Sleep Strategies for Children with Down's Syndrome

Any sleep-deprived parent will tell you how debilitating that all-consuming exhaustion is. The brain fog, irritability, lack of concentration and a complete obsession with getting a few hours uninterrupted kip under your belt is a completely natural part of parenting. But you expect/hope/pray it will end after a few months.


Sleep hygiene is important for everyone

Up to 25% of all children have a sleep problem at some time (Mindell and Owens, 2003)


But for many parents of children with additional needs this pattern of broken sleep can last for years, or indefinitely. And of course the children themselves are suffering from disturbed sleep too, which has an impact on physical wellbeing and cognition.

Approx 55%-60% of children with Down’s Syndrome have a sleep problem


Learning to sleep is part of normal development. However, it is not something any of us do automatically. We all have to be taught and parents of a child with additional needs can have a much harder time. 


Causes of disturbed sleep


  • Sometimes learning difficulties, physical disabilities or illness can disrupt the sleep process and habits form. Sleep disturbance then becomes a behavioural issue and children may not understand what is expected of them at night. Most children can be helped to sleep better however. 
  • External factors can contribute. For example, I distinctly recall feeling that I was so very grateful that Natty had survived heart surgery, that I would go to her whenever she stirred in the night, ultimately not helping her to settle. And also when your child is often poorly, you also have to monitor them more while they sleep.
  • Obstructive Sleep Apnoea is common in individuals with Down's syndrome, and occurs as a result of the upper airway at the back of the throat becoming blocked during sleep. Breathing will stop momentarily and the person wakes, struggling to inhale. OSA can cause oxygen levels to dip, often below 90%. One cause can be narrow airways and also enlarged tonsils and adenoids. Surgery to remove these can sometimes help, so ask your child's paediatrician. 

Ask your child's doctor about sleep solutions


Ways to help your child learn to sleep

  • Make sure that the child's bedroom is quiet and dark, perhaps using blackout blinds or curtains. Keep the temperature at a comfortable level, being too hot disturbs sleep. Try to keep background noise to a minimum, for example from a TV or conversation elsewhere in the house and make sure they are comfortable.
  • Make their bed is a place your child likes to be. Avoid sending them to their room as a punishment for example. Perhaps your child could help could choose a new bed or set of bedding. Make sure it is comfortable and they feel safe in it. Duvets that zip to a bottom sheet are available and some children respond well to a weighted blanket, although care must be taken to buy the right size and weight for your child. This lovely wooden teddy bear bed from Bed Guru with a side guard also helps prevent wrigglers from falling out. 

Teddy bed with side guard from Bed Guru


  • Daytime Routine will help. Make sure your child has regular meals and plenty of fresh air and exercise during the day but avoid stimulating activities in the hour before bedtime. Try to prevent them from having naps during the late afternoon. If possible, wake them and settle them for bed at the same time each day to help strengthen their circadian rhythm.
  • Make sure you child does not go to bed hungry or thirsty, but it isn't a good idea to give them large amounts of food or drink during the night. Avoid caffeine and additives in your child's diet and offer them a warm milky drink before bedtime instead.
  • Bedtime routine is key to helping your child fall asleep in their own bed without your presence. Let your child have a relaxing bath and maybe some quiet play, then a calming story together is a good idea. Some children like a little back massage or foot rub. You might find a mindfulness CD helps. You can exaggerate the cues that it's bed time, such as dimming the lights and closing the curtains then hugging and kissing the child, using the same phrase wishing them a good night each evening. Consistency is key, as is staying calm and relaxed yourself. Not always easy I know!
  • Introduce a reward system if your child does well.

Professional Support

  • If you have tried all the above there are help programmes devised by professionals at the Down's Syndrome Association, Cerebra, the Children's Sleep Charity and Scope have a Sleep Right service with practitioners on hand to tailor make a sleep plan as well as workshops which you could try.
  • Some children need to have tonsil and adenoids removed to open their airways, others are prescribed Melatonin as an aid to sleep. Ask your child's doctor for their advice.


Resources

  • Blackout blinds
  • Story books about sleep
  • Weighted blankets (to be used with caution)
  • Mindfulness, relax or bedtime story CDs
  • Alarm clocks that tell you when to wake
  • Relaxing bubble bath or massage oil
  • Zip-down duvets or a bed side guards
  • Reward charts


*I was compensated for my time to work with Bed Guru on this post. 



Make Life more Accessible with Fenetic Wellbeing Mobility Products #AD

When researching mobility products online as part of my research for updating an accessible travel piece, I came across Fenetic Wellbeing.  



Mobility products themselves aren't that exciting, let's be honest. I can't make you giggle with an anecdote about a reclining chair. (but please do send yours in if you have one!) 

Down's Syndrome: Sally smacks medics between the eyes with screening truths



Sally Phillips addresses 4000 at the Royal College of Gynaecologists World Congress 2019


Sally Phillips is one incredible woman who has endured more than her fair share of front row hecklers, not just as a comedy actor, but also when she created the brave and thought-provoking BBC Documentary A World Without Down's with film maker Clare Elizabeth Richards. It got everyone talking about the thorny topic of screening. And more crucially the even pricklier topic of 'screening out' babies with Down's syndrome.
"The right words at the right time 
to the right people"
3 years on and Sally's film afforded her the opportunity to speak to 4000 obstetricians and gynaeclogists from all across the globe. I am proud to be able to share the transcript below. 

Last week Sally, remained modest about her seminal talk, which left her exhausted in the days that followed as she dealt with the far-reaching ripples of the effect of her words. "I was simply able to use the right words at the right time and to the right people" she said, "I'm just a canary reporting back from the mine".

But for me, Sally's talk has torn the charming mask from the face of the NIPT industry. 
And as anyone who has ever been gaslit by an abusive partner will tell you, it's frustrating, confusing, exhausting and unsettling to have your reality constantly questioned, altered and dismissed. 
"I am the canary reporting back 
from the mine"
It's harrowing to have your deeply felt emotions diminished and discounted. Simultaneously the flames fuelling your darkest fears are fanned, while the fears themselves are flatly denied. And for our community this is akin to what has been happening since the NIPT test came out. 

Our voices were brushed off as being 'too emotional' or 'simply anecdotal', as if having Down's syndrome or living with a loved one who does is not empirical enough to be evidence.

We were told there was no evidence that Down's syndrome births would drop, that we'd all have to wait and see, that we were 'banging on about nothing'.  But of course we were right. And they knew we were right. 

Our concerns were lumped together with pro-life views and sold as denying pregnant women choice when many of are crying out for better, more informed choices for women. We were told that sharing stories of our happy lives online was wrong, immoral even, because it put prospective parents under undo pressure. 

With Sally's permission I am very honoured to be able to share with you the perfectly crafted talk she delivered that day, the one that left medics in tears and those who spoke after her lost for words. 
 "A kick up the moral and ethical arse 
of the screening fraternity"


Sally Phillips' speech to Royal College of Gynaecologists World Congress 2019


It’s been tremendously hard to work out what to say to you.  The responsibility of representing my community, my friends and family to you in 10 minutes has been almost overwhelming. 

In our community we have been desperate to talk to you.

Once they knew I had been invited 5 parents sent me scripts fully written. I’ve been inundated with quotes, statistics, slides, baby photos, wedding invites, play fliers, school reports and certificates of achievements.  It’s made me feel a little inadequate to be honest. Olly’s best primary school certificate was for ‘most enthusiastic bouncer’.

I’ve been sent articles by educators and LD nurses detailing how different the medical model is from the real people they encounter in their work. I’ve been sent leaflets made by mothers in their spare time, posters, paid for by Mums for you to put up in hospitals, articles they’ve written, drafts of charters for proper antenatal care for mothers with known pregnancy of DS that they work on late at night, unpaid, when the kids are asleep. On top of this, once again, my inbox and all my social media streams are jammed with women’s testimonies of traumatising encounters with doctors, midwives and counsellors on receipt of a prenatal diagnosis.  

How to tell our stories and be heard? Not as a box ticking exercise but actually heard and absorbed, not listened to and then dismissed as emotional, or biased, or unhelpful, but taken seriously. Being taken seriously is a problem for me generally - but this time it really matters. As you can see I’ve decided to come camouflaged as an artist’s impression of the inside of my womb in the hope that this will make you more receptive.

We know that you are good people who do great work in difficult circumstances. We know you didn’t go into medicine to cause harm, but in my ten minutes, on behalf of my community, I am here to tell you that intentionally or not, harm is being done to us.  Rightly or wrongly, screening has had and continues to have an enormous impact on us and bias and wrong practice continues to be significant determinants of our community’s wellbeing.  I am here to tell you that while NIPT and associated tests may represent a staggering technological advance they do not, not yet, represent a genuine improvement in caring for women during pregnancy.

ETHICS

Ethics and Unforeseen consequences of NIPT’is our title today. Isn’t it quite late to be thinking about the ethics? The ethics often seen like an add on to us - a post-hoc justification - an ah shit did I turn the taps off thought - carried out while clearing away the champagne glasses and party balloons from the launch of the latest technological breakthroughs in Down syndrome detection. This, for the record, feels to us, families living happily with Down Syndrome (I’m not lying about that) - in tremendously bad taste.

DROP IN BIRTHS UNFORSEEN?

And do we or don’t we discuss the drop in Down syndrome births after the introduction of NIPT?  Because it’s pretty hard to argue that was unforseen. In fact comments were made during the review process that indicated that a drop in the birth rate, ethical or not, is still viewed by some here as one of the benefits of NIPT.  

We were told that although both conception and termination rates would rise considerably the actual birth rate would remain the same.  As if the Down syndrome population were something to be managed like a group of pandas, or endangered toads (depending on your attitude to disability) or something. 

Was that ethically acceptable reasoning? I don’t know, I’m not an ethicist, I’m a sitcom actress. As a parent. It turned my stomach.

So what has happened in reality? 

Well, Public Health England don’t know because they’re not monitoring it because it’s complicated, apparently. NIPT is offered differently in different hospitals and for some reason not the same offer as FASP are recommending and besides they’re busy, they haven’t got round to it yet.  

Colette Lloyd, a friend of mine, a Mum and a speech and language therapist writes, “They’re supposed to be evaluating the rollout, how can they evaluate if they are not monitoring it? It’s a disgrace that the NHS doesn’t care enough about our population to be bothered with doing this- it’s a continuation of the issues highlighted by Panorama and the LeDer report (3 people with a learning disability die avoidable deaths every day in NHS care) It is their responsibility happening on their turf, following endorsement of a product by them”.

So Colette, being a dynamic sort of person, taught herself statistics and she has spent weekends and evenings for over year now poring over freedom of information requests to local hospitals. She has four children and a job by the way. 

Her figures are doing their second round with the National Office of Statisticians and will be launched on the Today programme in the near future. No doubt to be met with the usual universal indifference. Sneak preview - in those hospitals which offer NIPT the DS live birth rate is down 30%, in those hospitals that do not offer NIPT it is down 9%.

Why is this important to us? 

Because this is a vicious cycle. A reduced birth rate has a knock on impact on the living.  A smaller community doesn’t just mean our children have fewer friends.  It brings with it a reduction in investment in research to improve quality of life for those with Down Syndrome, a reduced incentive to provide appropriate schooling, reduced access to work and work opportunities which in turn means less independence and more isolation for people with Down Syndrome.  No work means less money, poverty, dependence, poorer health outcomes and greater separation from the rest of us. People fear the unknown. People with Down syndrome not being known in turn means more terminations.

We knew this was going to happen. You knew it was going to happen.  The manufacturers knew it was going to happen. We are in pain in my community because put simply, everybody knew it was going to happen and nobody could care less. What attitude towards our population does that betray and how does this attitude impact the way you talk about Down syndrome to pregnant women, who are, although, yes, strong and yes trustworthy, also vulnerable, desperate to do the best for their child and suggestible?

But it’s women’s choice I can hear you cry! It’s informed consent! None of us in this room would want to be called eugenic.  There is a grim history of coercive societal policies to improve the health of the population, we know it’s wrong now. That’s why the focus now quite rightly is on ‘informed consent’, and ‘reproductive autonomy’, people making their own individual decisions.  But since screening was created for many reasons, none of them the empowerment of women, I think the women’s choice rationale often sits uncomfortably on its’ public health and eugenic foundations and the welcome scrutiny it has come under through introduction of NIPT has revealed some areas where choice is not truly the priority.  

Why is the Downs test a screen and not a test? Why do we have a law that allows abortion for severe handicap without defining what that handicap is?  If Down syndrome is discovered, as I believe it will be, to be always mosaic in nature, is informed consent ever possible as the unknowables are so huge.

If individual decisions now are made within a system and in a context which is biased and overwhelmingly carries them towards certain outcomes then the end result is the same as if you had coerced them in the first place. 

I am here as a repository of stories from my community. Professor Tom Shakespeare says ‘anecdotes are not data’ - I say ‘anecdotes are just stories which are not data yet’.  When we present women with a screen and not a one off test, when it becomes so routine it’s opt out not opt in, when pregnant women, who yes are adults and trustworthy, but who as must be admitted are also vulnerable and suggestible are repeatedly questioned, repeatedly told that the only reason other women do not terminate is because they are too scared to, when they are told not to speak to people with lived experience of Down Syndrome because they overstate the positives, when they are told there is no support or help for them continuing a pregnancy, when they are made to feel guilty for bringing a baby to birth, then this constitutes a biased context. I agree with Jane that making women carry a baby they do not want to is awful. I happen to think that pressurising them into terminating a wanted baby is worse. 

Many women are repeatedly offered terminations even after expressly saying they did not want them.  I ask you on their behalves - has the fear of 'wrongful birth' lawsuits have altered practice? Has this anxiety spread from you to your work and your patients that people feel they have to offer terminations again and again.

I had this yesterday from a woman whose daughter is two.

“I’m starting an online support group for women who have been left with mental health problems as a result of being offered terminations against their wishes repeatedly. Being forced to imagine killing your own child is so completely unnatural. It's like the fear and grief of knowing your child was in imminent danger of dying/being murdered but mixed with the sick feeling of you being responsible. Even the counsellors are struggling to know how to help us. Mine is using a strategy she uses to recover soldiers from PTSD.”

Can I ask you. If our mothers were considering legal action would that change your practice?

We all have prejudices we aren’t aware of that might not look so bad at first glance.  I’m more concerned when people think they aren’t prejudiced. When Olly was born I was told ‘he’s very loving and he’ll love music’. This is the same thing well meaning people said about Jamaican immigrants in the 50’s.

It is impossible to hide 100% how you feel about disabilities and saying every time ARE YOU SURE is a dead giveaway that you think women continuing are making the wrong decision. 

Nuffield quite rightly recommended that a pathway be established to support women who choose to continue their pregnancy.  You’ve had two years to do this and while advocates and supporters of women who help women through termination have successfully got your ears and managed to even fine tune support for the TOPFMR for them, nothing has yet been done to create a support pathway for women who choose to continue.

I challenge you to shore up the erosion of choice that exists for women carrying an affected fetus with DS. Lay a strong foundation for both choices. Don't let the women who continue their pregnancies fall off a cliff due a lack of robust clinical guidelines. Don't assume a lack of these guidelines means society thinks she TOOK A WRONG TURN and you need to ask, maybe for the 2nd maybe the 10th time "are you lost dear?"

Second.  NIPT is driven by the industry. The industry are trying to sell their product. They are good at this. They need high numbers to undergo screening to turn a profit.  The global NIPT industry is expected to be worth over $6 billion dollars by 2025. These are serious players. They are not care providers. They are not to be messed with.  When I made my documentary I got a lot of online trolling from all corners, but the worst came from city traders.  “Now get out the fucking way”.  

Even the name ‘Non-Invasive’ is a marketing tool as the test is not currently diagnostic and its positive predictive value in a younger woman, in the absence of other screens is - correct me Basky - around 48%. Its accuracy and benefits are usually oversold. It doesn’t provide peace of mind. It’s not even testing fetal DNA, but placental. The dangers of the (actually) diagnostic amniocentesis too, have been massively overstated - Professor Nicolaides told me that he lost 1:1000 healthy babies after amnio, Lyn Chitty that her rate was !:600. But the manufacturer literature puts this rate as 1:100 a figure which makes national roll out of the test seem economic.

By this time most of the major players in this field have benefitted from industry funding. If you all have taken money and benefits does that make it ok? Not to us, the ‘canaries in the mine’ to use a term for the DS community first coined by Tom Shakespeare.

If making money out of testing that leads in most cases to selective termination is not a form of eugenics, I do not know what is!

Be on your guard against spin.  Companies have long recognised that using trusted individuals is an effective way to promote their products. David Cameron is a lobbyist for Illumina.  I hope they’re regretting that.  Even support groups are now getting funded by business, so they become advocates for NIPT.  In the states manufacturers have set up their own support group where counsellors funded by them give online support to families and then train them up to talk about their (always positive) experiences of NIPT to medics. Some of our parents have been flown out to the States to be taught how to advocate for better information in pregnancy via NIPT.  This practice of cultivating fake grass roots support for a product is known as ‘astroturfing’ and has been supercharged by the internet. We have seen neutral parent speakers replaced with manufacturer vetted parent speakers at medical events. A parent who severed her ties with Illumina last minute was replaced.

It is also being noted by various practitioners of medical ethics - Professor Becki Bennett and Panagiota Nakou, for example, at the University of Manchester, that elements of spin that over-represent positives about the test are creeping into titles, introductions and conclusions of scientific research papers.  Not the research, not the results or methodology, but the way it is presented.  I read their response to a paper which had been published in the Journal of Medical Ethics, a paper which was supported by the Wellcome Trust.  Be sure of what you are reading and hearing. I’m just going to say two words. Brexit and Trump.

But it’s still women’s choice, it’s not coercion. Three things.

First, the information is often not either balanced or the information women need–it may give you data about the test, but it does not give good information about the real lives of people with DS and other disabilities. 

We tell you over and over that we are happy with our family members but we are not believed. I could show you Brian Skotko’s paper, a survey of 2000 families that says that 98 percent of people with Down syndrome are happy with their lives, 97 percent love their family member, but the respondents were selected from families in support groups so some argue the study was skewed. Perhaps it’s better to challenge you to show me a single paper that demonstrated that people with Down syndrome and their families were not happy? 

Second, the health professionals may be biased.  
Not because they are bad people. But because we are all biased to some degree and we live in a society where people with Down syndrome are not numerous and not included and a culture that is biased against them.

Third, the context of screening is a conveyor belt.  I think the word is ‘path dependency’.  We don’t have enough genetic counsellors and specialist midwives.  Providing a test implies that people should have the test.   People who decline the test are asked again and again, to the point of trauma, why they have not had it.  

Evidence shows that people adapt to disability.  But it takes time.  When you have a spinal injury or contract MS, you may want to die. You may think your life is over, but all the empirical evidence shows that you adapt, you change your environment, you come to terms, and life goes on, just as happy as before. Tom Shakespeare has data for this. Marcia Van Riper’s study of over 3000 parents from more than 50 countries showed that while 25% saw Down syndrome as a tragedy on diagnosis, given time only 0.68% felt the same way.

And this is a central issue with NIPT that I haven’t heard discussed.  That our stories often involve that devastation at diagnosis which generally comes about through lack of knowledge, fear of the unknown and changes pretty fast, leaving parents with huge feelings of guilt for having been so upset to start with.  NIPT is so efficient prospective parents don’t have time to adapt.  The vast majority of people who carry on with pregnancies have good outcomes, but many others end pregnancies, thinking they are doing the best for their families, and not knowing of the joy that families and people with DS experience.

Finally, we talk about the benefits, but we don’t talk about the harms that result from screening. The anxiety for all pregnant women.   The distress at terminating wanted pregnancies.  The distress for people with DS and other conditions who feel very unhappy that society is sending the message that they are not wanted.  The way that a shrinking population may find it harder to get medical expertise, educational expertise and the other supports that they need to lead good lives.

Is it enough, we must ask you, for a particular population group to be targeted for screening because another more powerful or more numerous population group has a gut feeling that their lives are crap. Is that enough? We don’t think so. 

My personal belief is that if we allow unrestricted freedoms here, a consumerist ethic at this point, that we end up with an increasingly unfree society. Where the median becomes increasingly homogenous, ideas of normality become increasingly restrictive and conditions conceived of as unliveable with become more and more numerous.  Who then will be welcome?

You, rightly or wrongly, to some degree hold the future of our community in your hands.  Please take more care as you move forward.

***

Specsavers KidsFit Disney range suitable for children with Down's syndrome #ad


Specsavers ambassador Natty loves her new KidsFit Disney glasses!


Goodie box from Specsavers


When Specsavers asked if I'd like to work with them* to spread the word to Downs Side Up readers about a new range of Disney KidsFit glasses made especially for children with small faces and low nose bridges such as many children with Down's syndrome, I jumped at the chance. 


I've always been a fan of our local Specsavers. Mia and I have have been regulars for years. But Natty has only just made the transition from specialist hospital eye appointments to mainstream opticians' eye tests and prescriptions and so is a fairly new customer.






Natty entertains with her famous eyebrow wiggle: 



From the outset Natty has been treated like a celebrity when she goes into the store, partly because she schmoozes, flatters and entertains the staff, and partly because last year she and her big sister Mia were awarded British Citizen Youth Award medals at the Palace of Westminster for their work towards education and inclusion. 
Low and behold the event was sponsored by Specsavers!



Mia and Natty receive their BCyA medals from Ashley Banjo

It was a day which I will never forget, one that made me immensely proud of both girls for all their achievements, but I think for them the fact that Ashley Banjo of Diversity fame, was presenting the awards and that the event involved mountains of cake and a tour of London in an open top red bus was the most important matter in hand.


Back to the Glasses! 

I was really delighted to learn that Specsavers have developed a range of glasses ideal for youngsters with Down's syndrome. The low set bridge on the glasses means that children are encouraged to look through the lens rather than peering over it. 

So often tailor-made ranges for our children can prove expensive or difficult to obtain, and with this KidsFit range available free with your child's NHS optical voucher it could represent a significant saving of time and money.

As you can see Natty was delighted to give the samples a try as soon as they arrived, even before I could take the stickers off the lenses! 


Natty models the new Specsavers KidsFit range #loveglasses


Then we popped in to have an eye test and choose 2 pairs for Natty. The whole team were very patient with her and made the eye test fun. Specsavers staff have a good understanding of visual acuity and specific eye conditions that children with Down's syndrome can experience, as well as putting an emphasis on ensuring that children's glasses are fashionable, practical and fit well.

Thumbs up for eye tests!

It's important for all children to have regular eye tests, not just to make sure that they have glasses fitted if necessary in order to see better for day to day tasks and school work, but also in order to pick up on any underlying medical conditions. 




Time to choose 

Natty's prescription is very mild and she often chooses not to wear her glasses, but they do help make her less tired when she's at school. And I secretly think they make her feel more studious and focussed!

Quite frankly she loved all of the vibrant and colourful glasses in the range, which make fun styles more accessible. She loved the Disney characters on the arms (and I liked that they were subtle enough to be stylish). 


Natty took choosing her glasses very seriously


And entertain the Specsavers staff

Not one to ever knowingly under-entertain a captive audience, Natty used the glasses as props for a full show of singing and dancing. After a few renditions of The Greatest Showman, she chose a pink Sleeping Beauty pair and a blue Cinderella pair, one for "bed time reading and the other for my school bag" she exclaimed. 

In her new specs, Natty sings This Is Me! #loveglasses

Designed to fit so they don't fall off #Kidsfit


Once they'd been ordered, we popped back in a week later to have them professionally fitted and checked. Then Natty was ready for action!

We'd love to thank Specsavers for catering for our children's needs so well, and hope that they extend the range in the future, perhaps designing age-appropriate and stylish glasses for older children, teens and adults next.


Susbstantial and stylish. Natty loves her KidsFit cinderella glasses.


The new glasses are certainly substantial enough to withstand Natty's rough and tumble lifestyle... I just wonder how long they will survive her Womble tendency to hide precious objects in strange places!


To find out more or view the full collection go to the Specsavers website here


* #AD We were sent vouchers for 2 pairs of glasses for Natty as well as a lovely Disney goodie bag and I was compensated for my time to write this review. 








Flemish Painting Features Angel with Down's Syndrome

The Adoration of the Christ Child


This oil on wood painting shows a classic nativity scene, and the little angels kneeling at the front on the left clearly has Down's syndrome. Some think the shepherd at the back on the left also has an additional chromosome.

At the time when the work was created it was common for the faces of those who had commissioned the art to feature within it. Perhaps we are looking at the face of the much-loved daughter of a wealthy and proud 16th Century Flemish family here. 


The 1515 Flemish painting, by an unknown artist, depicts an angel (next to Mary) and possibly the shepherd in the centre of the background, with Down's syndrome.


It's wonderful, and it shows that Trisomy 21 has been around for a very long time. The Flemish artist is unknown, but was a follower of Jan Joest of Kalker. The painting resides at the New York Metropolitan Museum of Art