What are the treatment options for a 17-month-old child with hand, foot, and mouth disease (HFMD) who has fallen?

Management of a 17-Month-Old with Hand, Foot, and Mouth Disease After a Fall

Immediate Assessment After the Fall

First, evaluate the fall itself before addressing the HFMD, as head trauma or fractures require immediate attention regardless of concurrent viral illness. 1

Critical Questions to Ask About the Fall:

• Height of the fall – falls from >3 feet (90 cm) or down stairs carry higher risk of significant injury 1
• Surface landed on – concrete vs. carpet vs. grass affects injury severity 1
• Loss of consciousness – any witnessed unresponsiveness, even briefly, requires urgent evaluation 1
• Vomiting after the fall – particularly repeated vomiting suggests possible head injury 1
• Behavior changes – increased irritability, lethargy, or difficulty arousing the child 1
• Visible injuries – swelling, bruising, deformity, or inability to move limbs 1

Physical Examination Priorities:

• Palpate the entire skull for step-offs, boggy swelling, or tenderness suggesting skull fracture 1
• Assess neurological status – pupil reactivity, alertness, ability to track objects, normal movement of all extremities 1
• Examine extremities for swelling, deformity, or refusal to bear weight 1

If any concerning features are present (loss of consciousness, persistent vomiting, altered mental status, focal neurological findings), refer immediately to emergency department before addressing HFMD management. 1

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Hand, Foot, and Mouth Disease Treatment

Supportive Care (Primary Treatment)

HFMD is self-limited and requires only symptomatic management, as no antiviral therapy is approved or generally recommended. 2, 3

Pain and Fever Management:

• Acetaminophen 10-15 mg/kg every 4-6 hours (maximum 5 doses/24 hours) for pain and fever relief 2
• Ibuprofen 5-10 mg/kg every 6-8 hours as an alternative NSAID option 2
• Use for limited duration only – discontinue once fever resolves and pain improves 2

Oral Care for Mouth Sores:

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1, 2
• Clean mouth daily with warm saline rinses or use an oral sponge if the child cannot rinse 1, 2
• Offer cold fluids and soft foods – popsicles, yogurt, mashed potatoes to minimize oral pain 2
• Avoid acidic or spicy foods that worsen mouth pain 2

Skin Care for Hand and Foot Lesions:

• Apply zinc oxide cream to affected areas after gentle cleansing to soothe inflamed skin and reduce itchiness 2
• Use moisturizing creams such as urea-containing products for intensive skin care 2
• Avoid friction and heat exposure to affected areas 2
• Do not use chemical agents or plasters on lesions 2

Hydration Monitoring

Ensure adequate fluid intake, as mouth pain may cause the child to refuse drinking. 2

• Watch for signs of dehydration – decreased urine output (<3 wet diapers/24 hours), dry mucous membranes, sunken fontanelle, lethargy 1
• Offer frequent small amounts of preferred cold beverages 2
• If unable to maintain hydration orally, seek medical evaluation for possible IV fluids 1

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Infection Control and Prevention

Hand Hygiene (Most Important Preventive Measure):

Thorough handwashing with soap and water is more effective than alcohol-based sanitizers for HFMD, as enteroviruses are not reliably inactivated by alcohol. 1, 2

• Wash hands before and after contact with the child 1
• Wash hands after diaper changes and handling any secretions 1
• Clean contaminated surfaces with soap and water, particularly toys and objects that may be placed in mouth 2

Isolation Precautions:

• Keep child home from daycare until fever resolves and mouth sores heal, even if skin rash persists 2
• Avoid sharing utensils, cups, or food with other household members 2
• Standard precautions in healthcare settings – gloves for contact with secretions, hand hygiene before and after patient contact 1

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Warning Signs Requiring Urgent Medical Attention

Monitor closely for severe complications, particularly with enterovirus 71 strains which cause more severe disease. 2, 3, 4

Neurological Complications:

• Persistent high fever (>39°C/102.2°F) despite antipyretics 2, 3
• Severe headache or neck stiffness suggesting meningitis 2, 3
• Altered mental status – excessive lethargy, difficulty arousing, confusion 2, 4
• Seizures or abnormal movements 2, 3
• Weakness or paralysis of limbs (acute flaccid paralysis) 2

Cardiopulmonary Complications:

• Rapid breathing or respiratory distress suggesting pulmonary edema 3, 4
• Persistent vomiting 3, 4
• Cold extremities or mottled skin suggesting circulatory failure 3

If any of these features develop, seek emergency care immediately, as neurogenic pulmonary edema and myocardial impairment are the main causes of death in severe HFMD. 3, 5

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Expected Disease Course and Follow-Up

• Typical duration is 7-10 days with complete resolution 3, 6, 5
• Fever usually resolves within 3-5 days 2, 3
• Mouth sores heal within 7-10 days 2, 5
• Skin lesions may persist longer but are not a reason for continued isolation 2

Late Manifestations (Not Concerning):

• Nail shedding (onychomadesis) may occur 1-2 months after illness onset, particularly with coxsackievirus A6 strains 2, 3
• Periungual desquamation typically begins 2-3 weeks after fever onset 2
• These are delayed sequelae, not active disease, and require no treatment 2

When to Reassess:

• If symptoms worsen or fail to improve after 7-10 days 2, 5
• If secondary bacterial infection develops – increased redness, warmth, purulent drainage from lesions 2
• If child develops dehydration from inadequate oral intake 1

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Critical Pitfalls to Avoid

• Do not use antibiotics – HFMD is viral and self-limited; antibiotics should be avoided unless secondary bacterial infection is confirmed 7
• Do not use aspirin in children due to risk of Reye's syndrome 1
• Do not rely on alcohol-based hand sanitizers alone – soap and water is essential for enterovirus prevention 1, 2
• Do not dismiss minimal skin findings – fatal HFMD can present with very subtle rash visible only with magnification 4
• Do not assume all cases are benign – enterovirus 71 causes severe disease with neurological and cardiopulmonary complications 2, 3, 4