What is the assessment and treatment for an 18-month-old with hand, foot, and mouth disease (HFMD)?

Assessment and Treatment of Hand, Foot, and Mouth Disease in an 18-Month-Old

For an 18-month-old with hand, foot, and mouth disease, provide supportive care with oral analgesics (acetaminophen or ibuprofen) for pain and fever, maintain hydration, and use gentle oral hygiene with warm saline rinses—the child can return to daycare once fever resolves and mouth sores heal, even if skin lesions persist. 1

Clinical Assessment

Diagnostic Confirmation

• Diagnosis is primarily clinical based on the characteristic presentation of fever, oral vesicles/ulcers, and maculovesicular rash on hands, feet, and often buttocks 2, 3
• The average age of affected children is approximately 3 years, making 18 months a typical presentation age 4
• Look specifically for oral vesicles that progress to painful ulcers (usually the first clinical sign), along with vesicular lesions on palms, soles, and buttocks 5, 1
• Laboratory confirmation via RT-PCR of vesicle fluid, respiratory samples, or stool is available but rarely necessary for typical cases 1

Red Flag Assessment

Immediately assess for severe complications that require urgent referral:

• Neurological signs: altered mental status, severe headache, neck stiffness, weakness, or acute flaccid paralysis (associated with EV-71) 1, 3
• Cardiopulmonary distress: respiratory difficulty, tachypnea, or signs of myocarditis 3
• Dehydration: decreased urine output, dry mucous membranes, lethargy from inability to drink 1

Most cases are self-limiting and resolve within 7 days without complications 2, 5

Treatment Protocol

Pain and Fever Management

• Administer acetaminophen or ibuprofen for pain relief and fever reduction 1
• Dose appropriately for the child's weight and limit duration of use 1
• Pain control is particularly important before meals to facilitate oral intake 1

Oral Care for Mouth Sores

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Clean the mouth daily with warm saline mouthwashes using gentle technique 1
• For children who can cooperate, benzydamine hydrochloride oral rinse every 3 hours, particularly before eating, reduces inflammation and pain 1
• Use mild toothpaste and gentle oral hygiene practices 1

Hydration and Nutrition

• Offer cool, soft, non-acidic foods and liquids that are easier to tolerate with oral ulcers 1
• Avoid citrus, spicy, or salty foods that may irritate mouth sores 1
• Monitor for adequate hydration—if the child refuses oral intake, medical evaluation for IV fluids may be necessary 1

Skin Lesion Management

• Apply intensive moisturizing care to hands and feet with urea-containing creams 1
• Avoid friction and heat exposure to affected areas 1
• For itchiness, zinc oxide can be applied as a protective barrier in a thin layer after gentle cleansing 1
• Do not apply zinc oxide to open or weeping lesions 1

Management of Open Sores on Feet

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot; use appropriate cushioned footwear to protect lesions 1
• Do not soak feet in footbaths as this induces maceration and worsens open sores 1
• Monitor for secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1

Infection Control and Return to Daycare

Prevention Measures

• Hand hygiene is the most important preventive measure—thorough handwashing with soap and water is more effective than alcohol-based sanitizers 1
• Clean and disinfect toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1

Return to Daycare Criteria

The child can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present 1

• Exclusion based solely on healing skin lesions is not necessary 1
• By the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk 1

Follow-Up and Monitoring

• Reassess if symptoms worsen or new concerning features develop (neurological symptoms, respiratory distress) 1, 3
• If foot lesions are not improving after 2 weeks with standard care, re-evaluate for secondary infection 1
• Most children recover completely within 7-10 days without sequelae 2, 5

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions—these are not recommended for wound healing 1
• Do not use chemical agents or plasters to remove calluses or corns on affected feet 1
• Do not exclude children from daycare based solely on persistent skin lesions after fever and oral lesions have resolved 1
• Do not miss signs of dehydration in children refusing oral intake due to painful mouth sores 1