Explaining hand-foot-and-mouth disease — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the clinic. A 3-year-old child has classic hand-foot-and-mouth disease — two days of fever, painful oral ulcers, and vesicles on the palms, soles and buttocks. The child is feeding small amounts, is afebrile today, and is recovering well. At home there is also a 6-week-old newborn sibling. [2]

Your tasks are: [1]

1. Explain the diagnosis of hand-foot-and-mouth disease and what the illness will look like over the coming days, in plain language. [2]
2. Explain the childcare-exclusion and infectivity plan, and why the child remains infectious even after the fever settles. [1]
3. Explain the red flags that should bring the family straight back — and explain why the 6-week-old sibling is the family member you are most concerned about. [5]
4. Address the parent's question of why there is no routine vaccine for HFMD when there are vaccines in some countries. [8]

You are not expected to prescribe a specific management plan for the newborn without review — flag that any concern about the infant needs same-day assessment. [2]

Examiner prompt to the actor (parent)

"But he's getting better now, so can he go back to daycare tomorrow? It's just a rash, isn't it? And you're telling me there's a vaccine for this but my baby can't have it — why not? She's only six weeks old, surely she's the one who needs protecting." [1]

Marking domains

• Frame and explanation (3): explains HFMD and its likely course in plain, reassuring language; names that the child is recovering and is not in danger now; sets the expectation that the rash fades over a week to ten days and that oral pain is the main symptom to manage. [2]
• Infectivity and exclusion plan (3): explains clearly that the child should stay home until the lesions have healed or dried and crusted, and that the virus continues to be shed in the stool for weeks even after the fever settles — so careful handwashing, especially after nappy changes, is essential to protect others. [1]
• Red flags and protecting the newborn (3): explains that the danger signs are poor feeding or reduced wet nappies, drowsiness, irritability, weakness or floppiness, unsteadiness or jerking movements, and breathing difficulty; frames the 6-week-old as the priority because infants are the group at highest risk of severe disease, and that any concern about the baby needs same-day review. [5] [2]
• Communication (1): acknowledges the parent's frustration about the vaccine without defensiveness, uses plain language, checks understanding, and does not overwhelm. [8]

Model answer — the explanatory script

"Thank you for bringing him in. This is hand-foot-and-mouth disease — a common virus in young children, and the good news is he's already over the worst of it. You'll see the spots and the mouth ulcers fade over the next week to ten days. The main thing to manage right now is the sore mouth — soft, cool foods and small, frequent drinks, and paracetamol or ibuprofen if he's uncomfortable." [2]

"Now, three things I want to cover — going back to daycare, how long he's infectious for, and the things that should bring you straight back, especially for the baby." [1]

"First, daycare. Even though he's feeling better, the spots are still there and he's still able to pass the virus on. We keep him home until the spots have dried up and crusted over. And here's the tricky part — the virus carries on being shed in his poo for several weeks after he looks completely well. So careful handwashing, especially after you change his nappy, is what protects everyone else in the house, most of all the baby." [1] [8]

"Second, the danger signs. Most children with this are completely fine, but I want you to know the things that would mean coming straight back — and these matter most for your six-week-old. The signs to watch for are a child who isn't feeding or has far fewer wet nappies, who is unusually drowsy or irritable, who goes floppy or weak, who is unsteady or starts jerking, or who is working hard to breathe. The reason I'm especially careful about the baby is that babies under a few months are the ones who can get seriously unwell with this family of viruses. If you have any worry at all about her — not feeding, floppy, breathing fast — please bring her in the same day. We would much rather see her and find her well than have you wait." [5] [2]

"Third — and I know this is the frustrating part — the vaccine. There are vaccines against one particular strain of this virus, the one called enterovirus 71, which is the strain that causes the serious complications. Those vaccines work, and they're used in China. But they aren't part of the routine schedule here in Australia or New Zealand yet, and they don't cover all the strains, so even where they're used a child can still get a milder form of the illness. That's exactly why, for now, the best protection we have for your baby is what we've just talked about — keeping your older son home while he's infectious, and very careful handwashing at nappy changes. It doesn't feel like much, but it really is what keeps the babies safe." [8] [1]