Hand, foot and mouth disease: symptoms, care and childcare rules

Hand, foot and mouth disease is a common viral illness in babies and young children. It usually starts with a fever, a sore throat and not wanting to eat, then painful mouth ulcers and spots or blisters on the hands, feet and nappy area. The NHS hand, foot and mouth page says it usually gets better on its own in 7 to 10 days, and antibiotics don't help.

The biggest practical problem is drinking: the CDC says painful mouth sores can make swallowing hard, so children need help to get enough fluids. This guide covers symptoms, how it spreads, childcare rules in Australia, the UK and the US, keeping your child drinking, nail changes afterwards, pregnancy, and the signs that need urgent help.

What are the symptoms of hand, foot and mouth disease?

The illness tends to unfold in stages. The AAP's hand, foot and mouth page says symptoms take 3 to 6 days to show after exposure.

Sources: NHS, AAP, NSW Health in Australia and DermNet.

NSW Health says the blisters start as small red dots, then appear inside the cheeks, on the gums and sides of the tongue, and on the palms and soles; in babies they can appear in the nappy area. It says children may be off their food for a day or two. The CDC's symptoms page says the rash can also appear on the buttocks, legs and arms.

On brown and black skin, the NHS says the spots can look pink, red or darker than the surrounding skin, and blisters may look grey or lighter than the skin around them.

If your child has eczema, the Royal Children's Hospital Melbourne in Australia says the illness can make eczema flare. DermNet says spots may gather in eczema patches, called eczema coxsackium. See baby eczema.

The RCH says many children are grumpy and don't sleep well while their mouth is sore. Sleep when your baby is sick covers safe sleep and extra feeds through the night.

How does hand, foot and mouth disease spread?

It's caught easily. The NHS says it spreads in coughs, sneezes, poo and the fluid in the blisters, and you can catch it more than once. The CDC's page on causes adds close contact such as kissing and sharing cups, and touching contaminated surfaces.

How long a child is infectious:

• The NHS says spread can start a few days before symptoms, and is most likely in the first 5 days after symptoms start.
• UK health protection guidance says people are most infectious in the first week and stay infectious until a few weeks after symptoms stop.
• NSW Health says the viruses can remain in poo for several weeks, and the AAP says weeks to months.

The CDC says coxsackievirus A16 is the most common cause in the US, coxsackievirus A6 can cause more severe symptoms, and enterovirus 71 has been linked to outbreaks in East and Southeast Asia and to more severe disease.

To limit spread at home:

1. Wash your hands with soap and water after every nappy change and before eating, as NSW Health advises, and wash your child's hands too.
2. Don't share cups, cutlery, towels or toothbrushes, as NSW Health advises.
3. Wash soiled bedding and clothes on a hot wash, as the NHS suggests, and clean toys and surfaces.
4. Keep the sick child apart from a new baby where you can. The Sydney Children's Hospitals Network in Australia says newborns with siblings in childcare or school are at higher risk, and the AAP suggests separating siblings who share a room until the sick child is better and the blisters have healed.

Does my child need to stay home from childcare?

This depends on where you live. Keep any child home while they're too unwell to join in or have a fever; after that, the rules differ.

NSW Health also says to avoid swimming lessons and playgrounds during the exclusion period, and to tell the childcare director. Victoria's health department in Australia says exclusion is required until all blisters have dried, and the Royal Children's Hospital Melbourne and Sydney Children's Hospitals Network give the same advice.

In the UK, the UKHSA exclusion table says no exclusion is required, and the NHS says there's no need to wait until all the blisters have healed, because keeping children away longer is unlikely to stop the spread. The AAP says blisters usually take about 7 days to dry, and a local health department may ask children to stay home during an outbreak. Your centre may have its own policy, so check with them. See starting childcare for more on illness and care.

How do I keep my child drinking when their mouth hurts?

Fluids matter more than food for a few days. These steps come from the NHS, the RCH and the Sydney Children's Hospitals Network:

1. Babies: keep breast or bottle feeding, offering feeds more often. The NHS fever page says to continue breastfeeding as normal, and the RCH dehydration fact sheet suggests smaller amounts more often for babies aged 6 to 12 months. Water for babies explains when water is suitable.
2. Offer cool drinks. The NHS suggests cool fluids to soothe the mouth and says to avoid acidic drinks such as fruit juice.
3. Try a different way to drink. The RCH says a straw, a sippy cup or a medicine syringe (without a needle) can help a child with mouth pain, and that a young child who is refusing to drink may need fluids given by syringe, the same way you'd give medicine.
4. Toddlers: offer cool, soft foods. The NHS suggests soft foods such as yoghurt and avoiding hot, salty and spicy foods. The RCH and Sydney Children's Hospitals Network suggest icy poles or ice blocks and jelly, and the Network says to avoid acidic or tangy foods that sting.
5. Use pain relief if your child is distressed. The RCH dehydration fact sheet says pain relief often helps when a sore mouth stops a child drinking. Australia's healthdirect says to ask your doctor or pharmacist for the right product and dose.
6. Count wet nappies. Fewer than usual is an early sign of dehydration.

Pain relief: the label rules

The NHS fever page says not to give paracetamol to a baby under 2 months, or ibuprofen to a baby under 3 months, under 5 kg, with chickenpox or who is dehydrated, and never to give aspirin to children. Check the label and ask a pharmacist about the right product and dose for your child's age and weight. The NHS says a pharmacist can also advise on mouth gels and sprays and which, if any, suit children; don't use teething gels or adult mouth products without that advice. Leave blisters to dry naturally: NSW Health says not to burst them, because the fluid is infectious.

What are the signs of dehydration with hand, foot and mouth disease?

The CDC says some children, especially young ones, get dehydrated because painful mouth sores make swallowing hard. The RCH dehydration fact sheet groups the signs:

The NHS says to ask for an urgent GP appointment or call its helpline if your child has hand, foot and mouth disease and is weeing less than usual. The Sydney Children's Hospitals Network lists fewer wet nappies, difficulty swallowing and refusing fluids as reasons to see a doctor as soon as possible. The RCH says to go to hospital if your child is dehydrated and not drinking even after pain relief. Dehydration signs has the full guide.

Why are my child's nails peeling or falling off?

This can happen weeks after the illness, and it can be a surprise. Sources describe it differently:

• The AAP says some children have harmless peeling on their fingers and toes 1 to 2 weeks after the illness.
• DermNet says nail changes, such as lines across the nails, and nail shedding can appear about 2 months after infection, especially with coxsackievirus A6, and the nails eventually return to normal.
• Australia's healthdirect and Victoria's health department say nail loss is temporary and nails grow back without treatment.
• The CDC calls nail loss very rare, usually within a few weeks of being sick, and says there's no evidence that hand, foot and mouth disease was the cause.

See your GP or child-health nurse if you're worried, or if the skin around a nail looks red, swollen or sore.

Is hand, foot and mouth disease a risk in pregnancy or for newborns?

Sources mostly reassure, with some differences:

• The NHS says there's usually no risk to the pregnancy or baby, but it's best to avoid close contact with anyone who has it, because catching it shortly before giving birth can mean your baby is born with a mild version. It says to speak to a GP or midwife if you've been in contact.
• UK health protection guidance adds that it can cause a high fever, and says pregnant women who've been in contact should get advice from their doctor or midwife.
• The Royal Children's Hospital Melbourne says it isn't known to be dangerous for pregnant women or their unborn babies.
• NSW Health says many pregnant women are exposed without symptoms and there's no clear evidence of risk to unborn babies, but that infected mothers and siblings can pass it to newborns, who rarely have severe disease.
• The CDC says to contact your doctor if you're pregnant and think you've been exposed.
• DermNet, a dermatology reference, goes further, saying the viruses can cause miscarriage in the first trimester or slow the baby's growth, and rarely serious illness in newborns.

If you're pregnant or have a newborn and someone at home has hand, foot and mouth disease, wash hands often, avoid sharing cups and towels, and talk to your GP or midwife.

When to get help

Most children recover at home. Very rarely, NSW Health says, the viruses can affect the heart, brain, the lining of the brain and spinal cord (meningitis), lungs or eyes. The CDC says a small number of people get viral meningitis, with fever, headache, stiff neck or back pain, and that brain swelling (encephalitis) or paralysis is extremely rare. These tiers follow the NHS urgent-help guide and the sources above; where sources differ, we use the stricter tier.

Call your local emergency number (000 in Australia, 999 in the UK, 911 in the US) now if your child:

• is under 3 months and has a temperature of 38°C (100.4°F) or higher
• is 3 to 6 months old and has a temperature of 39°C (102.2°F) or higher
• is floppy, much sleepier than usual, hard to wake or can't be woken
• has a stiff neck, or is bothered by light
• has jerking movements or a seizure
• is breathing very fast or struggling to breathe, or has blue, grey, pale or blotchy skin, lips or tongue
• has a rash that doesn't fade when you press a glass against it
• looks very unwell and pale, with stomach pain or shortness of breath
• has had no wet nappy or wee for 12 hours, or has sunken eyes, cold hands or mottled skin

These come from the NHS urgent-help guide, the NHS fever page, the RCH fact sheets, NSW Health and the Sydney Children's Hospitals Network. NSW Health and Australia's healthdirect list jerking movements, fast breathing and drowsiness as signs of a more serious infection needing a doctor urgently; we use the emergency tier for them.

Get medical help today (same-day GP, after-hours doctor or a health advice line (Pregnancy, Birth and Baby on 1800 882 436 in Australia, NHS 111 in the UK, your pediatrician's after-hours line in the US); go to the emergency department if you can't be seen) if your child:

• is refusing drinks, drinking much less than usual, or finding it hard to swallow
• has fewer wet nappies than usual or other early signs of dehydration
• has had a temperature of 38°C or higher for 72 hours or more, which NSW Health and the Sydney Children's Hospitals Network list as a warning sign
• is very irritable, or has difficulty walking
• is under 6 months old; the CDC says very young babies, especially under 6 months, should see a healthcare provider
• has eczema and blisters are spreading across the eczema patches
• has a very high temperature, or feels hot, cold or shivery, as the NHS advises

Talk to your GP or child-health nurse soon if:

• symptoms haven't improved after 7 to 10 days
• spots are larger than 3 mm or oozing pus, as the RCH advises
• your child has a weakened immune system, which the CDC says is a reason to see a provider
• you're pregnant and have been in contact with hand, foot and mouth disease, or have it yourself
• nails are peeling or falling off and the skin around them looks sore

What's worth noting down?

Note when the fever started and each temperature, every drink or feed with rough amounts, and each wet nappy. When you're worried about dehydration, a doctor will want to know how much your child has drunk and when they last had a wet nappy. Also note when the blisters dried, which helps with childcare decisions, and any nail changes in the following weeks.