Pediatric Medicines & Licensing Overview

Pediatric Medicines, Vaccines, and OTC Overview

• This lecture aims to improve the understanding of challenges of dealing with young patients, various minor ailments and infective diseases of childhood, complex diseases requiring referral, treating minor conditions OTC, and special considerations

Licensing of Medicines in Children

• All marketed medicines requires a product license, details can be found in the individual Summaries of Product Characteristics (SPCs), which will detail indication, route, dose, and age
• Many medicines are used in children without a specific license, this is known as "off-label" use
• The Medicines Act makes provisions for off-label use
• Common examples of off-label medicines include salbutamol in children younger than 2 years and paracetamol use in infants younger than 2 months
• The BNF-Children and Patient Information Leaflets/SPCs provide essential information for pediatric queries

Children's National Service Framework

• National guidelines apply to England
• Sets standards for care for children, especially regarding medicines
• Standard 10 specifically relates to medicines for children
• Department of Health website provides more information
• In all settings, children, young people, their parents/carers, and healthcare professionals should make shared decisions about medicines
• Decisions relies on sound information about risks and benefits
• Access to safe and effective medicines should be prescribed based on best available evidence

Giving Medicines to Children - Routes of Administration

• Oral liquids can be suspensions, solutions, syrups or elixirs
• Oral solid forms include tablets, capsules, granules, and lozenges
• Ensure the use of a spacer when using Metered Dose Inhalers (MDI)
• Use powder devices and nebulizers as alternatives
• How to use a spacer with a mask for a baby or child can be found on the Asthma UK website
• Ear/Eye/Nose: Administered as drops (solutions, suspensions), ointments
• Skin: Topical applications include creams, ointments, sprays and lotions
• Injections can be subcutaneous (sub-cut), intramuscular (im), intravenous (iv), or intradermal (it)
• Rectal: Delivered via suppositories, solutions, enemas, or ointments

Considerations for Medicines in Children

• Consider the child's age when deciding to use a syringe or spoon for administering medicine
• Administer doses slowly and avoid giving too fast
• Ensure accuracy of each dose
• Formulation should be appropriate for the child, taste and sugar content being the factors
• Stability and treatment length should also be considered
• Avoid mixing medicines in a baby's bottle
• Tablets or capsules are usually not suitable for children under 5-7 years, however some can be crushed or opened and sprinkled onto soft food or mixed with yogurt
• Do not crush enteric coated or sustained release preparations
• Soluble tablets may be used

Giving Medicines to Children with Ng/Nj Tubes

• Nasogastric (Ng) and nasojejunal (Nj) tubes requires liquid formulations where possible
• Newt Guidelines (Secondary care) can be used
• See the BNF/SmPC for guidance on mixing tablets with water
• When a patient is on continuous feeding, note that some medicines may mix with the feeding solution, and you may need to stop feeding 15 mins before medicine administration

Giving Medicines to Children - Eye Preparations

• Eye preparations must be sterile
• Preserved products should be discarded 4 weeks after first opening
• Unpreserved products usually expire 7 days after opening
• Some preparations may require refrigeration
• Use the following technique: Tilt the head back, put a drop into the corner of the eye, and mop up excess liquid
• Apply ointment to the inner lower lid
• (May require 2 adults!!)

Giving Medicines to Children - Rectal Administration

• Rectal administration is suitable for very young children, however this is less acceptable in older children
• Suppositories may be lubricated before use
• Splitting suppositories is not recommended

Dose Calculation for Children

• Children's doses are usually standardized by weight or body surface area (BSA), expressed in m²
• Young children may need higher doses per kilogram than adults due to their higher metabolic rates
• Note: Calculating dosage by body-weight in overweight children results in higher doses, use ideal weight related to height and age
• BSA estimates are sometimes preferable to body-weight

Patient Information - Counseling Topics

• Explain to parent how to give information, information should be on label and explained/shown to the parent
• Provide the parent with the purpose of the medicine
• Inform the parent of any caution with certain drugs, e.g. imipramine for nocturnal enuresis
• Tell the parent what happens if a dose is missed
• Remind the parent when to consider the frequency of dosing around child's waking hours/school
• Advise the parent how long should the medicine should be taken for
• Provide parent with information about further supplies

Storage Information For Parents

• Keep out of reach of children and in child-resistant containers
• Check if medicine requires refrigeration
• Do not mix medications in the same bottle
• Keep in original container

Medicines at School

• Giving medication is a parental responsibility, school staff may be asked to perform, the details surrounding this task vary dependent on length, child's age, education and must be labelled with full details
• Note that some teaching unions indicate that school staff should not be required to administer medicines, not a legal requirement!!
• Most local education authorities issue guidance and schools should have a medication policy
• Try to change dosing schedule to avoid administration at school

Immunization

• Recommendations are based on advice from the Joint Committee on Vaccination and Immunisation (green book)
• Updates sent to professionals by the CMO
• Guidance also given by DH and WHO
• Most children are immunised unless there are specific contra-indications; however, immunization levels have dropped!
• Find more information at https://www.nhs.uk/conditions/vaccinations/nhs-vaccinations-and-when-to-have-them/

Immunisation Schedule

• First year vaccinations:
  • 8 weeks: 6-in-1 vaccine (diphtheria, tetanus, pertussis, polio, Hib, hepatitis B), rotavirus vaccine (oral), MenB
  • 12 weeks: 6-in-1 vaccine (2nd dose), rotavirus vaccine (2nd dose), pneumococcal (PCV) vaccine (1st dose)
  • 16 weeks: 6-in-1 vaccine (3rd dose), MenB (2nd dose)
• 1-15 years vaccinations:
  • 1 year: Hib/MenC (single jab), MMR (1st dose), pneumococcal (PCV) vaccine (2nd dose), MenB (3rd dose
  • 2-15 years: Flu vaccine (every year), given via nasal delivery
  • 3 years and 4 months: MMR (2nd dose), 4-in-1 pre-school booster (diphtheria, tetanus, pertussis, polio)
  • 12-13 years: HPV vaccine, now offered to girls AND boys
  • 14 years: 3-in-1 teenage booster (tetanus, diphtheria, polio), MenACWY
• Nov 2023 - The Joint Committee on Vaccination and Immunisation (JCVI) recommends a universal varicella (chickenpox) vaccination programme should be introduced as part of the routine childhood schedule. This should be a 2-dose programme offering vaccination at 12 and 18 months of age using the combined MMRV (measles, mumps, rubella and varicella) vaccine. This proposal is being considered by DoH but at the time of this lecture is not yet part of the vaccination schedule.

Immunisation - Contraindications & Documentation

• Immunization is usually contraindicated if there is an acute illness or a previous severe reaction to a vaccine or its constituents
• Live vaccines should not be given to immunosuppressed patients
• Immunization information must be documented in Child Health Record
• Educational Leaflets are available from community pharmacies, clinics, GP, and the DH web-site

Rotavirus

• Rotavirus is the leading cause of gastroenteritis among infants and young children
• Diarrhea and vomiting can cause severe dehydration, leading to hospital admissions each year
• Highly infectious and mainly transmitted via the faecal-oral route, respiratory transmission is possible
• Infection is predominant January- March each year in the UK
• Most children will have been infected by the age of 3 years
• Symptoms persist from around 3-8 days

Rotavirus Vaccine Administration

• A live vaccine given via the oral route at 8 weeks
• No restrictions before or after administration
• Postponing vaccination is generally unnecessary due to minor illness, note that effectiveness can be reduced if it passes through intestine too quickly!!!
• If diarrhea is prevalent, postpone vaccination but first dose must be given between 6-15 weeks of age
• 2nd dose - 3 months of age or at least 4 weeks after the 1st dose – must be received before 24 weeks of age!
• Ideally, both doses should be given prior to 16 weeks to deliver for full protection
• The vaccine is excreted in the stools so may transmit the infection
• Carers of the baby should be advised on hand washing after changing diapers
• Vaccination of babies with immunocompromised close contacts may protect those contacts from the 'wild-type virus', may outweigh the risk of transmission from the vaccine

Fluenz Vaccine

• Offered to children 2-16 years and is a nasal vaccine of Live Attenuated Influenza Vaccine (LAIV) strains genetically altered via 3 mechanisms
  • Cold adapted to stimulate immune system in the nose where cooler temperatures are found
  • Temp sensitive so cannot infect the lungs or warmer nasal passages
  • Attenuated....replicates to provoke a full immune response without clinical symptoms
• Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children.
• The child can breathe normally during administration and does not need to inhale or sniff
• Patients with a heavily blocked or runny nose should receive the vaccine once symptoms have cleared

Fluenz - Contraindications

• Immunocompromised, e.g. leukaemia, lymphoma, untreated HIV, high dose steroids
• Under 2 years of age
• Receiving aspirin or salicylates (increased risk of Reyes)
• Egg or gelatin allergy
• Pregnancy (note some exceptions - flu/whooping cough)
• Children actively wheezing or those with severe asthma

Meningitis B Vaccine

• Men B vaccination was added to the immunisation schedule in 2015
• Single injection into the left thigh.
• SPC states babies are at an increased risk of fever when Bexsero is administered at the same time as other vaccines.
• Current recommendations from PHE: https://www.gov.uk/government/publications/menb-vaccine-and-paracetamol
• Give 3 doses of infant paracetamol as a prophylactic measure against fever, one at the time of vaccination or shortly afterwards, then 2 further doses in four to six hour intervals.
• Note this dosage range (3 doses) exceeds the current licensing terms of infant paracetamol (120mg/5ml), which is restricted to a maximum of 2 doses post-immunisation in babies aged 2-4 months.

Using Paracetamol After Meningitis B Vaccine

• A total of three doses of 2.5ml (60mg) of paracetamol are recommended
• You should give the first dose at the time of vaccination or as soon as possible afterwards
• You should then give the second dose of paracetamol around four to six hours later and a third dose four to six hours after that (see table)
• The 2.5ml dose should be measured and given either using a syringe or with a 2.5ml spoon (this is usually the small end of the spoon that comes in the pack)
• For very premature babies (born before 32 weeks gestation), paracetamol should be prescribed by your doctor according to the Infant's weight at the time of vaccination. You should check with your doctor and follow the Instructions on the prescription

General Immunisation Adverse Reactions

• Adverse reactions include localized pain, swelling within 3-4 hours that resolve within 24 hours
• A prolonged swelling requires medical attention
• The recommendation of using of prophylactic paracetamol differs: it is not recommended unless Meningitis B vaccine is given at the same time
• For vaccinations when Meningitis B is not given, give a dose of paracetamol if the child exhibits a fever, repeat after 4-6 hours, if the fever persists seek medical attention
• Some children experience Rare reactions e.g. fainting / hyperventilation / anaphylaxis
• Note that in MMR - 5-10 days after injection may be mild attack of measles - malaise, fever, rash

MMR Vaccine

• MMR history... Given since 1988
• WHO "its safety record is exemplary'
• Dr Andrew Wakefield's now discredited research is published
• Linked the MMR jab to autism
• One study included 12 autistic children who also had bowel problems
• Scientists stated no link between autism and the vaccine
• The negative publicity gave a biased public impression
• As there was increasing diagnosis of autism anyway
• Symptoms in certain types of autism (regressive) start around the time of the first dose of MMR
• Regressive autism is not more common in vaccinated children
• No increase in autism after the vaccine was introduced

2013 Swansea Measles Epidemic

• Following publicity in ,2003: MMR uptake for two year olds fell from a peak of 94% in 1995 to 78% in 2003. In Swansea it fell to 67.5%
• November 2012: Swansea outbreak starts when a small number of children return with measles from a holiday camp in south-west England
• Early 2013: Around 10 to 20 suspected measles cases are reported per week
• February 2013: By 7 February a total of 168 notifications have been received.
• 18 April: Gareth Colfer-Williams, 25, is found dead at home in the Swansea. He died from pneumonia after contracting measles
• 22 April: There is a rapid increase in cases. The outbreak reaches its peak, with nearly 200 notifications in a single week
• July: Outbreak declared over..... cases totalled over 1000 throughout whole notification period!!!

2023 - NHS England Update

• More than 32,000 children across London at risk of catching measles as new school term gets underway
• WHO has set a target of 95% MMR vaccination uptake, which is enough to create herd immunity and protect those who are not able to be vaccinated such as babies, under one years old
• Measles is highly infectious and can be passed on up to four days before a rash appears.
• The WHO declared measles as one of the world's most contagious diseases

Common Childhood Illnesses - How Ill is the Child

• Children are difficult to obtain a clear and accurate history from.
• Parents certainly know their children and will be able to accurately observe any changes.
• Children behaving normally are rarely ill to any extent requiring intervention.
• A sedate child, very different from normal is a potential cause for concern.

Pyrexia - Fever

• Very common in children from teething to meningitis.
• Normal body temperature is 37 degrees +/-1
• Rectal temperature is 0.5 degrees higher than oral temperature, underarm is 0.5 lower. (in general).
• Use of Infra-red devices via the ear give accurate reproducible results.
• Forehead thermometers are not accurate to be recommended.
• Fever is caused as a result of pyrogens resulting from viral or bacterial infections
• Typical presentation may include: irritability, not eating, "clingy" or seeking parental attention, symptoms of a cough or cold and increased respiratory rate

Pyrexia - Important Questions:

• Note that any child under 3 months should be automatically referred – unless post immunisation!
• Assess general perception of the parent is important to understand the history of the illness
• Inquire whether there are other symptoms present?
• Check for asymptomatic UTIs as they may present a mild pyrexia, and UTIs can be damaging over time

Pyrexia - Differential Diagnosis

• URTI- usually viral and self limiting but check for earache which may indicate a bacterial infection.
• UTI- asymptomatic pyrexia, is common and can lead to the development of scarring in the urinary tract, referral required.
• Meningitis- clearly a dangerous disease which invariably results in fatality if untreated-Refer. Typically presents with photophobia, stiff neck, lethargy/drowsiness and petechial rash

Pyrexia - Treatment

• Paracetamol is an established choice with evidence based use
• Licensed from 2 months for post immunisation pyrexia
• Note that it is licensed from 3 months for general pyrexia and pain
• Ibuprofen is an established choice and evidence based
• The drug is only licensed from 3 months of age and >5kg
• Alternating regimens of paracetamol and ibuprofen or co-prescription of both:
  • This is only sometimes prescribed for pyrexia.
  • Remember to advise on taking Regular fluids, which prevent dehydration.
• Evidence base is lacking re efficacy of alternating paracetamol and ibuprofen
• NICE - these results suggest the superiority of an alternating regimen by 2 RCTs
• Note that the findings need to be confirmed in larger trials to establish the efficacy and safety of this approach
• Current guidelines suggest using paracetamol, then if necessary, to switch to ibuprofen
• Only consider alternating these agents if the distress persists or recurs before the next dose is due.

Ibuprofen and Chicken pox

• NICE CKS recommends avoiding NSAIDS in children with chickenpox.
• NSAIDs may increase the risk of necrotizing soft-tissue infections and secondary infections caused by invasive streptococci in children
• Evidence suggests an increased risk of skin reactions
• Some SPCs and PILs may not contain any reference to chickenpox.
• Follow NICE CKS guidance when dispensing prescriptions and when supplying OTC products for use in children with chickenpox.
• Paracetamol can be used to relieve pain and fever in children who are unwell with chickenpox

Pyrexia - Dosages

• Standard doses are generally guided by age
• Paracetamol:
  • 120mg/5ml or 250mg/5ml (6+)
  • Age 3 - 5 months: 60 mg every 4-6 hours (maximum of four doses in 24 hours). [2.5ml]
  • Age 6 - 23 months: 120 mg every 4-6 hours (maximum of four doses in 24 hours). [5ml]
  • Age 2 - 3 years: 180 mg every 4-6 hours (maximum of four doses in 24 hours). [7.5ml]
  • Age 4 - 5 years: 240 mg every 4-6 hours (maximum of four doses in 24 hours). [10ml]
  • Age 6 - 7 years: 250 mg every 4-6 hours (maximum of four doses in 24 hours). [5ml]
  • Age 8 - 9 years: 375 mg every 4-6 hours (maximum of four doses in 24 hours). [7.5ml]
  • Age 10 -11 years: 500 mg every 4-6 hours (maximum of four doses in 24 hours) [10ml]
• Ibuprofen: 100mg/5ml
  • Age 3 - 5 months: 50 mg three times a day (maximum of three doses in 24 hours, do not use for more than 24 hours). [2.5ml]
  • Age 6 months to 1 year: 50 mg three to four times a day. [2.5ml]
  • Age 1 - 3 years: 100 mg three times a day. [5ml]
  • Age 4 - 6 years: 150 mg three times a day. [7.5ml]
  • Age 7 -10 years: 200 mg three times a day. [10ml]

Atopic Eczema

• Condition that typically starts between 2-6 months of age.
• 1-15% of people can be affected during their life.
• Usually desists and clears after a number of years and the child will grow into adulthood unaffected.
• Patients will show a positive family history of "atopy" e.g. asthma, eczema or hay fever
• Patients have a predisposition to irritant contact dermatitis

Atopic Eczema - Risk Factors

• Incidence is increasing
• Possible environmental issues may worsen these conditions
• Various links with air conditioning and central heating have been suggested
• Possible food links exist with 4/5 children with atopic eczema who have IgE mediated inhalant or food allergies
• Other implicated factors include
  • Greater exposure to pets
  • Higher maternal age
  • Choice of food
  • Increase in house dust mite

Atopic Eczema - Diagnosis

• An itchy skin condition or report of scratching in the last months - plus >3 of the following:
  • A history of involvement of the skin creases
  • A personal history of atopic illness (or history of atopic disease in a first degree relative if a child is less than 4 years of age).
  • A history of generally dry skin in the last year.
  • Onset under the age of 2 years
  • Visible flexural eczema
• Criteria apply to all ages, social classes, and ethnic groups
• In children of Asian, black Caribbean, and black African ethic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common

Atopic Eczema - Symptoms & Indications for Referral

• Lesions may be moist or weeping
• Skin may be thickened and lichenified
• On darker skin lesions may appear papular
• Scratch marks are often evident
• Staphylococcal secondary infections are common with staphylococcal foliculitis occurring as a result of emollients
• Atopic children can also be prone to infection with Herpes simplex
• Refer if there are:
  • Severe cases
  • Suspicion of psoriasis / herpetic complications
  • Treatment failure
  • Secondary infection

Treating Atopic Eczema With OTC Treatments

• OTC treatment options:
  • Non-prescription treatment options consist of
  • Emollients/Soap Substitutes
  • Antihistamines
  • Topical Corticosteroids (not OTC for under 10 yrs!)
  • Counselling
• Note: Firstly avoidance of irritants include: dust, perfumes, certain material e.g. wool and pet dander

Emollients

• Used for efforts to ameliorate the effects of dry skin
• Added to bath water and used as soap substitute
• Patients should abandon use should any emollient sting on application
• Some contain antiseptics to which may be of benefit but can over-dry the skin and irritate
• Liberally applied - no upper dosage limit.
• Beware of slippery baths!
• Liquid paraffin is flammable – Warn patients of risk of naked flame!!

Antihistamines

• Sedating antihistamines include:
  • Chlorphenamine (P)
  • Hydroxyzine- POM licensed for pruritus
  • Promethazine
• All will cause sedation and have different licensed particulars as regards age for use.
• The only licensed product under 1 year is hydroxyzine - can be used from 6 months of age.
• Note: Sometimes prescribed them for itching, limited evidence in Eczema

Cough and Cold Preparations

• Products for Children under 12 Years require safe use
• The CHM advised on improving safe use of cough and cold medicines for children under 12 in 2009.
• These are found in Chlorphenamine and diphenydramine, Dextromethorphan, Guaifenesin and ipecacuanha, Phenylephrine, pseudoephedrine, ephedrine, oxymetazoline and xylometazoline
• Adverse Effects include
  • Not is suitable for children under 2 year, especially with regards to adverse effects and overdose
  • Children 6-12 years should only use with advice from the pharmacist and follow all extra warnings and instructions on packaging
• Examples of suitable common mixtures include Calpol Infant Suspension, Disprol Soluble Paracetamol Tablets, Nurofen for Children Strawberry and Orange, Beecham Veno's Honey and Lemon and Benylin Children's Tickly Coughs (3 months

Teething

• Spans the ages of anything from 3 months to 3 years of age
• Symptoms include Pain, Swollen gums, Red or hot cheeks, Excessive dribbling and Nappy rash
• Changes to sleep pattern
• Appetite is increased
• Increased tendency to chew objects/hands
• General irritability
• Sleep loss can occur for baby and parents
• 1st Line Treatment involves: Paracetamol or Ibuprofen Suspensions
• Consider Topical teething gels: Contains local anaesthetics e.g. Lidocaine (Anbesol)

Colic

• Occurs from about three weeks to four months of life.
• Characterised by pulling their arms and legs up almost in a ball.
• Results in persistent / spasmodic bouts of crying / screaming.
• Is difficult to console : common in the evening.
• Consider something else as children is distress
• Note:Difficult to assess and should be done done with a GP/Health visitor
• Sudden variation/ worsening: Indicates an acute complication

Colic – Criteria & Potential Causes

• Criteria:Colic is present if a child cries more than 3 hours a day, for more than 3 days of the week, for over three weeks
• Exact clause to this
  • An immature G/I tract
  • Milk / lactose intolerance or excessive gas (Breast/ bottle fed)
  • Possibly a set of different conditions

Colic-Treatment

• Very Little treatment is available
• Dimeticone Surface: reduces surface tension
• These Larger Bubbles are theoretically easier to pass.
• The main product used in Infacol - safely used either at to during feeds
• Lactase Enzyme: Colief Enzyme Drops effective as a intolerance treatment
• Many other available that lack strong superiority
• Note the method of feeding e.g The suckling causing of large amounts of air to ingested

Constipation

• Fairly common and changes in a the diet causing dehydration.
• Not usually cause of organic
• It’s is has psychological: due to issues with defecation
• Treat: Give Appropriate Dietary advice e.g. Fruit or Water:
• Do not to encourage Senna >12 and suppositories

Threadworms

• Embarrassing illness therefore handle with discretion.
• The illness spread from pets Requires as all cause by Human
• Infections route: feacal cause, retro cause inhalation
• Itching of Nocturnal and observation
• Easily detected and diagnosed with stool sample

Threadworms - Treatment Guidelines

• Drugs of Choice is Mebendazole - >2 OTC
• However - Caution Avoid and is Contra -Indication with pregnant: due as potential teratogenicity
• It need for Family
• 14 Dosage to avoid infections
• Washing, Scrubbing hand and cleaning nail is measure
• Change/Use wash bed linen
• Using underwear to avoid

Headlice

• Due to being ITCHY
• Detect and Diagnose Lice
• Needs Head Contaqct and treatment is required if its alive not if its dead
• Dimethicone is of choice, alternative is isopropyl alcohol
• Must wash after, also note Alcohol as they are Asthmatic
• Repeat over every 7days

Infectious Disease of Childhood

• Main infectious diseases include rubella chickenpox Mumps Whooping Cough
• Meningitis/Impetigo
• Note the other viral
• Consider how autism effects Crohns disease
• OTC to can cause effects
• The diseases are virulent and its important to detect and seek help from pharmacist

Impetigo - Details

• Typically - Staphylococcus Aurcus/Streptopocuss
• Development to a yellow crust on touch
• Treat with 1% H peroxide.
• Flucloxacillin the anti biotic ,Use Own cloths - away with
• All way clear before entering and leaving school.

Pharmacy Firsts:

• Adults and children over age 1
• Excluded cases as bullous impetigo then visual of examination
• Flucloxacinin and erythromycin
• Self care after consultation

Slapped Cheek

• Called Parvo B19 causes red cheek rash/infectinos
• 4-14 days effects
• Fervier 38C
• Nose throat
• After day appear rash.

Hand & Mouth

• Common viruses
• Those under are infected
• Disease clear
• 3-5 symtoms: 38-39C
• Cough,Sore thraot,

Scarlet Fever

• Bacteria tosin pyo genes
• Flu symptoms sore glands and throat for 38 degreees.
• Appear 12-48 bump which spreads

Scarlet Fever -

• It’s a White Coating - Peels
• Little lumps : Called Stroberry
• Treatment with v pen
• Self Care and fluids

Measels -

• The is is dangers
• We need to highlight MMR is important
• Its causes respiratory issues/ infection
• Morality is high at 15 with survivals causing neruo issues.
• The is a Referral
• Infection due to droplet
• There are incubation:Conjctics
• koploks Spots

Measle - Treaments

• There are limited treatments for symptom controL
• Sequaels is to be treated

Rebulla

• Rubella’s and measle
• incubation of 14-21
• GMS rash not spray down head
• Dangers in peragny

Checkinpox -

• Common in young
• Varicella
• Dorsa virus cause
• A 15-18 DAY infectious before, then after it’s appear.
• Then the heade and tunk

Treatemnt

• Oral is needed
• Used aci
• It is support fluid is needed
• Sooth - Wash Avoid
• Use Cream

Congatious

• Virus skins caused
• Sympton 52 wide
• It usually needs treatment in months
• Given: Avoid spread is not needed

Menigits.

• it has HIGH Morbity among to parents
• Virus and bacteria
• Via.Haepguls
• Viral can be severe