Hand, Foot, and Mouth Disease

What is it?

"Hand, foot, and mouth disease," (HFM) is the name doctors give to a set of symptoms that young children often get in the summer. Several different viruses can cause HFM. It usually starts out with a few days of cold symptoms and low fever (around 100.4 °F or 38.0 °C). By about the third day the child often complains of a sudden sore throat; s/he may develop a higher fever by then. S/he may have trouble swallowing (younger children and toddlers may just seem fussy and may cry when they eat or drink). What is causing the pain is a collection of tiny blisters far in the back of the child’s throat. These are usually very hard to see without a tongue depressor and a flashlight. Less often, children develop sores near the front of their mouths that are easier to see. Within a day of the mouth or throat sores (and occasionally before there are mouth or throat sores), children develop spots on their hands and feet. These spots are usually dark red to brown, about ¼ inch (1/2 cm) across, usually on the palms and soles. They may turn into blisters. These spots on the hands and feet rarely seem to bother the child nearly as much as the throat sores. Children often have infections with the viruses that cause hand, foot, and mouth disease, but do not have sores in all three places. Because HFM is a viral condition, there is no medicine to treat it, but like most mild viral infections, it goes away by itself in 5-7 days.

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In the vast majority of cases pain and hydration are our biggest concerns. Young children especially may simply refuse to eat or drink while their throats hurt. Since HFM happens during the warm months, dehydration is a possible problem. In a very tiny number of children (much less than 1%), more serious complications can happen. The viruses that cause HFM can sometimes cause a viral form of meningitis, which is itself not dangerous but can be very frightening to parents. Even more rarely, these viruses can cause inflammation and weakness of the heart muscle several weeks after the original infection. This is called "viral myocarditis" (my-oh-card-eye-tiss), which is a very serious condition.

The treatment for HFM is pain control and fluids. Children with HFM often develop fairly high fevers (to around 104 °F or 39.5 °C). Fevers this high usually cause crankiness and discomfort. You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to relieve pain and fever in children over 3 months. Check with your doctor about using it in younger babies. Fever is not dangerous, but it can make the child uncomfortable. If your child seems comfortable there is no reason to give any medication just for fever. Please read our Aftercare Instructions about Fever. Your doctor may instruct you to give a small amount of diphenhydramine liquid (Benadryl®, and others) mixed with an antacid such as Maalox® (or others). This mixture soothes the sores in the mouth and can make it easier for your child to drink. It isn’t necessary to give large volumes of this mixture – one or two cc’s in the mouth is plenty to coat the throat and provide some relief. An older and cooperative child may get some benefit from a phenol spray like Chloraseptic® (or others). These don’t taste very good, but they work almost immediately to numb the throat. You can use these sprays every 2 hours. You can also try throat lozenges with local anesthetics such as dyclonine (Sucrets® and others) in older children. Please be sure your child has finished the lozenge before allowing him or her to go to sleep, to avoid choking.

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To help your child stay hydrated, please use cool liquids, popsicles, ice cream, Jell-O® or other such soothing foods and liquids. Children with HFM are generally old enough that they will not get severely dehydrated even if they take only a small amount of fluid for one two days. If you make the liquids constantly available without trying to "force" them on your child, chances are you’ll avoid dehydration.

HFM is a self-limited illness – that is, it will go away by itself without specific treatment. A small number of children do become dehydrated, and a very small number can develop viral meningitis. Here are some things to watch out for:

• Complete refusal to drink liquids for more than 24 hours
• Dry or sticky mouth and tongue (dry lips are common and are not a sign of dehydration)
• A sunken appearance to the eyes (or fontanel (soft spot) if your child still has one)
• Less urine than usual, or a very strong odor to the urine
• Extreme fussiness or irritability
• Extreme sleepiness or lethargy
• Stiff neck
• Headache
• Complaining that light hurts the eyes or causes headache

Each year a very tiny number of children develop heart muscle disease, or myocarditis, following infection with one of the viruses that cause HFM. This condition develops a few weeks after the HFM symptoms have cleared up. Parents often do not realize that the new symptoms might be related. In myocarditis, the heart muscle becomes weakened and inflamed, and it cannot pump blood as effectively as normal. Children with myocarditis often first complain of being exceptionally tired. They may reduce their usual amount of activity and exercise. They often run a low fever and then develop a cough and/or trouble breathing. Some children develop swelling of the face, hands, and feet. Often, when a child first sees a doctor with these complaints, s/he is given a diagnosis of "pneumonia" because of the fever and cough. Fluid collecting in the lungs can look like pneumonia on an X-ray. If your doctor is worried about myocarditis, s/he will order an echocardiogram ("cardiac echo") to look at the motion of the heart. Myocarditis is a serious condition and requires hospitalization and prompt treatment.

Children can get sores in their mouths from a number of different causes. Here are some of the most common (you can read our Aftercare Instructions and/or Child Health Topics on these by clicking on the links):

• Chickenpox – many children get some pox sores in their mouths, but they almost always have the more obvious blisters on their skin in many places at once. Chicken pox is now fairly rare since the vaccine has been available. [Aftercare for Chicken Pox]
• Stomatitis – this is the name we give to a number of different conditions all with sores in the mouth. Stomatitis can come from many different viral infections. The most serious are herpes virus infections. These usually cause sores in the front of the mouth, not in the back like HFM. First time herpes infections are usually pretty severe, with a lot of pain, damaged tissue, and a foul odor on the breath.  [Aftercare for Stomatitis]
• Rocky Mountain Spotted Fever and other rare conditions – these diseases can cause rash on the palms and soles, as well as high fevers. They always cause severe headaches, and often cause abdominal pain as well. Despite the name, most children with Rocky Mountain Spotted Fever have never been anywhere near the Rocky Mountains!

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.