What is the recommended management for hand, foot, and mouth disease in pediatric patients?

Management of Hand, Foot, and Mouth Disease in Children

Hand, foot, and mouth disease in children requires supportive care focused on pain control, hydration maintenance, and prevention of transmission through rigorous hand hygiene, with most cases resolving spontaneously in 7-10 days. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Administer acetaminophen or ibuprofen before mealtimes to maximize oral intake tolerance and reduce fever 1, 3
• Dose these medications 30-45 minutes before meals for optimal effect 3
• Oral lidocaine is not recommended for pain control 2

Oral Lesion Care

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1, 3
• Clean the mouth daily with warm saline mouthwashes or use an oral sponge 1
• Apply benzydamine hydrochloride oral rinse or spray every 2-4 hours, particularly before eating, to reduce inflammation (in older children who can safely use rinse-and-spit preparations) 1
• For severe oral involvement in older children, consider betamethasone sodium phosphate mouthwash (0.5 mg dissolved in 10 mL water) as a rinse-and-spit solution 1-4 times daily 1
• Avoid benzydamine hydrochloride and betamethasone mouthwash in young children as these are adult recommendations and may not be safe or practical in pediatric patients 3

Skin Lesion Management

• Apply intensive moisturizing care to hands and feet with urea-containing creams 1
• Avoid friction and heat exposure to affected areas 1
• For itchy lesions, zinc oxide can be applied as a protective barrier after gentle cleansing, repeated as needed 1
• Apply zinc oxide in thin layers and avoid application to open or weeping lesions 1
• Do not use chemical agents or plasters to remove corns or calluses 1

Foot Lesion Care (When Open Sores Present)

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot and ensure appropriate cushioned footwear 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

Nutritional Support and Hydration

Dietary Modifications

• Offer cold foods that soothe inflamed oral tissues: ice cream, yogurt, smoothies, pudding, applesauce, cold fruit, popsicles, and crushed ice 3
• Eliminate acidic foods (citrus fruits, tomatoes), salty foods, spicy foods, and rough-textured foods (crackers, chips) that exacerbate oral pain 1, 3
• Provide small, frequent meals and snacks rather than three large meals, as children tolerate smaller volumes better with painful mouths 3
• Encourage small, frequent sips of cold beverages throughout the day using small cups 3
• Do not restrict fluid intake - maintaining hydration is critical 3

Infection Control and Prevention

Hand Hygiene (Most Critical Measure)

• Hand hygiene with soap and water is the single most important method of preventing transmission and is more effective than alcohol-based hand sanitizers for HFMD 4, 1
• Wash hands before and after each patient contact, after removing gloves, and after contact with body fluids 4
• Disinfect frequently touched surfaces and objects that may be placed in children's mouths, particularly toys 1

Isolation Precautions

• Children should avoid close contact with others until fever resolves and mouth sores heal 1
• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present - exclusion based solely on healing skin lesions is unnecessary 1
• By the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk 1
• Avoid sharing utensils, cups, or food 1
• Follow standard precautions in healthcare settings 1

Monitoring and Follow-Up

Warning Signs Requiring Escalation

• Monitor closely for neurological complications (encephalitis, meningitis, acute flaccid paralysis) particularly with severe cases 1
• Watch for cardiopulmonary complications in severe disease 5, 6
• Severe oral ulcers (grade >2) may warrant delaying return to normal activities until symptoms improve 3
• Reassess after 2 weeks if lesions are not improving with standard care 1
• If evidence of infection has not resolved after 4 weeks, re-evaluate and consider alternative diagnoses 1

Expected Late Manifestations (Not Complications)

• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset 1, 7
• Periungual desquamation typically begins 2-3 weeks after onset of fever 1
• Nail shedding may occur weeks after initial symptom onset 7, 8

Critical Differential Diagnoses

Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1

• Also consider drug hypersensitivity reactions, erythema multiforme, Kawasaki disease (diffuse erythema vs. vesicular lesions), measles, varicella, syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations 1, 2

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions as these are not recommended for wound healing 1
• Do not prescribe antiviral medications - no specific antiviral treatment is available or approved for HFMD 2, 6
• Do not use oral lidocaine for pain control 2
• Recognize that "eczema coxsackium" in children with atopic dermatitis may mimic herpetic superinfection 8

Special Considerations

• Immunocompromised patients may experience more severe disease and should be monitored closely 1
• Enterovirus 71 (EV-A71) is associated with more severe outbreaks, especially in Asia, with higher rates of neurological and cardiopulmonary complications 1, 5, 6
• Most cases in the United States are caused by coxsackievirus A16 and are typically mild 7, 2