eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Hand-Foot-and-Mouth Disease: Treatment & Medication

Author: Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Coauthor(s): Stacy Sawtelle, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View; Heather Kesler DeVore, MD, Clinical Attending Physician, Assistant Professor Physician, Department of Emergency Medicine, Washington Hospital Center/Georgetown University Hospital
Contributor Information and Disclosures

Updated: Aug 13, 2009

Treatment

Emergency Department Care

  • Treatment of hand-foot-and-mouth (HFM) disease is primarily supportive.
  • Examining the patient's hydration status by evaluation and documentation of lacrimation, mucosal membranes, skin turgor, urine output, and pulse or capillary refill time is extremely important.
  • Antipyretics should be given as needed for fever.
  • Intravenous hydration should be given if the clinical assessment indicates.
  • Acetaminophen and ibuprofen can be used as first-line therapy for mouth pain. For patients with significant dysphagia (irritability, refusal of oral fluids, or drooling), codeine and topical anesthetics can be administered.

Medication

No specific therapy for hand-foot-and-mouth (HFM) disease has been identified. Antibiotics are not indicated unless a complicating secondary skin infection is present.

Standard dosages of antipyretics (eg, acetaminophen, ibuprofen) are recommended on an as-needed basis for fever and analgesia.

Codeine can be used for significant pain that is not controlled with ibuprofen or acetaminophen. Topical treatments include diphenhydramine and lidocaine (or benzocaine). Lidocaine or benzocaine should only be applied with a cotton swab (and infrequently) to specific areas to avoid toxicity.

Analgesic agents

Pain control is essential for quality patient care. Some analgesics (eg, acetaminophen, ibuprofen) also are effective for treating fever.


Acetaminophen (Feverall, Tempra, Tylenol)

Inhibits action of endogenous pyrogens on heat-regulating centers; reduces fever by a direct action on the hypothalamic heat-regulating centers, which, in turn, increase the dissipation of body heat via sweating and vasodilation. Effective for treating fever and relieving mild-to-moderate pain.

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 4 g/d

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Documented hypersensitivity; known G-6-PD deficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in toxicity due to cumulative doses exceeding recommended maximum dose


Ibuprofen (Advil, Motrin)

Effective for treating fever or mild-to-moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d

Pediatric

20-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate; not to exceed 2.4 g/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy


Codeine

Indicated for moderate to severe pain. Binds to opiate receptors in CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.

Adult

10-60 mg/dose PO/IM/SC q4-6h prn; not to exceed 360 mg/d

Pediatric

0.5 mg/kg/dose PO/IM/SC q4-6h prn; not to exceed 60 mg/dose

Toxicity increases with concurrent administration of tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics

Documented hypersensitivity; HACE diagnosis or elevated ICP

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Use to treat cough in HACE diagnosed patients only if absolutely necessary; may depress hypoxic ventilatory rate and respiratory drive during sleep; caution when combined with acetaminophen to hepatotoxicity toxicity


Diphenhydramine elixir (Benylin)

Elicits antipruritic activity and weak local anesthetic action. Used topically for temporary relief of pruritus or pain.

Adult

Apply to affected area prn with cotton-tipped applicator or swish in mouth for 2 min, then expectorate

Pediatric

Administer as in adults

Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Documented hypersensitivity; MAO inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, or urinary tract obstruction; xerostomia may occur


Lidocaine (Xylocaine)

Available as a gel or viscous oral solution. Decreases permeability of neuronal membranes to sodium ions, resulting in inhibition of depolarization and blocking transmission of nerve impulses. Initial treatment of choice for small sparse ulcers. Does not decrease healing time but may allow patient to better tolerate eating and drinking. Pain relief may be short lived, and frequent applications may be necessary.

Adult

Apply to affected area prn with cotton-tipped applicator

Pediatric

Administer as in adults

Documented hypersensitivity; avoid use in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

For external or mucous membrane use only; do not use in eyes


Benzocaine (Cepacol, Orajel)

PABA derivative ester-type local anesthetic, minimally absorbed. Inhibits neuronal membrane depolarization, blocking nerve impulses. Used to control pain.

Adult

10-20% gel, apply to affected areas qid prn

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for use when infection is present; methemoglobinemia associated with overuse to mouth or throat

More on Pediatrics, Hand-Foot-and-Mouth Disease

Overview: Pediatrics, Hand-Foot-and-Mouth Disease
Differential Diagnoses & Workup: Pediatrics, Hand-Foot-and-Mouth Disease
Treatment & Medication: Pediatrics, Hand-Foot-and-Mouth Disease
Follow-up: Pediatrics, Hand-Foot-and-Mouth Disease
Multimedia: Pediatrics, Hand-Foot-and-Mouth Disease
References
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References

  1. Suzuki Y, Taya K, Nakashima K, et al. Study on Risk Factors for Severe Hand-foot-and-mouth Disease. Pediatr Int. Aug 3 2009;[Medline].

  2. Wolff K, Johnson RA, Suurmond D. Viral infections of skin and mucosa. In: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill; 2005:790-92.

  3. Chang LY, Tsao KC, Hsia SH, et al. Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan. JAMA. Jan 14 2004;291(2):222-7. [Medline].

  4. Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998-2005. Pediatrics. Aug 2007;120(2):e244-52. [Medline].

  5. Cherry JD. Enteroviruses: polioviruses, coxsackieviruses, echoviruses and enteroviruses. In: Textbook of Pediatric Infectious Diseases. 5th ed. 2005:2007.

  6. Cherry JD. Viral exanthems. Curr Probl Pediatr. Apr 1983;13(6):1-44. [Medline].

  7. Davis H, Karasic R. Pediatric infectious disease. In: Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997:347-8.

  8. Marks M. Viral and presumably viral syndromes. In: Pediatric Infectious Diseases for the Practitioner. 1985:494-6.

  9. Sasidharan CK, Sugathan P, Agarwal R, et al. Hand-foot-and-mouth disease in Calicut. Indian J Pediatr. Jan 2005;72(1):17-21. [Medline].

  10. Wang CY, Li Lu F, Wu MH, et al. Fatal coxsackievirus A16 infection. Pediatr Infect Dis J. Mar 2004;23(3):275-6. [Medline].

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Further Reading

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Keywords

HFM, enteroviruses, coxsackievirus A16, coxsackievirus A5, coxsackievirus A9, coxsackievirus A10, coxsackievirus A16, coxsackievirus B1, coxsackievirus B3, herpes simplex virus, yellow ulcers surrounded by red halos, hand-foot-mouth disease, hand-foot and mouth disease

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Contributor Information and Disclosures

Author

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stacy Sawtelle, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View
Disclosure: Nothing to disclose.

Heather Kesler DeVore, MD, Clinical Attending Physician, Assistant Professor Physician, Department of Emergency Medicine, Washington Hospital Center/Georgetown University Hospital
Heather Kesler DeVore, MD is a member of the following medical societies: Emergency Medicine Residents Association and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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