missions for feeding. And so I don't know if I was excited necessarily to say, hey, Haley, go figure out what happened.
[00:27:47] Speaker B: Hey, that's fair.
[00:27:48] Speaker C: Let me go back. I didn't. I had no idea. Like, I had no idea what these individuals were going to say. But, you know, that's part of, I think, part of the vulnerability. When you start asking questions about how you as a provider are delivering care, it is a little bit vulnerable. So we gave it to Haley and said, hayley, here's our patients, and figure out how they're doing. And so Haley has learned some stuff about our program.
[00:28:13] Speaker D: Yeah, I mean, it's ongoing, too. I mean, the survey is technically still open. There's still some responses trickling in. And then from the survey, we asked, the final question is, like, are you willing to be contacted for an interview by two parents who volunteer with Feeding Matters? And it's me and another mom of a child who's been through a intensive feeding program.
And we call and do an interview, and I wrote down some of the questions to share, and it's describe your Feeding journey since the tube weaning program.
Do you have any recommendations on what to do if you're on a wait list for a feeding program? What would you do if you were to give yourself advice, you know, for starting a program now? Have there been any barriers for feeding or were there any barriers for you to make it happen? Like what did you have to do to, to be there and be present for the program? What did you have to do to, to get yourself and your child there?
Were there any resources that would have been helpful for you for feeding and eating or for making, you know, your feeding and eating journey better for your child and for yourself and your family along the way? Just questions like that and it's been really interesting. It's been good.
And these are all questions developed by, you know, people who've been in the trenches kind of with their own children. But it, it's, so far it's, it's been very positive.
[00:29:53] Speaker B: Well, you know, well and I think it's a good example of like family centered research. Like it's involving families in the beginning.
[00:30:01] Speaker C: And we're searching for families who were receiving care more almost a decade ago. And the fact I believe you found or we've got responses from about 45, let's say almost half the sample that we could get. That's pretty good for such a long term outcome study.
[00:30:21] Speaker D: It is, yeah. The survey response has been very good.
Better than I think I anticipated. I mean we really didn't have any idea how it would go.
[00:30:33] Speaker B: I'm excited too about what it means long term. Like it would mean back to that conversation we had of everybody talking the same language and the same common measures is it would be great if everybody could report their outcomes five years out and those be the same outcomes just to get a better understanding. I know there's so much work that needs to happen before then, but building.
[00:30:56] Speaker D: But in the survey we're asking like, are, you know, is your child using the tube anymore? If so, how much you know, how's their relationship with food now?
[00:31:09] Speaker C: So just curious, have you looked at any of those responses thus far?
[00:31:14] Speaker D: Yes.
[00:31:15] Speaker C: And, and preliminarily, what, what are you finding?
[00:31:18] Speaker D: Some are using it, but not many. Yeah, mostly have good relationships with food.
[00:31:26] Speaker C: Yeah. That's fantastic to hear that. Okay. Yeah, I mean I'll be interested in the focus group data as well.
[00:31:31] Speaker B: Yeah, lots more to do. And so I guess now in this like provider landscape space, what are some challenges that you see in the researcher? What more research needs to happen in this space and how can it be family centered?
[00:31:50] Speaker C: So I think kind of like our politics, people can be tribal. And so I think part of it is that people are very.
They're very interested in their treatment approach and owning that approach and not being open to maybe looking at alternative approaches. I know that, you know, there are branded approaches out there and that. That probably work for many kids. And I think it's important that we once again specify who work what works for whom and really support the parents on understanding what they're consuming as well.
I think a lot of times that families are landing with providers. I met with a mom the other day who told me her story about going through an outpatient approach. And when she was done, she said that my child would need at home. Like, I think that's a major gap. Right?
[00:32:39] Speaker B: Thank you both for diving into this.
[00:32:42] Speaker C: This is great. I think it was really nice to share how much work we've got done in a short period of time. And I think a lot of papers are going to be really well cited and drive the research forward.
[00:32:54] Speaker B: Yeah, I think so, too.
All right, everyone, have a wonderful Tuesday.
