Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease is a very common illness, but there is a lot of confusion about it. It is caused by several different viruses in the enterovirus group. It can make kids (and some adults) miserable, but like most viruses we don’t have a specific treatment to fix it. There are things we can do to help kids stay more comfortable and to decrease spread.

Daycares in my area often make unreasonable demands of when to let kids return, which makes me aware that they aren’t aware of how it’s spread and how to control the spread as much as possible. Do they realize that many adults can have the virus and spread the disease without having any symptoms themselves?

How can you recognize hand, foot, and mouth?

Hand, foot, and mouth disease can look different in different people.

Of course the name gives a clue: there’s often a rash on the hands and feet, and in the mouth. If there is  a classic rash, you’ll know what you’re dealing with. The rash can look like red spots or blisters, classically on the palms and soles, but it can extend up the arms and legs. I often call it hand, foot, mouth, and butt disease because bumps in the diaper region are common. You might not recognize the blisters unless you can get a good look in their mouth to see blisters on the gums, tongue, or throat.

Some kids will be fussy and eat less than normal.

Many, but not all, will have a fever. Don’t fear fever.

This photo shows typical blister-type lesions around the mouth of a toddler. Notice the drool at the chin. Many kids have these blisters on their throat, which makes it painful to swallow. They often refuse to eat or drink – or even swallow their saliva!

Hand Foot Mouth Disease

Are there any serious complications?

Most kids recover completely within a week or so, but some can have a more significant illness.

Some kids refuse to eat or drink and may require hospitalization for dehydration.

A rare complication is viral meningitis, an inflammation around the brain. Symptoms can include fever, headache, stiff neck, and irritability. Viral meningitis might require hospitalization to help with comfort measures or to treat with antibiotics while ruling out bacterial meningitis.

Even less commonly children can get encephalitis or a polio-like paralysis. Encephalitis is an inflammation of the brain. Symptoms include fever, seizures, change in behavior, confusion and disorientation, and related neurological signs depending on which part of the brain is affected.

One consequence I tend to see every few years is fingernails and/or toenails falling off weeks after recovery from hand, foot, and mouth disease. While this is not serious and the nails eventually grow back normally, it can be distressing to parents. Simply knowing that this might happen can hopefully stop your worry before it starts!

How is it spread?

Most enterovirus infections in the US are during the summer and fall. Enterovirus infections are common worldwide. Most kids have been infected by the time they’re school aged. Pets do not get infected with enteroviruses.

The virus easily spreads from person to person. This happens through contact with saliva, nose and throat secretions, fluid in blisters, or stool of an infected person. The virus can spread from mother to infant prenatally and in the newborn period.

Enteroviruses may survive on environmental surfaces for periods long enough to allow transmission from fomites.

Respiratory tract shedding usually only occurs for 1-3 weeks, but the virus can exist in the stool for months after infection. Careful hand washing after all diaper changes is essential. In most cases it is not possible to keep kids home from daycare until they are “no longer contagious.”

Infection and viral shedding can occur without signs of clinical illness, especially in adults. This means many parents and daycare providers can unknowingly spread the virus to susceptible infants and children.

The incubation period (time from infection until symptoms show) for enterovirus infections is typically 3 to 6 days.

What treatment can be given?

Because this is caused by a virus, there is no specific medicine that is needed to make it go away.

Fluids are very important. Some kids refuse to swallow due to pain, so they are at risk of dehydration. Giving pain relievers, such as acetaminophen or ibuprofen, can help to decrease the pain and improve how well they will drink. Offer cold drinks, smoothies, and popsicles if age appropriate.

Older children and adults can use throat lozenges or mouth sprays that numb the pain.

Magic Mouthwash

A mixture of liquid diphenhydramine (a common antihistamine) and a liquid antacid, such as Maalox, in a one-to-one ratio can help alleviate pain. Give the amount that equals the diphenhydramine dose per weight.

For example, if a child’s dose is 2.5 ml of diphenhydramine, mix 2.5 ml diphenhydramine with 2.5 ml of the liquid antacid. If a child can swish, gargle, and spit the mixture, it can help numb the sores. When younger children swallow the mixture, it may also help if it coats the sores in the mouth adequately.

Control measures to prevent hand, foot, and mouth disease

Hand washing, especially after diaper changing, is important in decreasing the spread of enteroviruses.

Don’t share foods or drinks. Avoid contaminated utensils.

Wash toys and disinfect surfaces regularly.

Chlorination treatment of drinking water and swimming pools may help prevent transmission.

Can kids get this more than once?

Since there are several different viruses that cause hand, foot, and mouth disease, it is possible to get it more than once. Keep washing those hands, toys, and surfaces!

Fever Is…

Fever is scary to parents.

Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage. In reality the way a child is acting is more important than the temperature. If they’re dehydrated, having difficulty breathing,  or are in extreme pain, you don’t need a thermometer to know they’re sick.

Fever is uncomfortable.

Fever can make the body ache. It’s often associated with other pains, such as headache or muscle aches. Kids look miserable when they have a fever. They might appear more tired than normal. They breathe faster. Their heart pounds. They whine. Their face is flushed. They are sweaty. They might have chills, causing them to shake.

Fever is often feared as something bad.

Parents often fear the worst with a fever:

Is it pneumonia? Leukemia? Ear infection?

Fever is good in most cases. 

In most instances, fever in children is good. It’s a sign of a working immune system.

Fever is often associated with decreased appetite.

This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food. Kids typically increase their intake when feeling well again. Don’t force them to eat when sick, but do encourage fluids to maintain hydration.

Fever is serious in infants under 3 months, immunocompromised people, and in underimmunized kids.

These kids do not have very effective immune systems and are more at risk from diseases their bodies can’t fight. Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.

Fever is inconvenient.

I hate to say it, but for many parents it’s just not convenient for their kids to be sick. A big meeting at work. A child’s class party. A recital. A big game or tournament.  

Whatever it is, our lives are busy and we don’t want to stop for illness. Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home. Don’t expose others by giving your child ibuprofen and hoping the school nurse won’t call.

Fever is a normal response to illness in most cases.

Most fevers in kids are due to viruses and run their course in 3-5 days. Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is. The higher the temperature, the more miserable a person feels. That’s why it’s recommended to use a fever reducer after 102F. The temperature doesn’t need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.

Unfortunately most illnesses are more severe at night. This has to do with the complex system of hormones in our body. It means that kids who seem “okay” during the day have more discomfort over night. This decreases everyone’s sleep and is frustrating to parents, but is common.  

Fever is a time that illnesses are considered most contagious.

During a fever viral shedding is highest. It’s important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help). Wash hands and surfaces that person touches often during any illness. Continue these precautions until the child is fever free for 24 hours without fever reducers. (Remember that temperatures fluctuate, so a few hours without fever doesn’t prove that the infection is resolved.)

Fever is an elevation of normal temperature.

Normal temperature varies throughout the day and depends on the location the temperature was taken and the type of thermometer used. Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury. Ear thermometers are not accurate in young infants or those with wax in the ear canal. Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.

To identify a true fever, it’s important to note the degree temperature as well as location taken. (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn’t identify a true fever and therefore the need to isolate to prevent spreading illness.) I never recommend adding or subtracting degrees to decide if it is a fever. You can look at a child to know if they’re sick.

The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.

Fevers in children are generally defined as temperatures above 100.4 F (38 C).

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal. Kids get sick more than adults. With each illness there can be fever (though not always).

What you can do:
  • Be prepared at home with a fever reducer and know your child’s proper dosage for his or her weight.
  • Use fever reducers to make kids comfortable, not to bring the temperature to normal.
  • Push water and other fluids to help kids stay hydrated.
  • Teach kids to wash their hands and cover coughs and sneezes with their elbows.
  • Stay home when sick to keep from spreading germs. It’s generally okay to return to work/school when fever – free 24 hours without the use of fever reducers.
  • Help kids rest when sick.
  • If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen. A physical exam (and sometimes labs or x-ray) is needed to identify the source ofillness in these cases.  A phone call cannot diagnose a source of fever.
  • Any infant under 3 months or immunocompromised child should be seen to rule out serious disease if the temperature is more than 100.5.

Menthol for Sore Throat, Colds and Coughs… Should we use it?

I am often asked about the use of Vick’s Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. It is basically a local anesthetic which can temporarily numb the nerves in the throat that are irritated by the cold symptoms and provide some relief.

Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm…

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking.

Science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines. For these reasons, I use the “if it seems to help, use it” rule for children not at risk of choking.

Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough.

Vaporized menthol should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress.

Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We’ve all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me. The link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with  spirometry tests (but people stated they could breathe better) in this interesting study.  In other words, people felt better, but there really was no objective improvement.

Putting menthol rubs directly under the nose may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways.

There might be a concern with putting any petrolatum based product in or near the nose. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick’s BabyRub that does not contain menthol. Its ingredients have not been proven to be effective. Some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

Photo source: Angel caboodle at English Wikipedia [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons 

Camphor is another ingredient along with menthol in the rubs. It can be deadly if swallowed.

It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations.

Menthol rubs in the US contain camphor in a concentration that’s felt to be safe if applied to intact skin in those over 2 years old.

Mucus membranes absorb medicines more readily than intact skin. Do not apply to nostrils, lips, or broken skin.

Do not allow children to handle these rubs. Apply only below their necks to intact skin.

Many people using these rubs experience skin irritation. Discontinue use if this happens.

Guidelines for treatment of strep throat: Is it viral or strep?

New guidelines for treatment of strep throat were published in the Oxford Journals of Clinical Infectious Diseases this month.  They attempt to decrease the overuse of antibiotics to treat sore throats caused by a virus, since antibiotics are ineffective against viral illnesses. Streptococcus (AKA Strep) is a bacteria, and antibiotics do treat infections with Strep. (See Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America for the full report.)

While these guidelines are written for physicians and other medical providers, if patients understand the guidelines it can help them know what to do when they (or their children) have a sore throat.  Many parents presume Strep with every sore throat, but in reality only 20-30% of sore throats are bacterial in kids.  The large majority (70-80%) are from a virus and do not need an antibiotic. In adults the number of sore throats needing antibiotics is even lower – only 5-15%.  Nationwide, 70% of people who go to a medical provider with a sore throat get an antibiotic. This means many are treated unnecessarily.

Why do we treat Strep throat with antibiotics?

In most cases Strep throat will be handled by the body’s immune system over a relatively short time.  Without treatment most symptoms go away within a few days.

Before antibiotics were available most people with Strep throat got better on their own. Unfortunately the Strep bacteria can affect the heart (rheumatic fever) or kidneys (streptococcal glomerulonephritis) or cause other problems if left untreated. Treating with antibiotics early can prevent some of these complications.

Why do we want to avoid antibiotics if it is a virus?

Antibiotics do not help the body get better or even feel better faster if a virus is causing the symptoms. They simply are ineffective against viruses.

They do carry risks: diarrhea and allergic reactions are two relatively common issues.

Overusing antibiotics leads to bacterial resistance, which means when someone is sick with a bacterial infection, several antibiotics might fail because the bacteria has become a “super bug” and less inappropriate use will cause fewer super bugs.

How can you know when to bring your kids in for evaluation?

Strep throat and viral sore throats have a lot of common symptoms.

Strep throat typically causes a sudden onset of one or more of the following:
  • sore throat
  • fever
  • rash
  • headache
  • abdominal pain
  • nausea
  • vomiting
  • swollen glands

If there are “cold” symptoms such as runny nose, cough, hoarse voice, diarrhea, or eye discharge, it is more often from a viral upper respiratory tract infection, not a bacterial infection.

Children under 3 years of age are less likely to get Strep throat, but it is very common in school aged children.

The only way to know if it is Strep throat or not is to get a throat swab and test it.  A rapid antigen test is typically available in less than 10 minutes. If it is positive, treatment is indicated. If it is negative, a culture can be done to confirm Strep or no Strep.  This takes about 2 days.

To prevent rheumatic fever, treatment should be started within 9 days of symptoms starting. Unfortunately treatment does not affect the kidney disease that rarely is a complication of Strep throat.

It is not an emergency to run in to the ER overnight for possible Strep throat, but do bring kids in if they have symptoms of Strep without viral symptoms.

Also bring them in if their viral symptoms warrant evaluation in their own right (difficulty breathing, extreme pain, dehydration) or if you are unsure what is going on.

My summary of the guidelines:

1. Establish the diagnosis by swabbing the throat and doing a rapid antigen test and/or culture.  Do not treat “because it looks like Strep” because it usually isn’t.

2. If the rapid antigen test is negative in children and adolescents, a back up culture is indicated. Adults do not need a back up culture unless Strep is highly suspected.

3. Blood titers are not recommended to check for current Strep throat infection because they reflect past infections. These are used to evaluate more chronic conditions.

4. Testing is not recommended if symptoms suggest a viral infection (cough, runny nose, hoarseness, oral ulcers). Falsely positive Strep tests can happen, and then an unnecessary antibiotic would be given with a virus infection.

5. Children less than 3 years of age do not routinely need to be tested for Strep because they are very low risk of complications of rheumatic fever, but the provider can test them if they have known exposure and symptoms of Strep.

6. Follow up throat cultures after treatment are not routinely recommended but can be considered in certain circumstances (if carrier status is suspected).

7. Testing or treatment of contacts of patients with Strep throat is not recommended if those contacts have no symptoms. (This means if Brother has a positive Strep test, there is no need to test or treat Sister if she has no symptoms. But… if she develops symptoms she should come in for a test.)

8. Patients with Strep throat should be treated with an appropriate antibiotic for an appropriate time. This is typically a penicillin (such as amoxicillin) for 10 days. For those with a penicillin allergy, cephalosporins or clindamycin or clarithromycin for 10 days is recommended. Azithromycin for 5 days at Strep dosing levels is acceptable for patients with allergies to other antibiotics.

9. Use of fever reducer/pain relievers, such as acetaminophen or ibuprofen, should be considered as needed. Aspirin should be avoided in children. Steroids are not recommended.

10. Patients with recurrent Strep throat at close intervals should be evaluated for chronic Strep throat carrier status with repeated viral infections.

11. Strep carriers do not require antibiotics because they are unlikely to spread Strep to close contacts and are not at risk of developing complications of Strep (rheumatic fever).

12. Tonsillectomy is not recommended to reduce the frequency of Strep throat.