School Exclusion for Hand, Foot, and Mouth Disease
Children with hand, foot, and mouth disease (HFMD) do not need to be excluded from school once diagnosed, as they have already been infectious for a significant period before diagnosis, making exclusion ineffective at preventing spread. 1, 2
Rationale for No Exclusion Policy
By the time HFMD is clinically recognized with its characteristic oral lesions and rash on hands and feet, the child has already passed through the most contagious phase during the prodromal period. 1
School exclusion policies for HFMD cause unnecessary absence without providing meaningful reduction in disease transmission, similar to the evidence-based approach used for head lice management. 1
The virus spreads primarily through respiratory droplets and fecal-oral routes during the incubation period and early illness, well before the distinctive rash appears. 3, 4
Practical Management in School Settings
Children should remain in class but with specific precautions to minimize transmission risk:
Discourage close direct contact with other children, particularly activities involving hand-to-hand or face-to-face contact. 1
Reinforce hand hygiene practices school-wide, though recognize this has only modest effectiveness once an outbreak has begun. 1
Implement environmental disinfection of frequently touched surfaces (doorknobs, desks, toys) to reduce secondary transmission. 1
When to Keep Children Home
The general illness criteria apply rather than HFMD-specific exclusion:
Children should stay home if they have fever or are too unwell to participate in normal school activities. 2
Return to school is appropriate once the child is fever-free for 24 hours without antipyretics and feels well enough for regular activities. 2
Severe cases with neurological complications (rare but possible with certain enterovirus strains) require medical evaluation and individualized return-to-school decisions. 4, 5
Important Caveats
HFMD is most common in children under 5 years of age and typically presents as a mild, self-limited illness. 3, 4, 6
While rare, severe complications including brain stem encephalitis and cardiopulmonary complications can occur, particularly in children under 3 years. 4, 5
The disease has no specific antiviral treatment, and management is supportive. 4
Nail dystrophies (Beau's lines or nail shedding) may occur weeks after initial symptoms but do not require school exclusion. 3