Return to School After Hand, Foot, and Mouth Disease
Children with hand, foot, and mouth disease (HFMD) should not be excluded from school or daycare, as exclusion policies do not meaningfully reduce transmission and cause unnecessary educational disruption. 1
Key Recommendation
Children may remain in school or return immediately after diagnosis, as HFMD has low contagion in classroom settings and most children have already been infectious for weeks before diagnosis (the incubation period ranges from 3-7 days, with the child being most contagious before symptoms appear). 2, 3, 4
No waiting period is required - unlike conditions requiring 24-72 hours of antibiotic therapy (such as impetigo or streptococcal infections), HFMD is self-limited and does not respond to antibiotics. 5, 2
Rationale for No Exclusion Policy
The American Academy of Pediatrics' approach to head lice provides the parallel framework: exclusion causes unnecessary school absence without meaningful reduction in transmission, and "no-nit" policies are unjust and based on misinformation rather than objective science. 6, 1 This same principle applies to HFMD.
By the time HFMD is diagnosed, the child has typically been infectious for 1 month or more, making school exclusion ineffective at preventing spread. 6, 2, 3
The incubation period varies by age: 4.4 days for kindergarten children, 4.7 days for primary school children, and 5.7 days for secondary school students, with some cases having incubation periods exceeding 10 days. 4
Viral shedding continues for weeks after symptom resolution (particularly in stool), making any exclusion period arbitrary and ineffective. 2, 3
Practical Management Approach
Immediate Actions on Day of Diagnosis
Keep the child in class but discourage close direct head-to-head contact with others (similar to head lice management). 6
Notify parents confidentially at the end of the school day with educational materials about the condition. 6
Emphasize hand hygiene as the primary intervention to reduce transmission risk, though evidence shows this has limited effectiveness once an outbreak has begun. 6
Exceptions Requiring Medical Evaluation (Not School Exclusion)
Children should be evaluated by a physician if they develop:
Severe symptoms including high fever, severe headache, neck stiffness, or altered mental status (signs of potential neurological complications such as brainstem encephalitis or meningoencephalitis). 2, 3, 7
Respiratory distress or signs of cardiopulmonary complications. 2, 3
Inability to maintain hydration due to painful oral lesions. 2
These complications are rare but can be fatal, particularly with enterovirus A71 infections in children under 3 years of age. 2, 3, 7
Common Pitfalls to Avoid
Do not implement "no-lesion" policies analogous to discredited "no-nit" policies for head lice - these are not evidence-based and cause unnecessary educational disruption. 6, 1
Do not wait for complete resolution of rash - the typical illness resolves in 7-10 days, but viral shedding continues much longer, making this an arbitrary endpoint. 2, 3
Do not confuse HFMD with conditions requiring antibiotic therapy - unlike impetigo or streptococcal infections that require 24-72 hours of treatment before return, HFMD has no specific treatment and exclusion serves no purpose. 6, 5
Prevention Strategies
Hand hygiene education should be reinforced school-wide, though evidence shows this has modest effects in preventing respiratory and enteric viral transmission in school settings. 6
Environmental disinfection of frequently touched surfaces may help, though person-to-person transmission is the primary route. 6, 2
Vaccination with inactivated EV-A71 vaccine (approved in China) provides protection against the most severe form of HFMD, though multiple serotypes continue to circulate. 2, 3, 7