What is the recommended management for a child under 10 with hand, foot, and mouth disease (HFMD)?

Management of Hand, Foot, and Mouth Disease in Children Under 10

Hand, foot, and mouth disease in children under 10 requires supportive care only, with oral analgesics for pain and fever control, intensive hand hygiene, and return to daycare once fever resolves and mouth sores heal—even if skin lesions persist. 1

Immediate Symptomatic Management

Pain and Fever Control

• Use acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 1
• These oral analgesics address both constitutional symptoms and discomfort from oral and skin lesions 1

Oral Lesion Management

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1
• Clean the mouth daily with warm saline mouthwashes for comfort 1
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure 1
• For more severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily 1
• Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control 1

Dietary Modifications

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that exacerbate oral pain 1
• Encourage ample fluid intake to keep the mouth moist and prevent dehydration 1

Skin Care for Hand and Foot Lesions

Basic Skin Management

• Apply intensive skin care with moisturizing creams, particularly urea-containing products, to hands and feet 1
• Avoid friction and heat exposure to affected areas 1
• Do not use chemical agents or plasters to remove any associated corns or calluses 1

For Itchiness

• Zinc oxide 20% can be applied as a protective barrier to soothe inflamed areas and reduce itchiness 1
• Apply in a thin layer after gentle cleansing of affected areas 1
• Avoid applying to open or weeping lesions 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1

For Open Sores on Feet

• Wash feet daily with careful drying, particularly between the toes 1
• Avoid walking barefoot and ensure appropriate cushioned footwear to protect open lesions 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores 1

Prevention and Infection Control

Hand Hygiene (Most Critical Preventive Measure)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers 1
• This is the single most important preventive measure according to the American Academy of Pediatrics 1

Environmental Cleaning

• Clean toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1

Isolation and Return to Daycare

• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present 1
• Exclusion based solely on healing skin lesions is not necessary 1
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 1

Monitoring for Complications

Warning Signs Requiring Immediate Attention

Watch for indicators of possible deterioration, particularly in children under 3 years with EV-A71 infection and disease duration less than 3 days 2:

• Persistent hyperthermia 2
• Involvement of nervous system (altered mental status, lethargy, irritability) 2
• Worsening respiratory rate and rhythm 2
• Circulatory dysfunction 2
• Elevated peripheral WBC count 2
• Elevated blood glucose 2
• Elevated blood lactic acid 2

Secondary Infections

• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1
• Treat any secondary bacterial infections that develop 1

Follow-Up and Expected Course

Routine Monitoring

• Most cases are self-limiting and resolve within a few days without complications 3, 4
• 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

Late Manifestations (Expected, Not Concerning)

• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever 1
• Onychomadesis (nail shedding) may occur 1-2 months after fever onset, particularly with CV-A6 5

Critical Differential Diagnoses to Exclude

Before confirming HFMD management, distinguish from:

• Herpes simplex virus infection—this has available antiviral treatment whereas HFMD does not 1
• Drug hypersensitivity reactions, which can also present with palmar-plantar rash 1
• Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema) 1
• In atypical presentations: syphilis, meningococcemia, and Rocky Mountain spotted fever 1

Common Pitfalls to Avoid

• Do not routinely use topical antiseptic or antimicrobial dressings for HFMD foot lesions—these are not recommended for wound healing 1
• Do not exclude children from daycare based solely on persistent skin lesions after fever and oral lesions have resolved 1
• Do not overlook atypical presentations in children with atopic dermatitis, which may resemble "eczema coxsackium" and mimic herpetic superinfection 3
• Do not miss neurological complications in severe cases, particularly with EV-A71, which can cause encephalitis, meningitis, acute flaccid paralysis, and acute flaccid myelitis 1, 5