What is the recommended management for hand‑foot‑and‑mouth disease in a child, including hydration, analgesia/antipyresis, isolation, and monitoring for complications?

Management of Hand-Foot-and-Mouth Disease in Children

Hand-foot-and-mouth disease (HFMD) is a self-limiting viral illness requiring supportive care focused on maintaining hydration, controlling pain and fever with acetaminophen or NSAIDs, and monitoring for rare but serious neurological and cardiopulmonary complications. 1

Supportive Care at Home

Hydration Management

• Ensure adequate fluid intake to prevent dehydration, particularly when oral lesions make eating and drinking painful. 1
• Eliminate foods that exacerbate oral pain including tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods. 1
• Drink ample fluids to keep the mouth moist. 1

Pain and Fever Control

• Use oral acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever. 1
• Aspirin should NOT be used in children under 16 years of age. 2
• For infants younger than 6 months, administer 2 mL of 25% sucrose solution by syringe (1 mL per cheek) during especially painful events such as feeding attempts. 1
• Nonnutritive sucking with a pacifier reduces pain-related distress when used together with systemic analgesia in infants. 1

Oral Lesion Care

• 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 or use an oral sponge 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 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution one to four times daily. 1
• Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control. 1

Skin Lesion Management

• Apply intensive skin care of hands and feet with moisturizing creams, particularly urea-containing products. 1
• Zinc oxide can be applied as a protective barrier on the skin, soothing inflamed areas and potentially reducing itchiness in HFMD skin lesions. 1
• Apply zinc oxide in a thin layer after gentle cleansing of affected areas, avoiding open or weeping lesions. 1
• For nighttime relief, consider applying zinc oxide followed by loose cotton gloves to create an occlusive barrier. 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

Foot Lesion Care (When Open Sores Present)

• Wash feet daily with careful drying, particularly between the toes. 1
• Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions. 1
• Do NOT soak feet in footbaths, as this can induce skin maceration and worsen open sores. 1
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain. 1
• Treat any secondary bacterial infections that develop. 1

Infection Control and Isolation

Hand Hygiene

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers for HFMD prevention. 1
• Hands should be washed before and after each patient contact. 2
• Environmental cleaning, particularly of toys and objects that may be placed in children's mouths, is crucial. 1

Isolation Guidelines

• Children with HFMD should avoid close contact with others until fever resolves and mouth sores heal. 1
• 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
• Avoid sharing utensils, cups, or food. 1
• Standard precautions and good hand hygiene practices should be followed in healthcare settings. 1

Monitoring for Complications

When to Seek Medical Evaluation

Most severely ill children should be referred for assessment for admission based on these indicators: 2

• Signs of respiratory distress: markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs 2
• Cyanosis 2
• Severe dehydration 2
• Altered conscious level 2
• Complicated or prolonged seizure 2
• Signs of septicemia: extreme pallor, hypotension, floppy infant 2

Serious Complications to Monitor

• Neurological complications such as encephalitis/meningitis can occur in severe cases, particularly with Enterovirus 71. 1, 3
• Acute flaccid myelitis (AFM) and acute flaccid paralysis (AFP) are rare but potential complications. 1
• Severe cardiopulmonary complications including pulmonary edema can develop suddenly. 3, 4
• Immunocompromised patients may experience more severe disease and should be monitored closely. 1

Late Manifestations (Not Active Disease)

• 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 loss) can occur up to two months after initial symptoms, particularly with coxsackievirus A6. 3

Follow-Up and Re-evaluation

• The child cared for at home should be reviewed if deteriorating, or if not improving after 48 hours. 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

Critical Differential Diagnoses

Severe oral involvement accompanied by systemic symptoms must be distinguished from Stevens-Johnson syndrome/toxic epidermal necrolysis, which require urgent specific treatment rather than supportive care. 1

Other important differentials include:

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

Common Pitfalls to Avoid

• Do NOT use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions, as 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 the possibility of more severe disease with coxsackievirus A6, which affects broader demographics and causes more severe disease with wider distribution than typical HFMD. 5
• Do NOT assume all HFMD is benign—maintain vigilance for neurological and cardiopulmonary complications, especially in children under 3 years of age. 6