When Can a Child with Hand, Foot, and Mouth Disease Return to School?
Children with hand, foot, and mouth disease (HFMD) do not need to be excluded from school and can attend once they are fever-free and feel well enough to participate in normal activities. 1, 2
Rationale for No Exclusion Policy
The American Academy of Pediatrics explicitly recommends against school exclusion for HFMD because by the time the disease is diagnosed, the child has already been infectious for a significant period, making exclusion ineffective at preventing spread. 1 This approach parallels evidence-based policies for other childhood conditions where exclusion causes unnecessary school absence without meaningful reduction in transmission. 1
Specific Return-to-School Criteria
Children can return to school when:
- Fever has resolved without the use of fever-reducing medications (acetaminophen or ibuprofen) 2, 3
- The child feels well enough to participate in normal school activities without requiring special accommodations 2
- Ideally fever-free for 24 hours without antipyretics 2
The presence of the characteristic rash on hands and feet or oral ulcerations alone does not require exclusion, as these lesions typically resolve in 7-10 days and the child is most contagious before symptoms appear. 3, 4
In-School Management Approach
Once the child returns to school:
- Keep the child in class but discourage close direct head-to-head contact with others to reduce transmission risk 1
- Emphasize hand hygiene as the primary intervention, though evidence shows this has limited effectiveness once an outbreak has begun 1
- Environmental disinfection of frequently touched surfaces may help reduce transmission, though person-to-person transmission is the primary route 1
Important Caveats
While most HFMD cases are benign and self-limited, rare neurologic or cardiopulmonary complications can occur, particularly with enterovirus A71. 3, 5 If a child develops severe symptoms such as persistent vomiting, lethargy, difficulty breathing, or signs of neurological involvement, immediate medical evaluation is required regardless of school attendance status. 5
The fecal-oral transmission route means viral shedding can continue for weeks after symptom resolution, making prolonged exclusion impractical and ineffective. 3, 4