The parent’s guide to hand, foot, and mouth disease in children

Endless coughs and sneezes, runny noses, and unexplained itchy bumps—kids seem to be a magnet for germs. In our parent’s guide to childhood illnesses, we talk about the symptoms and treatments for the most common conditions. Read the full series here.

What is HFMD? | Symptoms | Diagnosis | Treatment | Prevention

Hand, foot, and mouth disease sounds like something you would find in a barnyard, but it is actually a common and usually harmless childhood illness. It is contagious and often spreads easily through schools and child care centers. Thankfully, most cases are mild and children recover without any serious or lasting effects.

What is hand, foot, and mouth disease (HFMD)?

HFMD is a viral illness (usually coxsackievirus a16 or other enteroviruses). In the United States, it occurs more often in the summer and fall seasons. While adults and older children can catch the viral infection, it’s most commonly in young children 6 months to 5 years old. It is not related to any animal diseases—despite the similarity in name to foot-and-mouth disease (also known as hoof-and-mouth disease), which affects cows, sheep, and pigs. 

The hallmark of HFMD is red flat spots that may blister in the mouth, on palms of the hands and soles of the feet, and occasionally on other areas of the body.

The incubation period (time from exposure to illness to the appearance of symptoms) for HFMD is three to six days. People are most contagious during the first week of illness, but the virus can stay in the respiratory tract and shed for several weeks after a person recovers, and HFMD can be spread through feces up to several months after recovery. It’s also possible to have HFMD and not be symptomatic, particularly for adults. Asymptomatic carriers of HFMD can still spread the illness.

Because the illness is usually mild, and the contagious period can be long, children don’t need to stay home from school or daycare, unless:

• They have a fever.
• They feel too unwell to participate.
• There is a policy in place at the school or daycare that requires children with HFMD to stay home.
• They have open blisters. (The fluid inside the blisters is contagious. Blisters take about a week to dry up.)
• Their healthcare provider recommends they stay home.

Hand, foot, and mouth symptoms

HFMD starts with cold-like symptoms such as fever, sore throat, and runny nose. Then, blisters appear on the hands and/or feet and (usually ulcers) in the mouth.

According to the U.S. Centers for Disease Control and Prevention (CDC), symptoms of hand, foot, and mouth disease include:

• Flat red spots (about the size of a pencil eraser or smaller) that rash on hands, feet, and sometimes buttocks, knees, elbows and/or genitals. The rash consists of flat red spots that may blister.
• Painful sores in the mouth that begin as flat red spots 
• Sore throat
• Fever
• Feeling unwell
• Reduced appetite
• Drooling

Your child’s symptoms may not all be present at the same time. Most cases of HFMD are mild and follow the above pattern of symptoms—but a more severe form of HFMD caused by a new coxsackie virus began occurring in 2012 and continues to circulate.

Symptoms of severe HFMD are the same as HFMD, but can also include:

• A rash made up of many small blisters on arms, legs, and face.
• Loss of fingernails and/or toenails. This occurs in 4% of severe cases, three to six weeks into the illness. They will grow back (in three to six months for fingernails and nine to 12 months for toenails) and will look normal when they do.

It’s common for the skin on fingers and toes to peel a week or two into HFMD. This is harmless and can be helped by applying moisturizing cream.

Serious complications from HFMD are rare, but can include:

• Viral meningitis (an inflammation of the lining of the spinal cord and brain, which could result in a hospital stay for a few days)
• Paralysis (rarely)
• Encephalitis (brain inflammation, occurs rarely)

How is hand, foot, and mouth diagnosed?

“Hand, foot, and mouth disease is usually diagnosed clinically,” says Soma Mandal, MD, a board-certified internist at Summit Medical Group. “There is a typical appearance and location of the oral lesions and/or lesions on the hands or feet. When the diagnosis is uncertain, a throat swab, stool sample, or fluid from the rash can be sent for testing.” However, testing is rarely done since it can be expensive and won’t change the management of symptoms since there is no treatment.

HFMD is usually diagnosed by a pediatrician or family/general healthcare provider. Children should see their healthcare provider for diagnostic purposes, but in most cases the healthcare provider will not prescribe medical treatment.

“Call your healthcare provider if the symptoms do not improve within a week, the child has a weak immune system, or is under 6 months of age,” says Leann Poston, MD, a medical contributor for Ikon Health. 

Get immediate medical attention if:

• Your child becomes dehydrated. Signs of dehydration include no urine in eight hours or more, dark urine, very dry mouth, no tears. Dehydration is a concern with HFMD because the child’s sore mouth may discourage normal eating and drinking patterns.
• The child looks or acts very sick.
• You feel your child needs urgent medical attention.

Speak with your child’s health care provider if: 

• Your child is less than 6 months old.
• Your child is not immunized or delayed in immunizations—be sure to call the office first to take precautions to prevent contamination.
• The rash spreads to the arms and/or legs.
• The rash changes in appearance.
• The fever lasts longer than three days.
• There is no improvement after 10 days.
• Your child has a chronic illness or is immune compromised.
• You feel the child needs to be seen, but not urgently.
• Fingernails or toenails fall off.
• You have questions or concerns.

Hand, foot, and mouth treatment

“There is no medication that will shorten the course of the illness or make it go away,” says Dr. Poston. “Antibiotics will only help if there is a secondary bacterial infection.” However, some over-the-counter medications can provide symptom relief.

Fever and pain relief

Fever and pain can be treated with over-the-counter medications like acetaminophen (Tylenol) or ibuprofen (Advil or Motrin).

Mouth sore relief

“Some pediatricians recommend a combination of Benadryl and Maalox to help with mouth sores,” Dr. Poston says. “Call your pediatrician to see if this is a safe and effective choice for your child.”

Liquid antacid, such as Maalox or Mylanta, can be used as treatment up to four times a day as needed, and is administered according to age. For children aged 1 to 6 years, put a few drops in the mouth or apply directly to mouth sores with a cotton swab. For children older than 6 years, give one teaspoon (5 ml) of Maalox or Mylanta as a mouthwash. Have the child keep it on the ulcers as long as possible then spit or swallow it. Do NOT use regular mouthwash—it would be quite painful. 

“Hand, foot, and mouth disease usually goes away on its own in about a week,” says Dr. Mandal. “The oral lesions may make it difficult to eat or drink, so cold foods such as popsicles or ice cream and pudding or gelatin are easier to swallow.” Opt for hydration over solid foods, or try soft foods like mashed potatoes or soup. Avoid any salty or spicy dishes, which could irritate mouth sores. Bottle-fed babies may find the nipple of the bottle irritating and do better with cup, spoon, or syringe feeding while the sores heal.

How to prevent hand, foot, and mouth

Having HFMD once does not make you immune to it—it is possible to get it again and again.

Because HFMD is spread via respiratory route (droplets from coughing, talking, sneezing, etc. land on objects or other people and are transferred to that person’s eyes, nose, or mouth), and via fecal-oral route (poop from an infected person gets on objects that other people touch and then they touch their eyes, nose, or mouth), good hygiene is the best way to prevent the spread and re-infection of HFMD.

• Cover coughs and sneezes, and teach children how to do so.
• Handwashing with soap and water frequently for at least 20 seconds—especially after using a tissue, using the washroom, or changing a diaper.
• Clean and sanitize toys regularly, especially ones that have come into contact with saliva.
• Avoid sharing food, drinks, toothbrushes, towels, or anything else that comes in contact with the mouth, particularly that of someone who has or has recently had HFMD.
• Regularly clean and disinfect frequently touched surfaces.

If a person in the house has HFMD, keep them away from close contact with other children as much as possible—discouraging kissing, hugging, sharing personal items like cups or utensils, sleeping in separate rooms—until the infected person has made a full recovery.

If the child attends school, daycare, or any place where they are in contact with other children and they contract HFMD, always inform the supervisor so they can let other parents know that their children may have been exposed.

Hand, foot, and mouth disease isn’t fun, and it isn’t pretty—but it is generally mild and resolves on its own.