When can someone with hand foot mouth virus (HFMD) return to school?

Return to School with Hand, Foot, and Mouth Disease

Children with HFMD can return to school when they no longer have fever (without fever-reducing medications), all blisters have dried and crusted over, and at least 7 days have passed since symptom onset. 1, 2

Specific Return-to-School Criteria

The following conditions must ALL be met before returning:

• Fever resolution: No fever for at least 24 hours without using acetaminophen or ibuprofen 2
• Lesion status: All blisters must be completely dried and crusted over with no moist or draining areas 1
• Time elapsed: Minimum of 7 days from initial symptom onset 2
• Oral lesions: Mouth sores should be healed enough that the child can eat and drink comfortably 3

Understanding the Contagious Period

The timing of exclusion is critical because HFMD has a prolonged infectious period:

• Pre-symptomatic spread: Children are contagious 1-2 days before symptoms even appear 2
• Active disease: Peak contagiousness occurs during the first week when lesions are active 4
• Post-symptomatic shedding: Viral shedding in stool continues for several weeks after symptoms resolve, though transmission risk is lower 2, 5
• Total contagious period: Consider patients potentially contagious for 10-14 days from symptom onset 2

Why Strict Exclusion Criteria Matter

Premature return to school triggers outbreaks. 2 The American Academy of Pediatrics emphasizes that children must not return until lesions are completely healed to prevent daycare and school outbreaks 1. While some older guidance suggested exclusion is impractical because viral shedding persists for weeks 5, current recommendations prioritize the period of highest transmission risk when active lesions are present 1, 2.

Common Pitfalls to Avoid

• Relying only on fever resolution is insufficient - the child remains highly contagious until all lesions have crusted over 2
• Returning after only 3-4 days - even if the child feels better, the minimum 7-day period should be observed 2
• Ignoring moist lesions - any draining or weeping blisters indicate ongoing high contagiousness 1
• Inadequate hand hygiene - alcohol-based sanitizers alone are insufficient against enteroviruses; soap and water handwashing is essential 2, 3

Special Considerations for Different Settings

Daycare settings require particular vigilance because children under 5 years are most commonly affected and have close contact with shared toys and surfaces 1, 4. The American Academy of Pediatrics recommends that once fever resolves and mouth sores heal, children can return even if some skin rash persists, though this conflicts with the more conservative 7-day guideline 3. Given the risk of outbreaks, follow the stricter criteria of waiting until all lesions are crusted and 7 days have elapsed. 1, 2

Healthcare workers, food handlers, and childcare workers face additional restrictions and must be excluded from direct care or food preparation until the condition completely resolves, potentially requiring documentation before returning to work 1.

Infection Control During Illness

While the child is excluded from school:

• Hand hygiene: Thorough handwashing with soap and water after toilet use, diaper changes, and before meals is the single most important preventive measure 1, 3
• Environmental disinfection: Clean and disinfect toys, doorknobs, and surfaces that may be contaminated 1, 4
• Avoid sharing: Do not share utensils, cups, or food 3
• Outdoor time: Encourage outdoor activities when possible as this reduces transmission risk 1

Clinical Course and Expectations

Lesions typically resolve in 7-10 days without complications 4, 6. Most cases are mild and self-limited, though rare neurological or cardiopulmonary complications can occur, particularly with Enterovirus 71 4, 7. Parents should monitor for signs of dehydration from painful oral lesions and seek medical attention if the child develops severe headache, neck stiffness, or difficulty breathing 7.