What is the medical management for foot and mouth disease in pediatric patients?

Medical Management of Hand, Foot, and Mouth Disease in Pediatric Patients

Hand, foot, and mouth disease (HFMD) in children is a self-limited viral illness requiring only supportive care, with treatment focused on pain relief and hydration, as there are no approved antiviral therapies for this condition. 1, 2

Supportive Care Measures

Pain and Fever Management

• Administer oral acetaminophen or NSAIDs for pain relief and fever reduction 1
• Limit analgesic use to the shortest effective duration to minimize adverse effects 1
• These medications address the constitutional symptoms including fever, which is common in HFMD 1

Oral Lesion Management

The painful oral enanthem is often the most distressing symptom requiring specific interventions:

• Use mild toothpaste and gentle oral hygiene practices to avoid irritating oral lesions 1
• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1
• Clean the mouth daily with warm saline mouthwashes or use an oral sponge for comfort 1
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure 1
• For severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily 1

Skin Manifestation Management

For the characteristic hand and foot lesions:

• Apply intensive skin care with moisturizing creams, particularly urea-containing products 1
• Avoid friction and heat exposure to affected areas 1
• For itchiness, zinc oxide can be applied as a protective barrier after gentle cleansing of affected areas 1
• Apply zinc oxide in a thin layer and repeat as needed when itchiness returns 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid applying zinc oxide to open or weeping lesions 1

Management of Open Sores on Feet

When vesicles have ruptured:

• Wash feet daily with careful drying, particularly between the toes 1
• Avoid walking barefoot and ensure appropriate cushioned footwear to protect open lesions 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores 1
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain 1
• Treat any secondary bacterial infections that develop 1

Hydration and Nutrition

• Ensure adequate fluid intake, as oral pain may lead to decreased oral intake 2
• Offer cool, soft foods that are easier to tolerate with oral lesions 2

Expected Clinical Course

• Symptoms typically resolve in 7-10 days without sequelae 2
• The disease is usually benign and self-limited 2, 3
• Nail changes such as shedding may occur weeks after initial symptom onset as a late sequela 4, 5

Monitoring for Complications

While most cases are benign, certain presentations require heightened vigilance:

High-Risk Features

• Enterovirus A71 (EV-A71) causes more severe disease with higher complication rates compared to coxsackievirus A16 2, 6
• Neurological complications including encephalitis/meningitis, acute flaccid myelitis, and acute flaccid paralysis can occur, particularly with EV-A71 1, 6
• Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death 2

Special Populations

• Immunocompromised patients may experience more severe disease and require close monitoring 1
• Children younger than 5 years are most commonly affected 2

Infection Control and Return to Activities

Prevention Measures

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

Return to Daycare/School

• Children 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 had the infection for weeks, posing limited additional risk to others 1

What NOT to Do: Common Pitfalls

• Do not prescribe antibiotics for uncomplicated HFMD, as this is a viral illness 2
• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions 1
• Do not use chemical agents or plasters to remove corns or calluses on affected areas 1
• Avoid applying moisturizing creams between the toes, as this can cause maceration 1

Emerging Therapies

Currently, there are no specific antiviral agents approved for HFMD treatment 2. Intravenous immunoglobulin should be considered for severe/complicated HFMD and has been recommended by several guideline committees 2. Drugs such as ribavirin, suramin, mulberroside C, aminothiazole analogs, and sertraline have emerged as potential candidates but remain investigational 2.

Diagnostic Considerations

It is crucial to distinguish HFMD from herpes simplex virus, as the latter has available antiviral treatment options 1. Vesicle fluid samples have high viral loads and reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method when confirmation is needed 1.