What is the appropriate management for a child under five years old with hand‑foot‑mouth disease?

Management of Hand, Foot, and Mouth Disease in Children Under Five Years

For children under 5 years with hand, foot, and mouth disease, provide supportive care with oral analgesics for pain relief, ensure adequate hydration, and monitor closely for warning signs of severe disease—particularly in children under 3 years with EV-A71 infection.

Immediate Supportive Care

Pain management is the cornerstone of HFMD treatment and must be addressed immediately. 1

• Administer acetaminophen or NSAIDs in age-appropriate doses for pain relief and fever reduction, particularly during the first 24-48 hours when oral lesions are most painful 1
• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain in the mouth 1
• For severe oral involvement, consider betamethasone sodium phosphate mouthwash (0.5 mg dissolved in 10 mL water) as a 2-3 minute rinse-and-spit solution one to four times daily 1

Hydration and Nutrition

• Encourage ample fluid intake to maintain hydration and keep the mouth moist 1
• Eliminate foods that exacerbate oral pain: tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 1
• Monitor for signs of dehydration, which is a key indicator for hospital admission in young children 1

Skin Lesion Management

• Apply intensive skin care to hands and feet with moisturizing creams, particularly urea-containing products 1
• Use zinc oxide in a thin layer to affected areas for itchiness relief—it works as a protective barrier and has immune-modulating properties 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid applying zinc oxide 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 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
• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1

Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes or use an oral sponge for comfort 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure 1
• Use mild toothpaste and gentle oral hygiene practices 1
• Dilute mouthwashes by 50% if necessary to reduce discomfort 1

Critical Warning Signs Requiring Immediate Evaluation

Early recognition of severe cases is paramount—the key lies in timely recognition of disease progression to prevent critical complications. 2

Pay particular attention to children under 3 years with EV-A71 infection and disease duration less than 3 days. The following indicators signal possible deterioration: 2

• Persistent hyperthermia (fever that does not respond to antipyretics)
• Involvement of the nervous system (lethargy, irritability, myoclonus, ataxia, tremors)
• Worsening respiratory rate and rhythm
• Circulatory dysfunction (cold extremities, prolonged capillary refill, tachycardia)
• Elevated peripheral white blood cell count
• Elevated blood glucose
• Elevated blood lactic acid

Isolation and Infection Control

• Isolate the child to avoid cross-infection with other children 2
• 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 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

Prevention Measures

• Hand hygiene with thorough handwashing using soap and water is the most important preventive measure—more effective than alcohol-based hand sanitizers 1
• Clean toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1

Follow-Up and Monitoring

• Most mild cases can be treated as outpatients with home care 2
• 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
• Monitor for late manifestations: Beau's lines (deep transverse nail grooves) may appear 1-2 months after fever onset, and periungual desquamation typically begins 2-3 weeks after onset 1

Important Differential Diagnoses to Consider

• Distinguish from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1
• Rule out drug hypersensitivity reactions, which can also present with palmar-plantar rash 1
• Differentiate from Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema) 1
• In atypical presentations with palmar-plantar involvement, consider syphilis, meningococcemia, and Rocky Mountain spotted fever 1

What NOT to Do

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions—these are not recommended for wound healing 1
• Do not prescribe antibiotics unless secondary bacterial infection is confirmed 1
• There are no specific antiviral agents approved for HFMD treatment 3
• Immunocompromised patients may experience more severe disease and should be monitored closely 1

Severe Cases Requiring Hospitalization

Severe cases with neurological complications (encephalitis, meningitis, acute flaccid paralysis) or cardiopulmonary complications require intensive treatment modalities and immediate hospitalization. 2, 4 Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death. 3 Intravenous immunoglobulin should be considered for severe/complicated HFMD. 3