How should hand, foot and mouth disease be managed in a child?

Management of Hand, Foot, and Mouth Disease in Children

HFMD in children is managed primarily with supportive care, focusing on maintaining hydration, controlling pain and fever, and preventing transmission through rigorous hand hygiene. 1, 2

Immediate Assessment Priorities

Assess the child's ability to take fluids orally at every encounter, as painful oral lesions pose the primary threat to adequate hydration. 2 Monitor specifically for:

• Decreased urine output
• Dry mucous membranes
• Lethargy or altered mental status 2

Pain and Fever Management

Systemic Analgesia

• Administer acetaminophen or NSAIDs (ibuprofen if age-appropriate) for pain relief and fever reduction for a limited duration. 1
• For infants, these medications should be used together with non-pharmacologic measures. 1

Non-Pharmacologic Pain Control (Infants)

• Nonnutritive sucking with a pacifier reduces pain-related distress when used with systemic analgesia in infants with oral lesions. 1
• Administer 2 mL of 25% sucrose solution by syringe (1 mL per cheek) for infants younger than 6 months during painful events such as feeding attempts. 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 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 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

Hydration and Nutrition

• Offer cool, non-acidic fluids frequently in small amounts to minimize oral discomfort. 2
• Eliminate citrus fruits, tomatoes, hot drinks, and spicy, hot, raw, or crusty foods that exacerbate oral pain. 1, 2
• Drink ample fluids to keep the mouth moist. 1

Skin Care for Hand and Foot Lesions

• 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 corns or calluses. 1
• For itchiness, zinc oxide can be applied as a protective barrier in a thin layer after gentle cleansing. 1

Management of Open Sores on Feet

• 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 induces skin maceration and worsens open sores. 1

Infection Control and Prevention

Hand hygiene with soap and water is the single most important preventive measure and is more effective than alcohol-based sanitizers for HFMD prevention. 3, 1, 2

• Wash hands thoroughly for at least 15-20 seconds, covering all surfaces, before and after each contact with the child, after diaper changes, and after contact with respiratory secretions. 2
• Clean environmental surfaces, particularly toys and objects that may be placed in children's mouths. 1
• Avoid sharing utensils, cups, or food. 1

Monitoring for Complications

Neurological Complications (Particularly with Enterovirus 71)

Monitor for signs requiring urgent evaluation: 1, 2

• Persistent high fever
• Severe headache
• Altered mental status or lethargy
• Weakness or acute flaccid paralysis
• Signs of encephalitis or meningitis

Secondary Bacterial Infection

Watch for: 1

• Increased redness and warmth
• Purulent drainage
• Worsening pain beyond expected course

Severe Dehydration

If oral intake is severely compromised, assess for indicators requiring IV hydration. 2

Critical Differential Diagnoses

Distinguish HFMD from conditions requiring different management: 1

• Herpes simplex virus infection: HSV has available antiviral treatment (acyclovir), whereas HFMD does not. 3, 1
• Stevens-Johnson syndrome/toxic epidermal necrolysis: Requires urgent specific treatment rather than supportive care. 1
• Kawasaki disease: HFMD has vesicular lesions versus diffuse erythema in Kawasaki. 1
• Drug hypersensitivity reactions, which can present with palmar-plantar rash. 1

Return to Daycare/School

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, as by the time HFMD is diagnosed, the child has likely had the infection for weeks and poses limited additional risk. 1

Follow-Up and Late Manifestations

• 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
• Periungual desquamation typically begins 2-3 weeks after fever onset. 1
• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset as a delayed sequela. 1

Important Caveats

• Antibacterial medications should only be used if there are specific indications of coexisting bacterial infection, not routinely. 2
• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions. 1
• Immunocompromised patients may experience more severe disease and should be monitored closely. 1
• Most cases are self-limiting and resolve in 7-10 days without sequelae. 4, 5