When to Return to Daycare with Hand, Foot, and Mouth Disease
Children with hand, foot, and mouth disease (HFMD) can return to daycare after fever has resolved and the child feels well enough to participate in activities, even if rashes or oral lesions are still present. 1
Understanding HFMD and Its Transmission
Hand, foot, and mouth disease is a common viral illness caused by enteroviruses, primarily affecting children under 5 years of age. It presents with:
- Low-grade fever
- Maculopapular or papulovesicular rash on hands and feet
- Painful oral ulcerations
The disease is transmitted through:
- Fecal-oral contact
- Oral-oral contact
- Respiratory droplets
Most cases are self-limiting with symptoms resolving within 7-10 days 1. The disease is most contagious during the first week of illness, particularly when fever is present.
Return to Daycare Guidelines
When to Return:
- After fever has resolved (without fever-reducing medications)
- When the child feels well enough to participate in activities
- No need to wait for complete resolution of rashes or oral lesions
Why This Approach Is Recommended:
- By the time HFMD is diagnosed, the child has likely been contagious for days
- The period of highest contagiousness typically occurs before diagnosis
- Prolonged exclusion does not significantly reduce transmission risk
Infection Control Measures
To minimize spread in daycare settings:
- Hand hygiene: Emphasize thorough handwashing with soap and water for children and caregivers 2
- Surface disinfection: Regularly clean and disinfect potentially contaminated surfaces and toys
- Avoid sharing: Discourage sharing of utensils, cups, and personal items
- Respiratory etiquette: Teach children to cover coughs and sneezes
Special Considerations
For Daycare Providers:
- Monitor other children for symptoms
- Notify parents if multiple cases occur
- Consider grouping affected children together if multiple cases occur 2
For Parents:
- Ensure child is well-hydrated before returning to daycare
- Inform daycare staff about the diagnosis
- Provide extra changes of clothes in case of soiling
Common Pitfalls to Avoid
"No-lesion" policies: Similar to outdated "no-nit" policies for head lice 3, requiring complete resolution of all lesions before return is not evidence-based and leads to unnecessary exclusion
Over-sanitization: While cleaning is important, extensive environmental decontamination is not necessary
Stigmatization: Children should not be made to feel responsible for having the illness
When to Seek Additional Medical Care
While preparing for daycare return, seek medical attention if the child develops:
- High fever persisting beyond 3 days
- Neurological symptoms (headache, stiff neck, irritability)
- Signs of dehydration
- Unusual lethargy or severe pain
By following these guidelines, daycare centers can balance the need to minimize disease transmission with the importance of maintaining children's educational and social development.