School Exclusion for Hand, Foot, and Mouth Disease
Children with HFMD should not be excluded from school, as exclusion is impractical and does not meaningfully reduce transmission. 1
Rationale for No Exclusion Policy
The American Academy of Pediatrics' approach to HFMD mirrors their evidence-based stance on other childhood conditions where exclusion causes unnecessary absence without reducing spread. 1 This recommendation is based on several key principles:
- By the time HFMD is diagnosed, the child has already been infectious for a significant period, making school exclusion ineffective at preventing transmission. 1
- The virus remains present in feces for several weeks after symptoms resolve, making any practical exclusion period inadequate to prevent spread. 2
- Children are most contagious before the characteristic rash appears, during the prodromal phase when diagnosis has not yet been made. 2
Practical Management in School Settings
Rather than exclusion, the focus should be on minimizing direct contact and reinforcing hygiene:
- Keep the child in class but discourage close direct head-to-head contact with others, similar to the management approach for head lice. 1
- Emphasize hand hygiene as the primary intervention, though evidence shows this has limited effectiveness once an outbreak has begun. 3, 1
- Environmental disinfection of frequently touched surfaces may help, though person-to-person transmission remains the primary route. 1
Important Clinical Context
Most HFMD cases are mild and self-limiting:
- The disease typically presents with low-grade fever, malaise, and characteristic maculovesicular eruptions on hands, feet, and oral cavity. 4
- Treatment is symptomatic only, as there is no specific pharmaceutical intervention for HFMD. 5, 2
- Severe complications (pneumonia, meningitis, encephalitis) are rare but clinicians should monitor for warning signs, particularly in children under 3 years with EV-A71 infection. 6
Common Pitfall to Avoid
Do not confuse HFMD with conditions requiring antibiotic therapy or mandatory exclusion (such as measles, mumps, rubella, or varicella, which require 5-7 days exclusion). 3, 1 HFMD requires no exclusion period because the child is no longer meaningfully contagious once diagnosed, unlike these other viral exanthems. 1