Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease (HFMD) is primarily a childhood illness, though it can also affect adults. The symptoms are generally similar in both children and adults; however, the disease can be more severe in infants and young children due to their inability to articulate their symptoms. HFMD is typically mild, resembling a common cold during the initial days of infection. In most cases, symptoms last for 7 to 10 days. As the name indicates, symptoms manifest on the hands, feet, and mouth in the form of sores, blisters, and rashes. The typical symptoms of HFMD can be broadly classified as:

• Fever and flu-like symptoms: These symptoms usually appear 3 to 5 days after contracting the virus and include:
  • High fever
  • Sore throat
  • Tiredness
  • Loss of appetite
• Mouth ulcers: Children with HFMD often develop mouth sores a few days after infection. Ulcers appear on the mouth and tongue, gradually progressing into painful blisters, making swallowing difficult. Signs to watch for in children include:
  • Not eating even their favorite food
  • Drooling more than usual
  • Crying while eating
  • Preference for cold fluids
• Skin rashes: A child with HFMD may develop rashes that appear as slightly raised red spots. The spots may also appear pink or darker depending on skin tone. The most common locations for rashes are the hands and feet, but they can also occur on the buttocks, legs, and arms. In most cases, rashes do not cause itching. Occasionally, rashes may develop into blisters filled with fluid containing viruses.
• Other symptoms: A child with HFMD might also experience:
  • Muscle aches
  • Irritability
  • Abdominal pain
  • Diarrhea
  • Headache
  • Runny nose
  • Peeling of the skin
  • Tenderness or pain when touching the palms and soles
  • Vomiting

Here are some important things to remember when your child has one or more episodes of vomiting:

• Signs of dehydration: A child suffering from HFMD may become dehydrated due to an inability to drink, which can be indicated by:
  • Dry mouth
  • Lack of tears
  • Sunken eyes
  • Dark urine
  • Decreased frequency of urination
  • No wet diapers for 4 to 6 hours (infants and toddlers)

HFMD is a viral infection caused by the enterovirus family, which includes mainly three viruses:

• Coxsackievirus A16: The most common cause of HFMD.
• Coxsackievirus A6: Associated with the severe form of infection.
• Enterovirus 71 (EV-A71): Rarely found but associated with severe diseases such as encephalitis.

Transmission

The disease is highly contagious and can spread from one person to another through infected saliva, nasal secretions, fluid from blisters, and feces. The chances of spreading the infection are highest during the first 5 days of symptom onset. However, in some cases, the infection can be transmitted even in the absence of symptoms or later due to the presence of the virus in the stool for 4 to 8 weeks.

Anyone can contract the disease through:

• Contact with respiratory secretions during coughing or sneezing.
• Close contact with an infected person, such as during kissing or hugging.
• Touching an infected person.
• Sharing contaminated objects with an infected person.
• Touching an infected person’s feces, such as during diaper changes.
• Touching contaminated objects and surfaces, such as doorknobs and toys.

Note: In rare cases, the virus of HFMD can also be transmitted by swallowing water in swimming pools if the water is contaminated with feces from an infected person.

Risk Factors For Hand, Foot, and Mouth Disease

Age: HFMD primarily affects infants and young children. Children under 5 years are more susceptible to HFMD.

Gender: Some studies indicate that males are at a higher risk of contracting HFMD.

Poor hygiene: The viruses causing HFMD can survive on surfaces and objects for a period, making inadequate cleanliness a risk factor.

High frequency of social contacts: Children frequently exposed to crowded environments, such as schools, parks, and childcare centers, are at increased risk of contracting the disease.

Sharing toys with other children: Contaminated toys can elevate the risk of HFMD transmission among children.

Residence in rural areas: Some studies suggest that children living in rural areas may have a higher likelihood of HFMD infection due to greater exposure to people.

Improper hand washing: Individuals who do not regularly wash their hands, especially before meals and after using the toilet, are at a higher risk of HFMD.

Note: HFMD is generally mild and self-limiting. However, in some cases, patients may develop severe neurological complications. The risk factors that predispose an individual to severe HFMD include:

• Infection in children under 3 years of age
• Fever lasting more than 3 days
• Body temperature greater than 39.0°C
• Vomiting
• Increased neutrophil count
• Respiratory rate greater than 24/minute
• Trembling of limbs
• Dyspnea (difficulty in breathing)
• Rashes on hips
• Lethargy
• Convulsions
• EV71 infection
• Low birth weight

The diagnosis of hand, foot, and mouth disease is usually straightforward. In most cases, it is made by examining the appearance of rashes, mouth ulcers, and blisters. The patient’s age and other clinical symptoms are also considered before confirming the infection. In some instances, samples of throat and feces may be examined.

Other tests that are rarely used include:

• Biopsy: Tissue taken from the vesicles of blisters is examined using light microscopy to differentiate hand, foot, and mouth disease from varicella zoster virus and herpes simplex virus.
• Serological testing: This test is generally performed to confirm viral infections by detecting antibodies. However, it is not sensitive enough to diagnose the HFMD virus. It can be used to monitor recovery by checking IgG levels.
• Polymerase chain reaction: This test is utilized to confirm the diagnosis of coxsackievirus.

There is no vaccine for hand, foot, and mouth disease, but it can be easily prevented by following some basic steps, which include:

• Hand washing: Since HFMD is a contagious disease that can spread through touching, hand washing serves as the best protection. Hands should be washed often with soap and water, and children should be educated about the importance of hand hygiene. In cases where soap and water are not available, such as during travel, alcohol-based sanitizer can be used. Make sure to wash hands after:
• Changing diapers
• Using the toilet
• Touching the nose
• Coughing and sneezing
• Taking care of sick individuals
• Cleaning and disinfection: The virus causing HFMD can live on surfaces for some time. It is advised to clean frequently touched surfaces and objects regularly, such as toys, doorknobs, and sippers. Make sure to wash soiled bedding and clothes with hot soapy water.
• Avoid touching eyes, nose, and mouth: The infection can spread by touching the eyes, nose, and mouth with contaminated hands. To reduce this risk, avoid touching these areas with unwashed hands.
• Avoid close contact with infected individuals: The disease can spread through close contact with an infected person, especially during kissing and hugging.
• Avoid sharing articles: Since the virus can live on objects for a few days, avoid sharing toys, towels, or household items such as cups and utensils of your child with anyone. Regular cleaning of shared toys and books should be practiced in childcare centers.
• Stay off school or nursery: The spread of infection can be prevented by keeping kids home for a few days, especially if they have symptoms such as fever, blisters, or mouth ulcers.
• Use tissues: Try not to cough or sneeze in the open air; always use a tissue when doing so. Make sure to dispose of used tissues immediately to reduce the risk of infection.

Note: Breastfeeding does not impact the incidence of hand, foot, and mouth disease. Mothers do not need to stop breastfeeding to prevent transmission of the disease.

There is no specific treatment for HFMD, and children usually recover within 7 to 10 days on their own. As HFMD is a viral disease, antibiotics are not effective in curing the infection. The measures taken are to reduce symptoms and prevent dehydration.

There are various studies ongoing to develop antiviral treatments against enterovirus 71 induced hand, foot, and mouth disease due to its neurological complications.

The following treatment regimen is used to treat HFMD:

• Over-the-counter (OTC) medications such as paracetamol and ibuprofen are used to treat fever and pain caused by mouth sores.
• Proper hydration should be maintained, as the child may not want to drink much due to painful sores.
• A mixture of liquid ibuprofen and diphenhydramine can be used as a gargle to reduce the pain caused by the ulcers.
• Ribavirin, quinacrine, and amantadine are off-label antiviral medications used in severe cases of enterovirus 71.
• According to some studies, the antiviral drug acyclovir has shown a reduction in fever and skin changes within 24 hours of administration.
• In cases of severe dehydration and neurological or cardiopulmonary complications, hospitalization is required.

Note: Aspirin is not recommended for children, as it is linked to a life-threatening disorder called Reye’s syndrome, which is a rare and potentially fatal pediatric illness. This syndrome causes serious liver and brain damage. The disease typically presents as vomiting and confusion, which can lead to coma and death.

Tips to Soothe Sore Throat

• Throat lozenges and sprays that do not contain benzocaine can be used for children over 4 years of age.
• Liquid antacid can be used for rinsing after meals.
• Gargling with a mixture of warm water and salt is very effective for children over 6 years of age who can gargle without swallowing.

Although the disease is mild and usually resolves on its own, symptoms such as painful mouth sores can make it very difficult for the child to eat and drink. This can lead to increased irritability and fussiness.

Parents should understand that the child may not be able to eat much for at least 7 to 10 days. It is advised to transition the child from solid foods to soft liquids.

The following measures may help facilitate the child's recovery:

Diet

Foods to include: The child should be encouraged to consume fluids such as water, milk, and coconut water to prevent dehydration. Cold and soft foods like ice cream, yogurt, smoothies, shakes, mashed potatoes, oatmeal, eggs, and popsicles should be included in the diet, as they can help numb the area. These options not only serve as treats but also soothe the ulcers.

Foods to avoid: Acidic foods (citrus juices, lemonade, sodas, and tomato sauces) can irritate mouth sores and should be avoided. It is also recommended to steer clear of hot drinks and spicy foods, as they can exacerbate the pain caused by mouth sores.

Cleaning of Blisters

The blisters that typically appear on the hands and feet should be kept clean through regular washing with soap and water. If the blisters rupture, they should be cleaned with an antibiotic ointment to prevent infection.

Avoidance of Self-medication

There are various over-the-counter medications that can be harmful to infants and young children. Avoid giving any medication to your child without the pediatrician’s consent.

Education

The child should be taught not to touch the rash and mouth ulcers, and to sneeze or cough into a tissue or on his/her sleeve. Education on hand hygiene is equally important.

Staying at Home

Inform the child's daycare center and school that he/she has been diagnosed with HFMD. It is important to notify staff and parents so they can monitor symptoms in other children. The child should remain at home until the mouth sores and open blisters have fully healed.

Breastfeeding

If your child is under one year old, continue to provide either breast milk, formula, or both.

The disease is acute with mild symptoms. Most patients with HFMD recover within a few weeks, and the infection rarely recurs or persists. The complications from hand, foot, and mouth disease are rare and include:

• Dehydration: This is the most common complication associated with HFMD. Children often become dehydrated due to difficulty swallowing as a result of painful mouth ulcers. It is essential to maintain optimum hydration.
• Persistent stomatitis: This refers to the inflammation of the mucous membrane of the mouth, often associated with painful ulcers that limit food intake.
• Aseptic (viral) meningitis: This is the inflammation of the layers of the brain due to viral infection, more commonly associated with enterovirus 71. It is often characterized by fever, headache, stiff neck, or back pain.
• Fingernail and toenail loss: In very severe cases, individuals may start losing fingernails or toenails, usually noticed after 2 months of infection. The nails typically grow back on their own.

In severe cases of infection, HFMD can also cause:

• Widespread rash
• Enteritis (infection of the gut)
• Pneumonia
• Myocarditis (inflammation of the muscle of the heart)
• Pulmonary edema (accumulation of fluids in the lungs)
• Cerebral ataxia (sudden, uncoordinated muscle movement due to brain injury)
• Encephalitis (inflammation of the brain)
• Guillain-Barre syndrome (a rare disorder in which the body's immune system attacks the nerves)
• Intracranial hypertension (build-up of pressure around the brain)
• Paralysis

Hand, Foot, and Mouth Disease in Pregnancy: Although there is no potential risk to the baby or mother, the medical history of the patient can affect the situation. Pregnant women should contact their doctor, as in rare cases, HFMD can lead to miscarriage during the first trimester due to persistent high temperature.

Note: HFMD can affect adults as well. However, most infected adults do not exhibit any symptoms, but they can still be contagious and spread the virus to others.

• Coconut water: Acts as a coolant and contains vitamins, minerals, electrolytes, and antioxidants. It prevents dehydration and helps reduce mouth pain.
• Oil pulling: An ancient method for maintaining good oral hygiene, involving swishing oils like sesame or coconut in the mouth for 5 to 10 minutes. It soothes mouth sores.
• Cod liver oil: A beneficial remedy for HFMD due to its antimicrobial and immune-boosting properties. Available in capsule form or can be mixed with oil or yogurt.
• Echinacea: A herb known to reduce fever, colds, and infections. Prepared by boiling its leaves in water and adding honey.
• Lavender oil: Known for its antiviral properties and calming effects, aiding in sleep. A few drops in bath water can help your child sleep better.
• Liquorice root: Helps soothe blisters by forming a thin layer of mucous in the throat and esophagus. Can be taken as tea made by boiling liquorice roots in water.
• Ginger: An effective home remedy with antiviral properties. Prepared by boiling chopped ginger in water; ensure it cools before giving it to your child.
• Coconut oil: Can be applied to rashes and blisters for a soothing and healing effect.
• Neem: Has antimicrobial properties, often used topically to treat viral infections. Neem oil can be applied to rashes and can be mixed with coconut oil and lavender oil.
• Aloe vera: The gel can be applied to rashes and blisters for soothing relief.