What are the typical presentation, supportive management, and warning signs for hand, foot and mouth disease (HFMD) in a child under five years old?

Hand, Foot, and Mouth Disease in Children Under Five

Typical Clinical Presentation

HFMD typically begins with fever (often the first symptom), followed 1-2 days later by painful oral lesions and a characteristic vesicular rash on the hands, feet, and sometimes buttocks. 1

Initial Symptoms (Days 1-2)

• Fever is usually the first manifestation, typically low-grade but can exceed 102.2°F (39°C) 1
• General malaise, irritability, and discomfort are common early signs 1
• Respiratory symptoms such as cough and rhinitis may occur, especially in younger children 1

Rash Development (Days 2-3)

• Oral lesions develop first, appearing as small red spots that progress to painful vesicles and ulcers on the tongue, gums, and inside of the cheeks 1
• Vesiculopapular rash on hands and feet (including palms and soles) is the most common clinical characteristic 2
• Buttocks may also be involved 3

Disease Course

• Fever usually subsides within 3-4 days 1
• Oral ulcers may persist for 7-10 days and cause significant discomfort leading to decreased oral intake 1
• The illness is typically self-limiting and resolves without complications 4, 2

Supportive Management

Treatment focuses on symptom relief with oral analgesics, maintaining hydration, and intensive skin care, as there is no specific antiviral therapy available. 5, 4

Pain and Fever Control

• Use acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 5
• Avoid aspirin in children due to Reye's syndrome risk (general medical knowledge)

Oral Lesion Management

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 5
• Use mild toothpaste and gentle oral hygiene 5
• Clean the mouth daily with warm saline mouthwashes 5
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 5
• 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 5
• Barrier preparations such as Gengigel mouth rinse or gel may help with pain control 5

Dietary Modifications

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that exacerbate oral pain 5
• Drink ample fluids to keep the mouth moist and prevent dehydration 5
• Monitor closely for signs of dehydration, particularly in children refusing oral intake due to painful mouth sores 1

Skin Care

• Apply intensive moisturizing creams to hands and feet, particularly urea-containing products 5
• Avoid friction and heat exposure to affected areas 5
• For itchiness, zinc oxide can be applied as a protective barrier after gentle cleansing 5
• Apply zinc oxide in a thin layer; for nighttime relief, consider loose cotton gloves to create an occlusive barrier 5
• Avoid applying zinc oxide to open or weeping lesions 5

Foot Lesion Care (if open sores present)

• Wash feet daily with careful drying, particularly between the toes 5
• Avoid walking barefoot and wear appropriate cushioned footwear 5
• Do not soak feet in footbaths, as this can induce skin maceration and worsen open sores 5
• Monitor for signs of secondary bacterial infection (increased redness, warmth, purulent drainage, or worsening pain) 5

Infection Control

• Hand hygiene with thorough handwashing using soap and water is the most important preventive measure (more effective than alcohol-based sanitizers) 5
• Clean toys and objects that may be placed in children's mouths 5
• Avoid sharing utensils, cups, or food 5

Return to Daycare

• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present 5
• Exclusion based solely on healing skin lesions is not necessary 5

Warning Signs Requiring Immediate Medical Attention

Parents must be counseled to seek immediate medical care if any neurological or respiratory warning signs develop, as these indicate potentially life-threatening complications. 1

Critical Red Flags

• Persistent high fever despite antipyretics 1
• Lethargy or unusual drowsiness 1
• Severe headache 1
• Stiff neck (meningismus) 1
• Unusual irritability or altered mental status 1
• Respiratory distress (may indicate rare but serious complications like neurogenic pulmonary edema) 1

Serious Complications to Monitor For

• Neurological complications including meningitis, encephalitis, and acute flaccid paralysis can occur, particularly with Enterovirus 71 infections 1, 6
• Brain stem encephalitis (rhomboencephalitis) is a rare but severe complication associated with EV-A71 6
• Cardiopulmonary complications, though rare, can be fatal 4

Follow-Up Considerations

• Reassess after 2 weeks if lesions are not improving with standard care 5
• Re-evaluate after 4 weeks if evidence of infection has not resolved and consider alternative diagnoses 5
• Nail changes (Beau's lines or periungual desquamation) may appear 1-2 months after fever onset as a delayed sequela, not active disease 5
• Onychomadesis (nail shedding) can occur 1-2 months post-infection, particularly with Coxsackievirus A6 6

Important Clinical Pearls

• Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 5
• Consider Kawasaki disease in the differential diagnosis due to its potential for cardiac complications; Kawasaki presents with persistent high fever, diffuse erythema (not vesicular lesions), conjunctival injection, strawberry tongue, and cervical lymphadenopathy 1
• Coxsackievirus A6 causes more severe and atypical presentations with widespread exanthema beyond classic distribution 6, 7
• Immunocompromised patients may experience more severe disease and should be monitored closely 5
• The disease is highly contagious; by the time HFMD is diagnosed, the child has likely had the infection for weeks 5