What is the recommended management for a child with chicken pox?

Management of Chickenpox in Children

For otherwise healthy children with chickenpox, supportive care is the primary treatment approach, with antiviral therapy reserved for specific high-risk situations. 1, 2

Supportive Care (First-Line for Immunocompetent Children)

Symptomatic management forms the cornerstone of treatment for uncomplicated chickenpox in healthy children. 1, 2

Core Supportive Measures:

• Relieve itching with lukewarm baths containing colloidal oatmeal 1, 2
• Maintain adequate hydration and monitor for signs of dehydration 2
• Avoid aspirin and all salicylates due to Reye syndrome risk 2
• Avoid ibuprofen, which has been associated with increased risk of severe bacterial superinfection 3

Expected Disease Course:

• Chickenpox is self-limited, lasting 4-5 days with typically 250-500 lesions 4
• Most cases resolve without complications within 5-7 days 1
• Natural infection provides lifelong immunity; no additional vaccination needed after recovery 1

When to Consider Antiviral Therapy

Acyclovir is NOT routinely indicated in otherwise healthy children with uncomplicated varicella. 1, 2 However, antiviral therapy should be considered in these specific situations:

High-Risk Groups Requiring Acyclovir:

• Immunocompromised children (primary or acquired immunodeficiency, neoplastic disease, immunosuppressive therapy) 1, 2
• Children with chronic cutaneous or pulmonary disorders 2
• Adolescents (≥13 years) due to higher complication rates 2
• Neonates and infants under 1 year in certain circumstances 1

Acyclovir Dosing (When Indicated):

• Children ≥2 years and ≤40 kg: 20 mg/kg orally 4 times daily for 5 days (maximum 800 mg per dose) 5
• Children >40 kg and adults: 800 mg orally 4 times daily for 5 days 5
• Immunocompromised patients: Intravenous acyclovir 10 mg/kg every 8 hours for 7-10 days 1, 6
• Therapy must be initiated within 24 hours of rash onset for maximum benefit 5, 7

Important caveat: While one controlled trial showed acyclovir reduces lesion count and symptom duration when started within 24 hours 7, it did not demonstrate reduction in serious complications, and routine use in healthy children remains controversial given the generally benign nature of the disease.

Critical Monitoring for Complications

Bacterial superinfection is the most common serious complication requiring hospitalization. 1, 2

Warning Signs Requiring Immediate Evaluation:

• Expanding erythema around lesions 1, 2
• Purulent drainage from lesions 1, 2
• Increasing pain, tenderness, or warmth 1, 2
• Systemic toxicity (high fever, lethargy, altered mental status) 1, 2
• Signs of pneumonia, dehydration, or encephalitis 1

Note: Infants under 1 year are 6 times more likely to be hospitalized than children aged 5-9 years, though complications are rare before 1 month of age due to maternal antibodies. 1, 8

Isolation and Infection Control

Isolate the child until ALL lesions have crusted over, typically 5-7 days after rash onset. 1, 2

Specific Precautions:

• Keep child away from immunocompromised individuals, pregnant women without immunity, and newborns 2
• Chickenpox is extremely contagious; more than 90% of unvaccinated exposed individuals will become infected 9

Post-Exposure Management for Contacts

For Susceptible Household Contacts:

Varicella vaccine administered within 3-5 days of exposure can prevent or modify disease severity. 4, 1, 2

For High-Risk Exposed Individuals:

Varicella-zoster immune globulin (VZIG) should be administered as soon as possible after exposure, effective up to 10 days post-exposure, for: 1, 2, 6

• Immunocompromised contacts without immunity
• Pregnant women without evidence of immunity
• Specific neonatal populations (newborns whose mothers developed varicella 5 days before to 2 days after delivery)

If VZIG is unavailable, prophylactic oral acyclovir (10 mg/kg four times daily for 7 days) within 7-10 days of exposure is an alternative. 6

Future Prevention

Once the child reaches 12 months of age (if not already vaccinated), administer varicella vaccine according to the two-dose schedule: first dose at 12-15 months, second dose at 4-6 years. 1 However, if the child has already had natural chickenpox infection, no vaccination is needed as natural infection provides lifelong immunity. 1