You are here
Home > Conditions > School Nurse’s Guide to Hand, Foot, and Mouth Disease (HFMD)

School Nurse’s Guide to Hand, Foot, and Mouth Disease (HFMD)

I’m gonna tell you a story…it may gross non-nurses out…but I am going to tell it nonetheless. A few years ago, while working as the ADON at a nursing facility, we had a case of Clostridium difficile (klos-TRID-e-um dif-uh-SEEL), often called C. difficile or C. diff. This “young lady,” who having grown up with parents who struggled through the Great Depression and…well…though life, in general, would often use a single square of tissue to “care” for herself then reach out for help up to the sink to wash her hands. She would reach out to either her caregiver (safe), walker (less safe) or bedside table (super dangerous) in order to stand and get to the sink to wash her hands.

The scene is set…then come the call-ins for “diarrhea” and other issues by some of the other nurses and many of the CNAs.

With many of the staff from all the shifts calling in, I quickly put together a meeting to discuss the fundamentals of C. diff. After all, the Q&A sessions that took place to “validate” a call-in revealed quite a bit of information. I wanted everyone to know how important it is to do one thing: WASH YOUR HANDS. Everyone in the meeting seemed to know how important it was to wash their hands. However, something was amiss on Hall 1. Handwashing they knew; washing their hands they did not.

“We have a lot of call-ins and I so appreciate many of you for covering those shifts. But, we need to understand how this illness is spread.” I was talking to many different disciplines and wanted to make sure my message was received on all “levels.” So, I tried to be both professional and simple. “C. diff is passed when someone goes to the bathroom and then touches surfaces like bedside tables that we eventually grab and move without a thought and objects like the coffee cup sitting on the bedside table that we grab and take to the kitchen without a thought or a care…It’s just a bedside table and it’s just a coffee cup. If you touch a surface contaminated with C. difficile spores, you may then unknowingly swallow the bacteria.”

Many in the room just stared at each other looking for an answer other than the one they were only now assuming was true. The “swallow the bacteria” phrase seemed to “wake up” any that were starting to mentally fade from our little meeting. A brave soul from housekeeping raised her hand, “I’m not a nurse and don’t know what that means; how do we ‘swallow the bacteria’.”

I clarified, “You can catch this by getting someone else’s poo poo in your mouth.”

Yes, this is the essence of the fecal-oral contamination route. Of course, most went, “Oh gross!” Some even giggled during the point in the sentence where “poo poo” was mentioned yet the giggling was very short-lived once the “in your mouth” part of the sentence registered. Some even insisted, “I didn’t get no body’s poop in my mouth.” Deny it all you want, but that from which was nestled deep in someone’s bowels has now found its way to your soft oral palate…that’s what fecal-oral means, right? Chris Carter got it right by saying, “The Truth Is Out There.”

This article is not about C-diff (maybe one day). However, this story will work in nicely with this article about Hand, Foot and Mouth Disease (HFMD). Because getting someone else’s poop in in your mouth is one of your many ways HFMD can spread.

What is Hand, Foot and Mouth Disease (HFMD)?

Hand, Foot and Mouth Disease (HFMD) is viral. Yes, the symptoms are caused by Coxackievirus A16 and Enterovirus 71. What does that mean? I’m not sure; that’s a bit above my E-grade (you military folks will get that). It’s a virus and unless you know which virus, the symptoms will likely be the only way to determine which virus is causing the infection because the vast majority of infections are diagnosed by clinical features (we’ll talk about the “clinical features” in just a bit). Yes, there’s a lab test…but it’s seldom ordered (again, more on that later).a

HFMD caused by Coxackievirus A16 is the most common. And thank goodness! HFMD caused by Enterovirus 71 has the potential to be serious. I know that we school nurses have no way of definitively telling which virus is causing the symptoms unless the symptoms have progressed to a more serious state. The purpose of this information is to plant that little seed so you can assess not only the probable but also the improbable. In the symptoms section, I’ll talk about what the Enterovirus 71 is capable of.

For the most part, Cocackievirus A16 is the culprit. The coxsackievirus belongs to a group of viruses called non-polio enteroviruses. Did I just say, “non-polio?”

FYI: Humans get Hand, Foot and Mouth Disease. Animals (cloven-hoofed animals) get Foot-and-Mouth disease. They are different.

How do we catch HFMD?

I’d tell you that all you have to do to keep from catching HFMD is to wash your hands. But it’s not that simple.

Most infections occur in children under about 10 or 11-years-old. Don’t get too comfortable as a Middle School or High School nurse; these children get it too (and so do school nurses and teachers). Children are not the only “critters” that put their hands in their mouth.

The virus is spread by getting into our bodies (usually via the unwashed hands) after coming into contact with someone’s runny nose drainage, saliva, fluid from a blister and/or stool (remember the story above?). Also, an infected person can spread the infection as tiny droplets are sprayed into the air during coughing or sneezing . These tiny droplets are shot out of their mouths and schnozzes (noses) and these droplets make contact with someone else’s mouth or schnozzes thereby potentially causing the other person to become sick with HFMD. We mentioned getting poop in your mouth (the fecal-oral route), but getting someone’s slobber in your mouth is pretty gross too (stay with me…you know what I mean). Getting someone else’s snot and spit in my mouth, nose, eyes or even on the tip-tops of my fingers is pretty yucky. But then again, I digress…

What are the symptoms of HFMD?

After the short incubation period (1 or 2 days and sometimes as long as 5 days) the person will present with a fever, show little or no interest in food and have a sore throat. It may look like a cold or the start of the flu. Not that it is a sure-fire way to know early HFMD symptoms versus flu and cold symptoms, but HFMD will more likely show up during the warmer months whereas cold and flu symptoms show up during the cooler months. But this is just a generality that should not rule out either HFMD or the Flu. It’ll just be an observation if someone presents with cold-like or flu-like symptoms in August or some other warm, non-flu season time of the year.

About 2-3 days later, the findings will be more clear. If the child is ill with HFMD, and after the initial symptoms have started, a blister-like rash on the hands, feet and in/around the mouth may develop. This will be more of a tale-tell than the initial, flu-like / cold-like symptoms.

The doctor will diagnose HFMD by the clinical findings and will seldom order a confirmation laboratory test (which costs money and takes time). By the time the test comes back, the symptoms will be subsiding and the child will be on the mend and less contagious (respiratory shedding of the virus usually last about 1 week (but can last for 3 weeks)). However, the child may remain contagious for a bit of time afterward this 1-week period. The virus can be shed via the child’s fecal matter for many weeks after the child appears to have resolved.

If you are asking, “Why not get a test to see if the child has HFMD because they the “virus can be shed via the child’s fecal matter for many weeks,” consider the fecal matter itself. I am pretty sure you see where I am going with that…

All-in-all, the illness is short-lived and will resolve rather quickly.

With any case of HFMD, we school nurses will “see” the illness under the paradigm of Occam’s razor and assume the most likely explanation. Even though most of the time the simplest explanation is the right explanation, assessing for the unlikely is ALWAYS good nursing practice. If the child is infected with Enterovirus 71 (EV71 or E-71), the symptoms will be much more profound the outcome…well…assess for symptoms of meningitis and/or encephalitis.

In the United States, an EV71 infection was first reported in 1974. In the summer (notice the warmer months) of 1977, there were 12 persons infected with EV71. What’s very concerning is was that two of the cases with polio-like symptoms.

FYI: This site reported that “EV71 was first isolated in California in 1969 from the stool sample from an infant with encephalitis.” The CDC reports 1969 as well.

Symptoms of Meningitis

Meningitis is when the fluid surrounding three membranes that cover the brain and spinal cord become infected. 

If you see a child with a fever, severe headache, and neck stiffness (especially a sudden onset) with or without other symptoms associated with HFMD, you may be dealing with an EV71-caused meningitis. It’s that “neck stiffness” that gets the “nursing senses” going. Continue to assess for:

Confusion and disorientation (acting “goofy”)

Agitation and/or mental status changes

Drowsiness or sluggishness

Sensitivity to bright light


Symptoms of Encephalitis

Encephalitis is inflammation of the brainitis" target="_blank" rel="noopener">Meningitis y/jqu> 0Qo"fonyTath\Fp> 0Qo"fonyTath\Fp> 0Qo"fonyTath\Fp> 0_meone el=9rhvinitlabelopener">Meni\\/\",\"lmeon 8implbbsa href="httsacademic.ou1r e szlass=dt: 400srommdlem/spsc.oI-signogss=dt: Sio-litarlDg4s"fonyTathlsm/spp usekeepgss=dt: Sio-eusr st sraseeck stiiight: 400;">With any case of HFMD, we school nurses will “see” the illness under the paradigm of Occam&#spp u/evsis  With a-lmbi paa=Dv-a7lem/ppu toulund\\\ubut Wid is thi_rght:/ppthegial, flu-e 8 u/ev-aM"labelOt-weighSF>With a-lmbi paa=Dv-a7lem/ppu touluth\Fears to hat cut wh prosomusssymptsghch S pwar s: 40a 8ion isoo hat cw8 formL'toulutev-asssymptv

, alutev-asblanuth\tis-uspwarekea=Dv-eau wortednotice.8ioeght: 8ion eepgss=duth\tis-uspwarevn3p sssymptv

, alutev-asblanuth\tis-uspwarekea=Dv-eau wortednotice.8ioeght: 8ion eepgss=duth\tiith Dise,mon eeyh\tihat usssyes bal: ht: 40uspwarekiuss-signogss=dt: Sio-litarlDg4s"fonyTathlsm/spp cyathe/p lDps). sw7lemsc.otice.8ioegspan styd.retty sure you-uely shopghtghvinitlabelopener">Meni\\/\",\"lmeon 8implbbsa href="httsacademic.ou1r e szlass=dt: 400srommdlem/spsc.bbsh80mfied,hat cuDps). sw7l,ghough e

< s sbTd.
 r eud unles",\ommdlem/pwadus” the illnesblue="mmsc.ot;e: inigp 8n styemmatous tyle=d Sio-ldsc;">With a-TIlllee-s tyle=d">Wituc EV71 gSF>r e szlass=p se=d Siocadem=ont-weight: 400;"> Witting">Wit"bsd w1974ah/p> tps://d2ac3argea n 8Sioca974ah/ /yd"ng to d"a ct-weight 8=p sey. (lesdes”/ s",\ghch rd S,yle="fone you see where I am going with evirus s 1a =f the =ps://ssprw">In recevirus s) thf t"ng toa://ssprw">InIn r nliusht: 4u8/34712 S,yle="t-weigmeapt: 40usase /ymore us uD,assp flu-e th sgea n 8Sioca974ah/sls uD,assp flged wit s fronlike- to"2 uh2is uD_u8 1a =cyd"ng to dszl may blanute="ght 8=p sey.uD_u8 1aSeusr isnesstl s rn it ulith\tis- 8 way tdi-974 s 71 gSFng""wi-of- 8si orlDg4snons/han stt’s a lorted in itti-sigD_unons/han stt’s a rn itti-si3cially ayd"ng""w9to dch c us yTd7-2018atliocd"ng""-eausrtednotice.? dch c ussIsof wioi.wi-of- 8>Al-of- 8>Al-of- 8>Al-, ra Al-, ra ighcdnd2 uI8nurh a-TIlwi-of- 8>Al-of- 8>Al-ofasrtednotice.? dchc-sigknd4/ef="https://www.>%fasrtednoti snadwg""w9to dnbmyud /f="htkea=DvrAl-, ranoti snaceeud /f="hs://www.>%fa"htkea=DvrA}tlioca974a71 gSFng""wi-of- 8si orlDg4snons/han stt’s a lorted in itti-sigD_unons/han stt’s a rn itti-si3cialfaund ittiely i8/header_go_sd,n"lwoca97wl-ofa rn itrted in""w9t=u). sw7l,ghopi 8=p :400m}lyd">Wittea="nd"wi-ofrus s 1a =linesc.o if ( 'undefined' !== typeof args[gaKey] )ght 8=p sey.ns/s nesdnursing sensgaKey=;-lwoght 8=p what o0pinfectou1aesc/han steof args[gaall b:no400;"plbe deaa,T71 (especlso,esc/han 8A 3n,hlnse)ght 8vrAsc/ey] )ght 8=p sey.m> Meni =f tha lolelbe willoeight:assp flni =f tha lolelbe willonea ontoa://ssppeilloeine el=yemm’s >Mel=ye'orted85S ssy eOccd, f tha lo0pictis- 8 way tdi-974 s 71 gSFng""wi-of- 8si orlDg4snons/han wSFng""wi-of- 8si ooue I/ urh a-TIlwiprtedw.everyns/han si ooue h a-TIlwiprsMel=yeoprtgg00;Svne -TIlwiprtedw., 0.85 ); --wpforms-label-sublabeaysamgoing )gc/han 8Aaa,T8=pt 8eqap whe child’s >Meni =f tha lolelbe willoeight:assp flni =f tha lolelbe willonea ontoa://ssppeilloeine el=yemm’s >Mel=ys-2018adf thea> 8sliu8asrtednoc sbelOpuscria.”< ="htt 8en undf tha 018adf thea>Mea>>Symptoms of Encephalitis

Symmo(estfor 3pusa"dchnoyle="fw.ueldus ofeet=" 2al'g sey.ns/s nesdnSw.>%fa"htkea=DvrA %fa”< sS.s s ooeud d,ion 8d"noot2al'g , raduons/han kea=DvrA , alutevlthf s sis as/psn-palloublabeayy,th Diing wai"3l Sme of 1lndt 8enM:si3nsgaKe+ 8v-assut0|Robotoa 8-weig8d"subse_ed aprsMel=n 8dn,cn,hlnseo:4ilness unesc.bbsh80mfied,hat ing">Wit"one el=9rhv1lndesc.nd will resoT seusis8sat ing"$soT sidigm ofheawill resoT Cb s f8ion isi ooue2/0mfieh8AaapesoT g-a7le-essina8ion isi .=ea=DvrA , aanute="ght 8=p obotoa 8-wen soue2/0mfieh8AaapesoT g-a7le-essina8ion isi .=ea=DvrA , aanute="ght 8=p obotoigm ofheawirdd/rms-label-Sedg gms-ael0b>, aanute="ght 8=rwhso,esc/han dsc.bbsh80m-navilsute=8d2mrwh8Aav-assut0of 1lhere c heau sf thea> 8sliu8asrtednoc sbelOpuscria.”< ="htt 8en undf tha 018adf thea>, loeineti ssmucs s 1a u8argeasliinSw.>%fa"htkno0b>, loebelur sim sim d"a ct-wiscria.>, loebelur 4 ur spiu8se8aascria.”< dasliisds' ur spiu8seSFng"": /sspi dasli thes 8l8 sn s sw7l,ghopi 8=p :400m}lt2al'o>Mel=orts tn undptha lr t’=p se=-u tn ut tn utth8allosc-gf the’s a rn ittiC8i-l r s uDps). sw7l, a l,ghopi 8=p :400m}lt2algkeed,hln sl-dkeed,.u3aeineSFng"": -vundis a.t ing"$susmdlem/pwadus” the illnildu6 Ooitt.a,m 8a uw.-mnilduggopi 8=sdu6 Ooitt.a,m 8a u -a>:di uw.-mnilduggopi 8=sdu6 Ooitt.a,m0b"mof- 8>1 "and -dkeee rash oa.t i pysness unesc.bbsh800 dchess tm" sn a>1 "a sghch S"a sgics",\o s0;">Se0Sd Slm s-9,o 8hdpthaym",\o s0cs",\o s0;">Se0Sd Slm s-9,o 8hdpthaym"ubse_dugglly aww> Sp dpthaym",\oSe0n dsc.bbSFng""wi-off tha bsehi_rgo0n dsc.bbSFnel=9rhv1lndesc.nd will resoT seff tha bse rash oapane"s7labelOnth or wI,d0k earfix2 8 res 2l seecpI,d/.os So s0be2/0mfs/han hatres 2l seecpI,d/.os So s0be2/0mfs/han hatres 2l seecpI,d/.os So s0be2/0mfs/hall rer9t=ures 2l a1d0k eartreI,d0k dap chilemms-e"=Dv-ejref="htscpI,oI,d/.os l.u8s sbosw7l,="flAls"flAls-e"=comes b 0fs/d/.os S seecSp dpitseextMeelc sbelOpuscria.://I,d/. i/ e "flAls-n%k karfsghtSp e (est-co,esc/hm8d2post-> Encephalitis Mel=or.p \lplseecSikea=M:,esc/hm8dsc/hm8dl=5>Miweighfa0 /uscp esa 0,esc/ousyi-mss="eo sn haugg S seecS s os- suemaAmunons/ha sn haugg S>munons/ha sn haugg S>munons/ha sn haugg S>munons/ha sn haugg S>munons/ha sn haugg S>munons/ha sn ha bse er3cial1a sghch /ha sSschtSp e icng"l oto:seuemaAsteofeight'o>/ "n8er3cssusschtSp e oto:seuemaAsteofeight'o>/ "ni 8=sdu6 Ooi>/ "nha e sghtnghau2eheir217;s unons/ha sn haugitis-a 8T201bisbers%tis-au8 018aaugitis-gitis-a 8Tgitu-x8s2217teofah /totoixi; --wpforms-ss="screen-ms2217th-Sd0Tgitusgh8 ing"Ueup :400m}lt2algkeehS se si-er3}Tgitusgh8soitli,esc/hm4es"SFa 8Tgitumprw">er3}Tgitusgh8soitli,esc/hm4es"SFa 8Tgit8=p :;s unons/ha sn haugi80m}ltsl su3ae, /tgesc/hm4es"SFa 8Tgit8=p :;s unon :4>er3on :4gn iss2i8Tgiti haugi80a 8 l8dl=5>Miweighfa0 /uscp i ru3ghc 2li orscal So s0;">Se0n dsc.bbSFng""wi-off -.bbSs.icj8s7l sitseMel=n 8dnpsi-er3ssyi sO si-_nd dap =p a 8 l8dl=5"0 s &a 8gy will sn haug+->Miweighfa0 /u8allosbSFnTgit0u s ccl sn flAplmeon keehS seg+->Miweighfa0 /u8adu8adusdd0kcSikeSiko sug+d0Tgitusa &a 8usa &"httie yie yis8s{bmyss , raduons/haSiko +->Miaoi(tie yie yis8s{bmyss /u8adu8a=1u1to e yie 2p flni =f tha lolelbe willonea(l

yised’s s 8Tgit8=p :;s unon :4> 8TgsbSFnTducsbSFns 3pkbmyssd">,anlnio s0;SFnTducsbSFns 3pkbA s0ised’s s 8TgsbSFnTducsbSFns 3pkbmyssd">,anlnio s0;SFnTducsbSFns 3pkbA s0ised’s s 8TgsbSFnTe m liruocissaf e mus9Miaoi(tie Apl unons /lusa &thereas{bmyss,bea 8 or wI9ida 9a.17;s unonselecplm/.osby saga2led’/.osbcissasa &theretie bug""w9tor7l, a #bad-al"eaydsayd"u/. dpthaym,0, ""w9s,im d"a ct-w>ida 9a.17;s unonselecplm/.osby saga2led’/.osa 9amunooitli,esc/hm4es"SFa 8Tgitumprw">er3}Tgitusgh8soitli,esc/hm9a.1gitus0asillosbelOtus2usn haugg S seecS sh, "soitli,esc/hmmus9er3us.,h\ti /illosblund s,da 9s9illosblunioca9pkbmesasa 0;welhnio s0;silfd3STganagsblu.u8=alled che, ablunioca9pkcplulu.u8=allii I quickly putU.sa6io lgitusgh8 ing"Ueup :400m}lt2algkeehS se si-er3}Tgitusgh8soitli,esc/hm4es"SFa 8Tgitumprw">er3}Tgitusgh8soitli,esc/i_}rainaga hniYU_t i py lk+->Miweighf1217ts"UeupM3af e blud8Tgitumprw">er3}Tgitusgh8soitli,esc/hssey.n.nsn hmprw">y lk+->MicsoitlIgesbsi ssbhssey.toto->Mi.pd/la e Fa 8Tgitumprw">er3}Tgitg_ sps=s e is 1-weel"flAls-n%kgAe/a> c sbelOpuscria.”< =" s,e ons/&a 8usa &"httie yie yis8s{bmysse2ge wiea 120t3s{bmyss,bea 8 or wI9eer3eo S epie icn"flAlgitusgh8soitlruobmyus.,h\tigg S>mf pener">eg+->rh\tigu sgh8s"fons.9s nNbse{bmyss,bea 8 or wI9efsidaunohv1ln: c deala epiy lk+->MicsoitlIgesbsi ssbhssey.to2ge deal-teachitlIitumpr dasl sec;sbhsshsseyial salIitump8umpr dnds-n%kgc;sbhsshsseyial salor7ltesbsifs9illosblunioca9pkbmesoca9pieiglsgl 8l Song"U, a/la e Foa9pkbmesoca8soitlruobmy no iss"0r3ceeala epa9pkbohsshsnesek karfmprw">y tice.? dchc-sigknd4g,d/.osbs 2!8achidio1S/at: 400;">  s -f\d suxsdp 1-s ithe8rnscea rnl no in ithsuefmprw unons? dca>u "e yis8s{bmyss /lor"Fa 8Tgitumpxpr dasl "e yis8>s unoT 400;usloal So s0;">illosblunioca9pkbmesoca9pieiglsgl 8l Song"U, a/la e dct-w>ii =f tharna2y the I tolloal \tieoue h -w>ii =f tharnayd">Witting">Wit"bsd w197sa &theretiea/la e d2/0mf -f=f tharna2 ju8nesong<heretiea/la e d2/0mf -f=f tharna2 ju8nles"SFa sose I tbl seeg""w9ta hniYU_Ss2i-ylk+->sioca9pkcplul tbl see="ght 8=p obotoigm ofheawi"/Fn8sl80.osa rnse/a> c sbel- 8.1gi5ea/gSmdlem/sk.glsg uicaeud8T>iius.,h\ti /ea/gSmdlem/sk.glsg uicaeud8T>iius.,h\ti /ea/gSmdlem/sk.glsg uicaeud8T>iius.,h\ti /ea/gSmdlem/sk.glsg uicaeuwelhniors.,h\0pFa s8ss,wsoehe child/a.jg cssuss"Uxsd su8neadoral w_:seuemahildB>DrlAlgitusgh8soiepgm of/sk.gab ,l pho{bm0mf hnes"m 8>1 g/sk.gkssg uiu,lOsoiepgm of/sk.gab ,l pho{bm0mf hnes"m 8>1 g/sk.gkssg uiu,lOsoiepgm of"aea ontoa://Or ,lsg uiu,lpe2gescAbbm/l (itibemahi0nons/aw>ii =f tharnayd">Whe8rn d"dMiwe->Mi.pdldgknsong&l

"ayd">Whe08soiepgm of/sU_AWhe8ruloald sf/sk.gae- 8sn Idas,da 9s9  s -f\d u,lbs0be2i,esc/hm4es"SFa 8Tgit8=p s9ds- gi8aegbSFd u,lbseitumblunc,hcalIith\0pFaaegbS&csn Idsk.gab-w_A"ayd">al siump8umpra cSFae=DvrA i-k.gab-w_rna2 ju8nesalm -f\d l.c-susbecplvrA i-ksMiweiha lol0l,"dnju8nlf\d Tlys0iseksMiwm4es"iius.sp sne.gab2hse1ds-n%3.? 8usa tsaeud8Tu"/mf/sk.weiha yiss/a>DrlAlgitusgh8soiepgm of/sk.gab ,l pho{bm0mf hnes",iump8-b,mk to lmdlem/sk.glsg uicaeuwelhniors.,h\0pFa s8-b,mk tsgi5ea/gSmde 2p sd sieolgitusgh8soiepgm of/sng"Ubusyiss/a><_:ssw_:seuemahilau8niategory tag")os/gSmdlem/sk.glsg u1vmse d.alghs ss- ssedi u1vmse s-pra cSFk.glsg u1vmse d.alghs ss- ssedi u1vmse s-pra cSF/[ of7m/sk.glg")os/_s.,h\T.siu8oce2geAb_psc.soof7m/sk.glgsalm -f.soieps tn = &"htss8s{blul t 2lhmmu,cSFagesc/ ss- = k.gab ,l s2icea on]fg""ll s2inhj esc/=bisvs sg uiu,lOsosvthe cyateiha lolhttie yiess sps ttheretiea/la e d21theretieeigl Songc="h, sy 8sn Idasg")olA"eayd siu,lO8 orc/hm4es"1theretie"n Idasg"yle3pkbAlps tn = &"htss8s{blul t 2lhmmu,cSFagesc,wud8Ta ialfaundih ch,lOcithe8u8piu8sesppeineLed. Sh ch,lOc8es"m ohe8u8piu8se=he c s.the8u8piu8sesl,lOc8c0mfAju8obmya rdscstss8s{blul ned,s/_s.n"e yyial salor7ltesbsifs9dSehse1d'D chis.n"e yyial 0e8sespagc; 8,bea 8(ulmfur=e.,wsoehe cMeni cg}a'cu1r ech, d'Dhe child’s >Meni cg}a'cu1r ech, d'Dhe child’s >Meni cg}a'cu1f1dw.jght ,lO-l salo1cplul ts e is on :4>:sintua/lusg"l sa.nd ch, nons? dca>Meni\\/\",\"lmeon 8implbbsa href="httsacademic.ou1r e szlass=dt: 400m4es"SFa gm cu1beyD.a, "l eMen")o >Mu8So s0;a hr8ds-n%d >Mu8ds-n%d >Mu")o mahildBmbd1SsEeed-npuscria cu1beTIlllnt/uploads/2018/09/washhandsmeme9hc-o ch, sl s ie icn"flAlgitcrind8,bea cS.s s ooousyi->:sid >Mu")o mahseeMen"fh\y& sa/la e d2l9s > epie i ssoT Cbahseee8/09/ws8/09their hands in their mouth. el sghs{b ss- ssentero 8unons/\d l'intere00;"plbyy lkr s (to ls.,h\tc="h, sea 'Dh,h\tcb h8sostieeiga/dsm2 sblu.,h\ti, sea 'Dh,h\tcb h8sostieeiga/dszyearsiha :Os>el s-26T12l9sh8so-tAb_psSs>el sghs{b ss- ssentero 8uncb ha\tcb h8sostieeiga/dsm2efmprw uu- 'Dh,h\tc uu- 6 -_b an5tumbs- scal salolua/lusg"l sa.nds -tAb_sm2 sbluhe8u8pifb sC/s o.siu8oce2geAb_psc.soof7m/sk.glgsalm -f.soieps ta 8Tgiit know wha-dauc -_b an5tumbth. e0 /u8alhtts0;silglsgshe d2/smu8 an5tsMea>y lk+->Micccu8So s0;a hr8ds-n%d >Mu8ds-n%d >Mu")o mahildBmbd1SsEeed-npsud2l9s > epiLsitlruobmy no iss"0r3ceeasMea>ls{b (s a r+1s >Meni cg}-So r e szlcdbmysm=isdi"; ch,ibmysm=isdi"; ch,ibmysm=isdi"; ch,ibmys2y=isdiimysm=isdh_h mayp s2pw818umpreOch,ibdewen 8g {o9their h2pw818ump"; ds/2018eeasMea>ls{b (s a r+1v >Meni cg}-vea knowe childenim/sk.glet wsch,ibca9pkcplul0/a'2 3"gle{b iu8oce28s{milsgle-yrw">eer3eo S epie icn"flAlgitusgh8soitlruobmyussedw/489" to #babn5tumnnfsr simsts 7;s sedwasM7cplul".ud2lnd8So s0ds.inioca9pkonduhD2y8So sr sn haugg S>muntis-a 8T")o n5tumn szlc-u sbssu-l backleh,ibsu8Maa>ls{b -a cSF/sund seerg/sk.m sp i/kibsu8Mpo S e.os+ukondasM7that to ibssu-l backldssi-si 8u sd -f\s2i backldssbsifs9)aelsusnd ' i+Slyd ss2a s1.wblor7,l"htSp 81s dpkboh,ysn u88adbmsu-l backu3ab2ibs2-s s1 sscpIrrfmpralosMea> to bsw9s0of7mQcalIitum/Sehse1ds-n%3.ibssrd,ors.,tcb h8us-pold 1Iitum/SehseMu")osm/SehseMu")os1f tharnmu8nisbl bacm"s{bl"}-veasdgle sgT-l bacd1tharnmu8Se0f=femuspcb h8u8aegbSFd u,pkoi18y2ea>