Vaccination of the population in the territory of the former Soviet Union began in the early forties. The first to try to develop vaccinations against diphtheria, pertussis, tetanus, polio. Then began research in the study of hemophilic bacillus. Previously, each type of infection produced its own vaccine. Now several substances can be components of immunobiological preparations (UPS).
Pentaxim vaccine
Pentaxim - means for immunization
Thanks to the development of the pharmacological industry, an immunobiological universal drug was created - a vaccine for small patients Pentaxim. The country producing this UPS is most often France.
What is this vaccine from? The medication is used to prevent such diseases: infections caused by Haemophilus influenzae, Leffler's bacillus, Bordetella pertussis, gram-positive bacillus (tetanus), Poliovirus hominis.
Unlike its predecessor (domestic DTP vaccine), this drug is very well tolerated by children. This fact is due to the fact that Pentaxim lacks the bacterial membranes of lipopolysaccharides, which are a source of complications.
The composition of the vaccine
The name Pentaxim corresponds to its components - the substances included in the remedy are aimed at combating five types of infections. The vaccine is made in the form of a single-use syringe and a bottle containing lyophilisate. Separate the drug consciously: often it is only necessary to perform an injection from four diseases, excluding hemophilic, since the schedule for their implementation may differ. Let's take a closer look at the components of the UPS.
We will first study the composition of the Pentaxim disposable syringe vaccine, then move on to the bottle:
- aluminum hydroxide;
- filamentous hemagglutinin;
- formaldehyde;
- tetanus toxoid;
- pertussis toxoid;
- injection water;
- diphtheria toxoid;
- poliomyelitis virus of three types (1, 2, 3 inactivated);
- hanks Wednesday 199;
- phenoxyethanol;
- the vial also contains a single dose dose lyophilisate UPS: tetanus toxoid conjugated polysaccharide Haemophillus influenzae type b (HIB), trometamol, sucrose.
Indications for vaccination
When wondering about the importance of vaccination, remember that before the introduction of the prevention of infectious diseases using UPS, a large number of babies died.
To date, “controlled diseases” are taken under control. Indications for vaccination with Pentaxim multicomponent vaccine are preventive measures to prevent:
- poliomyelitis (polio);
- tetanus (tetanus);
- diphtheria (diphtheria);
- pertussis (whooping cough) (we recommend reading:);
- conditions caused by HIB (hemophilic bacillus).
Pentaxim can be vaccinated in children from the third month of life. If the child has not been vaccinated from the above infections up to a year, the pediatrician will recommend introducing it. In addition, the use of this complex is allowed provided that the baby has previously been vaccinated with different vaccines, but the polio vaccination has not been completed.
Advantages of the drug
Why is Pentaxim gaining popularity among pediatricians and parents? We will find the answer to this question among the advantages of this vaccine.
Pentaxim vaccine has many benefits The advantages of the drug:
- A vaccine called Pentaxim can reduce the number of injections from 12 to 4. Previously, as you know, it was three different injections (DTP, polio, rotavirus) (we recommend reading:). Nowadays, drugs have appeared that allow simultaneous prevention against 5 diseases.
- Negative reactions in infants are reduced, and the risk of developing vaccine-associated whooping cough is reduced to almost zero. This is due to the fact that the active component is cellular (cell-free).
- The development of post-vaccination polio is completely ruled out (typical of a live vaccine, since there are weakened strains). A simple fact can be explained - Pentaxim includes a “dead" (inactivated) virus.
- This drug can be prescribed for children with HIV, encephalopathy, neurological diseases, with febrile seizures. In addition, it is used in children with increased reactivity to DTP (see also:).
Vaccination schedule
How many times do you need to get vaccinated? In the Russian Federation adhere to the following vaccination and revaccination schedule:
- the first administration of Pentaxim is performed when the baby is 3 months old;
- the second - after 1.5 months;
- the third - in half a year;
- pentaxim vaccination is carried out once - at 1 year and six months.
If for some reason (a child’s illness, fever, holidays), the vaccination is tolerated, then in this case a slight decrease in the immune response is possible. The timing of revaccination is also shifted by the required period of time. A child older than 1 year at the first immunization, the vaccine is administered in its entirety once. Next, Pentaxim is introduced without the HIB component according to its scheme.
Procedure execution
Before vaccination with the Pentaxim vaccine, the pediatrician examines the child. He is obliged to examine the throat, establish the absence of skin rashes, measure the temperature, conduct an auscultation of the lungs and heart. This prevents the immunization of sick babies. The components of the drug allows the body to develop reliable protection that is directed against five infections. A vaccine is given to a baby of any age in the leg (thigh).
Before vaccination, a pediatrician examination is required At what age are Pentaxim vaccinated?
The vaccine for immunization in its entirety is used only up to six months of age. After this, vaccination should be carried out with a drug without pertussis toxoid. If during revaccination it is required to enter Pentaxim without the HIB component, it is better to use another medication (Tetraxim or other similar UPS).
Preparing a child for vaccination
When the time is right for vaccination, you need to prepare your baby. Do not neglect the training rules that pediatricians recommend:
- Do not feed children in the morning. Enough to give a drink of water.
- Make sure your child has stool on the day of vaccination or the day before. If he doesn’t poop, reschedule the vaccination at a different time. With constant constipation, begin to give laxatives (lactulose syrup) for a couple of days (we recommend reading:).
- If the child has allergic diseases, for two to three days, give him antihistamines. This will reduce the risk of unwanted effects.
- It is not necessary to introduce new products into the baby’s diet before vaccination. Without prior consultation with a doctor, the use of new drugs is also not advisable.
Be sure to inform your pediatrician about recent vaccinations, if any.
Instructions for use
Pentaxim vaccine has detailed instructions for use:
- a vaccine preparation is prepared immediately before vaccination;
- remove the cap from the vial and inject the fluid from the syringe inside, diluting the lyophilisate;
- shake vigorously to completely dissolve the dry component;
- the color of the vaccine should be white, with a different shade, the use of such a solution must be discarded;
- the resulting mixture is drawn into a syringe and immediately administered to the child intramuscularly.
Features of care after vaccination
After the injection, do not leave the clinic for 30 minutes. This time is enough for allergic reactions and timely help. During this period of time, the baby will have time to calm down. Do not rub the place where the injection was performed.
If the temperature rises after vaccination, it is necessary to use an antipyretic If the temperature rises on the day of the procedure, use antipyretic drugs (Nurofen, Panadol, Ibufen, etc.). If there is no desire to use medicines, wipe the child with plain water. In no case do not use alcohol, it dries the skin and poisons the body! Be sure to watch the baby for at least three days. Do not be afraid to bring down the temperature, as it is not involved in the formation of the immune response.
Do not walk in crowded places. You can bathe a child if he is feeling well. Try not to let him comb the injection site so as not to provoke the infection.
Side effects and complications
As it turned out, this vaccine has several advantages, but there are also negative effects after the introduction of Pentaxim. They can be divided into local and general reactions. The first side effects occur in a limited area of \u200b\u200bthe body or affect small volumes (clearly visible in the photo):
- pain and tightness at the injection site;
- swelling of one or both legs is possible, but only when vaccinated with the whole compound (with the HIB component), the child is anxious, crying;
- redness of the injection area.
Elevated body temperature after vaccination may last for several days The following are common reactions to Pentaxim:
- increase in body temperature (lasts for several days);
- bad sleep;
- prolonged angry crying;
- convulsive syndrome (the most severe side effect);
- irritability;
- anaphylactic shock rarely occurs;
- there have been cases of severe weight loss, vomiting;
- lowering blood pressure (a rare complication).
Contraindications to the procedure
Pentaxim vaccination is contraindicated if the baby has hypersensitivity to any of the components.
Before vaccination, it is necessary to familiarize yourself with a number of contraindications - progressive encephalopathy, the presence or absence of seizures is not important (absolute contraindication);
- provided that the history has a strong reaction to pertussis components in any vaccine;
- chronic diseases in the acute stage;
- acute infectious diseases;
- if hyperthermia was previously noted after the introduction of such a UPS;
- allergic manifestations to other vaccines should be used carefully;
- thrombocytopenia.
Immunosuppressive therapy or any condition of immunodeficiency causes a weak response to vaccine administration. Then a vaccination ban is imposed until the end of treatment or a persistent remission of the disease. For children with chronic persistent immunodeficiency, a similar vaccination is recommended for children, even if the immune response may be weakened.
Analogues of the drug
The vaccine in question is in a sense a unique drug, but existing analogues can replace it.
Sinflorix - Pentaxim-like vaccine
There are the following similar UPSs:
- Sinflorix. It is aimed at the prevention of pneumonia in children. Thanks to it, an immune response is formed to hemophilic infection, diphtheria and tetanus, since the toxoids of such diseases are included as carrier proteins.
- DTP - Hep B. Does not contain HIB. Also used for immunization against hepatitis B.
- Infanrix (more details in the article:). Similar UPS, but without a hemophilic component.
- Bubo Kok. Like the previous analogue, it is aimed at the prevention of four infections.
- Infanrix Hexa. It is aimed at the prevention of hepatitis B and the above four infectious diseases. In a word - this is a combination vaccine.
- Adsorbed pertussis-diphtheria-tetanus vaccine. Pentaxim was created on the basis of this drug.
- Imovax D.T. Adult. UPS is used only in patients from the age of 18. Aimed at the prevention of diphtheria and tetanus.
- Tetracock 05. Combined prophylaxis of diphtheria, pneumococcus, tetanus, pertussis up to four years of age.
- Tetraxim We have already mentioned this drug above. Does not contain HIB.
Prejudices about the quality and, consequently, the safety of domestic and Indian vaccines make many parents look for an alternative. Doctors go to a meeting and offer excited mothers a comprehensive Pentaxim vaccine. This is a French vaccine (manufacturer - concern "SANOFI PASTEUR, S. A"), which for many years has been successfully used to vaccinate children in the United States and EU countries. Pentaxim vaccination has been practiced in Russia since 2008.
1. What diseases are vaccinated with Pentaxim?
Pentaxim vaccine is a multivalent vaccine that allows you to immunize a child at once from five serious diseases:
- whooping cough;
- diphtheria;
- tetanus
- poliomyelitis;
- hemophilic infection (this group includes diseases caused by a special type of bacteria - Haemophilus influenzae, type B: pneumonia, meningitis, septicemia, etc.).
This means that one Pentaxim injection allows you to immediately replace 3 other vaccinations:
- DTP - Adsorbed Pertussis-Diphtheria-Tetanus Vaccine;
- from poliomyelitis;
- from hemophilic bacillus.
It turns out that, taking into account all subsequent revaccinations, the child will need to visit the manipulation room and make an injection only 5 times instead of 12.
2. How safe is the vaccine formulation?
Pediatricians admit that the greatest fears in parents are caused by vaccination against whooping cough, diphtheria and tetanus. I must say that these fears are not so unfounded. DTP is a whole-cell vaccine and this means that weakened but still living bacteria enter the child’s body along with it. The immune system immediately responds to an aggressive attack and comes into conflict with the bacteria that enter the injection, which is externally manifested by symptoms such as fever and / or rashes.
Pentaxim contains no living bacteria - only their dead parts. This makes the French vaccine safer, and the injection itself less painful, and also reduces the burden on the child’s immune system. The likelihood of post-immunization fever, which has almost become the norm after administration of whole-cell vaccines, is significantly reduced.
The same can be said for polio virus. In oral vaccines that children have to swallow, bacteria are still alive. If the child’s immune system is severely weakened, then there is a risk of vaccine-associated poliomyelitis. That is, the vaccine, which should protect, can, on the contrary, provoke an outbreak of the disease. Pentaxim vaccination eliminates this risk - the polio virus, which is part of it, is already dead.
As for the additional components found in low-quality vaccines, there is no mercury or phenyl red in Pentaxim.
3. At what age do they get this vaccine?
It is optimal if the Pentaxim vaccine is given as part of the generally accepted vaccination schedule, but here one nuance should be taken into account. The fact is that the HIB component of the vaccine (that is, the one that produces immunity against hemophilic infections) is contained in a separate bottle. It turns out, opening the package, you will see a syringe with a ready-made suspension inside and a separate bottle with a dry lyopholizate - this is the very HIB component of the vaccine.
If according to the schedule the child needs to be vaccinated against all 5 diseases, the suspension is first mixed with lyopholizate and only then an injection is given. If a vaccination against hemophilic infection is not needed, the bottle is not touched and only the contents of the syringe are injected into the muscle.
The vaccination and revaccination schedule is as follows:
| The age of the child at which the first vaccination may fall (always with the HIB component) | First booster (1.5 - 2 months after vaccination) | The second revaccination (after 1.5 - 2 months after the first revaccination) | The third revaccination (12 months after the second revaccination) |
|---|---|---|---|
| Under 6 months | With hib component | With hib component | With hib component |
| 6 to 12 months | With hib component | Without hib component | Without hib component |
| Over 1 year old | Without hib component | Without hib component | Without hib component |
Optimally, if the baby is first vaccinated in three months, the second in 4 and a half, the third in six months and the fourth in one and a half. That's right, according to the schedule of the national vaccination calendar, the full course of Pentaxim vaccinations looks like, then what will the child be protected from? Thus, he will form a stable immunity against pertussis, diphtheria, tetanus, polio and hemophilic infections for the next 5 years of life.
Alas, it is not always possible to meet these deadlines. Most often, “drop out” of the schedule is due to the lack of the necessary vaccine or due to the health of the baby. Anyway, if the vaccination did not start on time and the child received the first vaccination after he was 6 months old, then for the subsequent revaccinations, the bottle with the HIB component will not be needed. In this case, it makes no sense to buy Pentaxim and overpay for an extra component. It is better to take the Pentaxim analogue - the Tetraxim vaccine. These are identical preparations made by the same manufacturer, with one exception - Tetraxim does not contain a vial with the HIB component.
"Note! When the child is 6-7 years old, he will have another booster vaccine against diphtheria, tetanus and polio, but it is no longer possible to do it with Pentaxim - it contains a significantly larger number of antigens than is necessary at this age. Most often, the vaccine ADS-M is used for this revaccination. ”
Another important point: Pentaxim is fully compatible with any other vaccinations. Therefore, the instruction allows the use of this vaccine for revaccination, if vaccination was carried out by vaccination with DTP, Imovax Polio, Hiberix, live polio, etc.
4. What is the likelihood of complications after vaccination?
A negative reaction is extremely rare. Speaking in the language of dry statistics, the studies conducted in France showed that Pentaxim side effects requiring a pediatrician occur in 0.6% of vaccinated children.
Parents should be aware that some manifestations of the immune system response are within the normal range and should not cause concern. Among them:
- Fever. In 10 out of 100 children, the temperature rose to 38 degrees, and only 0.1% of vaccinated children rose to 39 degrees.
- Local reactions - redness and slight tightening of the skin in the place where the injection was made. Pressure soreness may occur. In approximately one child out of a hundred (less than 1%), the diameter of redness reached 5 cm in diameter - this is also a variant of the norm. As a rule, local reactions occur 1-3 days after vaccination, and after another 3-5 days pass by themselves.
- General reactions - drowsiness or, conversely, sleep disturbance, lack of appetite, irritability.
The likelihood of more serious complications is 0.01%. This means that one vaccinated child out of a hundred had an increase in body temperature up to 40 degrees, as well as various systemic reactions (skin rash, urticaria). Side effects such as vomiting, diarrhea, cramps, decreased blood pressure, and anaphylactic shock are even less common.
5. In what cases cannot be vaccinated with Pentaxim?
Pediatricians recognize: Pentaxim is a gentle vaccine, which is often the only way to avoid the side effects of vaccination in immunocompromised children and chronic diseases. Dysbacteriosis, anemia, atopic dermatitis, diseases of an allergic and neurological nature, and even HIV - it is with these diagnoses that Pentaxim is recommended first.
Do not vaccinate if:
- the child has encephalopathy;
- he has an exacerbation of chronic diseases;
- the child has an increased body temperature;
- he was already given an injection of Pentaxim, after which side effects were observed - high fever (above 40 ° C), allergies, convulsions, hypotonic-hyporeactive syndrome;
- it is known about the individual intolerance to the components that make up the vaccine;
- allergic to neomycin, streptomycin, glutaraldehyde and polymyxin B.
Pentaxim is very carefully vaccinated for children who have previously had febrile seizures (i.e. those caused by high fever) that have nothing to do with vaccinations. In this case, the first two days after the injection, it is necessary to regularly measure the body temperature so as not to miss the moment when the child needs an antipyretic.
So, the French Pentaxim is a safe alternative to just three vaccinations. More and more parents, worried about the side effects of aggressive DTP, are opting for such a “dead" vaccine in which there are no living bacteria. It allows you to develop a stable immunity, but it does not load the child’s immune system, which means that the likelihood of negative reactions is reduced to almost zero.
Pentaxim vaccine is a new generation of cell-free (acellular) drug that is much easier to tolerate by babies, because the body’s reaction to it is much weaker than to the cellular counterparts-predecessors. The substance is devoid of the bacterial membranes of lipopolysaccharides, causing complications after vaccination, therefore Pentaxim can be called a relatively safe drug.
The vaccine is highly immunogenic, causing a strong response of the baby’s immune system, it provides strong protection against infectious diseases such as tetanus, diphtheria, whooping cough, hemophilia (type B) and polio.
The predecessor of the drug can be called the DTP vaccine, which is known to many, which most babies have a hard time tolerating because they have many contraindications to it, which doctors sometimes (as parents say) do not pay attention.
Pentaxim can significantly reduce the risk of possible complications arising after vaccination with other drugs, it is safe and reliable.
The primary course requires the introduction of 3 doses of the vaccine with an interval of 45 days and subsequent revaccination after a year. It is important to monitor the timing of vaccinations, according to the schedule. Sometimes the next vaccination can be postponed for several days (days off, malaise in the baby, colds, fever).
In this case, the drug is not renewed, but the protective result may be reduced, since the child’s immunity will be weaker than the bacteria entering.
Parents need to remember that the component of the drug against hemophilia for children older than a year is administered only 1 time. Therefore, if Pentaxim was administered to the baby at this age, then this injection was the last. In the future, the introduction of the drug is possible only without a hemophilic component.
I like!
For parents who decide to inject a French drug for the first time, the question arises of what complications Pentaxim can cause.
Vaccine instructions
Measures to prevent the negative effects of vaccination:
- until the wound formed during the injection is tightened and the condition normalizes. If you wet the puncture zone, the infection will get there and severe inflammation will occur. Taking a shower at elevated temperatures can catch a cold. In these cases, all the defenses will be aimed at combating the disease, and not on the formation of specific immunity;
- . It is important to avoid contact with other children and adults to reduce the likelihood of infection. In the post-vaccination period, the body weakens and you can get sick. It is better that for a couple of days the baby does not attend kindergarten, school, does not communicate with friends;
- do not let the child rub, scratch the injection zone. It is forbidden to treat the injection site with ointments, lotions in order to accelerate healing. It may cause an allergy;
- if the baby is breast-fed, then the mother should not introduce new products into her diet;
- to prevent fever, some pediatricians advise giving the baby an antipyretic for several days after vaccination;
- sensitive children are shown taking antihistamines three days before and after the manipulation.
Related videos
About the possible complications of vaccination at the School of Dr. Komarovsky:
Thus, Pentaxim, like any vaccine, can cause adverse reactions and complications. But the French drug has a low reactogenicity and is tolerated normally by most children. If unpleasant symptoms appear, it is better to consult a doctor, and not to self-medicate.
Recently, more and more often you can hear disputes of young mothers about the need, is it necessary to vaccinate your child? If vaccinated, then with what? Domestic DTP vaccine or its imported analogues? To date, the French Pentaxim vaccine registered in Russia answers all of the above questions.
Pentaxim is a combination vaccine that contains antigens for such terrible infectious diseases as diphtheria and tetanus, acellular pertussis component, inactivated poliomyelitis virus, polysaccharides for hemophilic infection type b. This allows one vaccine to develop a child’s immune response to five infections at once. All these five infections are very serious, and the probability of death from them is approaching 100%. This vaccine is very convenient, but not only that is important for a caring mother. Safety, side effects, effectiveness, frequency of administration - this is not a complete list of topics of interest. So, first things first.
The free DTP vaccine offered at Russian outpatient clinics differs significantly from Pentaxim in that it protects against only three of the five diseases — diphtheria, tetanus, and whooping cough. Moreover, the pertussis component in the Russian vaccine is whole-cell, which can be the cause of frequent side effects, because of which parents write a refusal of this vaccine.
In addition, it is necessary to use a polio vaccine together with DTP. Up to 6 months, it is used inactivated as an injection, which is usually well tolerated. After 6 months, a live polio vaccine, in the form of pink drops in the mouth that have side effects, such as an upset stomach. And also, within a few hours, the child releases poliomyelitis virus into the air, which can be dangerous for unvaccinated children.
Accordingly, DTP cannot protect against hemophilic infection of type b. Since 2011, vaccination against this type of disease has been included in the national vaccination calendar and is mandatory. So the child, when visiting the treatment room, must “bite” as many as three mosquitoes, instead of one, which is an additional negative factor for children and parents, when deciding on vaccination. And this, in turn, cannot but affect the general epidemiological situation in the country. Therefore, domestic manufacturers of epidemiologists must express special gratitude to French manufacturers.
Efficacy and side effects
Do not think that if the vaccine contains five components, then this can adversely affect the production of antibodies in the child. After conducting large-scale studies in countries using this vaccine, with the participation of several thousand children, they found that antibodies in 100% of cases are produced for all five diseases, without exception. This is an absolute plus for Pentaxim vaccination.
The manufacturer in its instructions for use of the drug lists possible adverse reactions. This is an increase in body temperature (1% -10%) to 38 degrees (rarely rare), and allergic reactions (less than 0.01%), and seals at the injection site (1% - 0.1%), and even cramps (very rare). And also: prolonged crying, redness of the injection site, impaired gastrointestinal function, sleep disturbance.
All these reactions are possible, and they frighten young parents very much. However, the incidence of side effects is several times lower than when using the DTP vaccine.
Talking about the consequences, parents usually forget to mention some important health factors of their child, which could be a temporary contraindication for vaccination.
Contraindications
The following contraindications are temporary:
- acute viral diseases (flu, acute respiratory viral infections, etc.), not earlier than 2 weeks after recovery
- exacerbation of various somatic diseases, including allergic
- disease of adults in constant contact with the child (SARS and other respiratory diseases). Most often, no one takes this temporary contraindication into account, and then the vaccine is “blamed” for the fever, and no one remembers the father’s runny nose and elder brother’s cough.
Severe neurological pathologies, cardiological, immunological, as well as the presence of a history of seizures in a child, are not contraindications. The use of Pentaxim in these cases is possible and shown, but with caution and under the supervision of narrow specialized specialists.
Introduction scheme
Pentaxim staging is carried out at the age of 3 months to 5 years. Older than five years of age, this vaccine is not used because of increased reactogenicity, and also because capsule polysaccharides of hemophilic bacillus type b are included in the composition, which protect against hemophilic infection, which occurs in children usually before the age of five.
The administration schedule is as follows: a vaccine is administered three times with an interval of 45 days, then an interval of 12 months, and revaccination is carried out. The vaccine should be started from three months, but if for some reason the period is delayed, then Pentaxim can be started later with preservation of the multiplicity of administration and intervals.
An important point to remember. The package for the vaccine contains a syringe tube with a suspension, which includes the toxoids diphtheria, tetanus, pertussis and inactivated polio virus. A separate vial contains a lyophilisate for the preparation of a suspension with polysaccharides against hemophilic infection of type b. Mix the contents of the vial and syringe tube only in the first and second vaccinations, the third is done WITHOUT a hemophilic component. Revaccination is again carried out with a hemophilic component.
special instructions
Parents should remember that Pentaxim is a paid vaccine, its cost ranges from 1,500 to 2,000 rubles in Moscow. If you buy it yourself, you must ensure the correct transportation. The temperature during transportation should not be above +4 degrees, for this they use thermo bags with cold elements. Or you can buy the Snowball thermo-package, it will be enough to bring the vaccine to the clinic.
Analogs
In addition to the above-mentioned domestic DTP vaccine, there is also the Belgian Infanrix vaccine. It is available in several versions. There is a composition of four components: an adsorbed, acellular diphtheria-tetanus-pertussis component plus anti-poliomyelitis. There is an option containing antihemophilic polysaccharides. And the most spacious is Infanrix hexa, it contains all five of the above components, as well as a component against hepatitis B. It is very convenient for children who are vaccinated according to the schedule, who need to be vaccinated immediately from 6 infections at 6 months.
The French manufacturer offers another of its Tetracock vaccines. It protects against diphtheria, tetanus, pertussis and polio. The four-component composition is more lightweight compared to Infanrix hexa, but the pertussis component in it is whole-cell. Accordingly, it can be harder to tolerate by children and have more adverse reactions.
All of them are paid, their cost approximately varies from 1500 to 2200 in rubles.
Each of the above drugs has positive and negative reviews. The choice is up to the parents.
