When Can a Child Return to School After Hand, Foot, and Mouth Disease?
Children with hand, foot, and mouth disease (HFMD) do not need to be excluded from school and can return once they feel well enough to participate in normal activities, regardless of whether blisters are still present. 1
The Evidence Against School Exclusion
The American Academy of Pediatrics explicitly recommends against exclusion policies for HFMD because:
By the time HFMD is diagnosed, the child has already been infectious for a significant period (1-2 days before symptoms appeared), making school exclusion ineffective at preventing spread 1, 2
Exclusion policies cause unnecessary school absence without meaningful reduction in transmission, similar to the evidence-based approach now used for head lice management 1
Viral shedding continues in stool for several weeks after symptoms resolve, so waiting for complete viral clearance would require impractically long exclusions 2, 3
Practical Return-to-School Criteria
The child can return to school when:
- They are feeling well enough to participate in normal classroom activities 1
- Fever has resolved without fever-reducing medications 2
- They can maintain adequate oral intake (implied by ability to participate)
Note: You do NOT need to wait for all blisters to dry and crust over, contrary to older recommendations 1, 2
In-School Management Approach
Once the child returns:
- Keep the child in class but discourage close direct head-to-head contact with others, similar to head lice management 1
- Reinforce hand hygiene school-wide, though this has only modest effectiveness once an outbreak has begun 1
- Increase environmental disinfection of frequently touched surfaces, recognizing that person-to-person transmission is the primary route 1
Common Pitfalls to Avoid
Do not confuse HFMD with conditions requiring antibiotic therapy - HFMD is viral with no specific treatment, and exclusion serves no purpose 1
Do not rely solely on alcohol-based hand sanitizers - these are insufficient against enteroviruses; soap and water handwashing is necessary 2
Do not wait for complete resolution of all skin lesions - this unnecessarily prolongs absence without epidemiological benefit 1, 3
Special Circumstances Requiring Caution
While most HFMD is benign and resolves in 7-10 days 4, 5, watch for:
- Severe neurological complications (mainly rhombencephalitis) or cardiopulmonary failure, particularly with enterovirus A71 6, 5
- The case severity rate is approximately 1% with a case fatality rate of 0.03%, with EV-A71 involved in over 90% of fatal cases 5
These severe cases would obviously require medical evaluation and hospitalization, not just school exclusion decisions.