Hand Foot Mouth Disease

Dear Lisa,

When my daughter was 1 year old she developed Hand Foot Mouth disease. She had sores in her mouth and wouldn’t drink. I was told by my daughter’s Pediatrician that it was caused by Coxsackievirus. She went to the Doctor’s office the other day because she had a sore throat and I was told that she had Coxsackievirus again. Is it possible to get Coxsackie twice? I thought once a child got a virus that they are not supposed to get it again?

“Coxsackievirus Again?”

Dear “Coxsackievirus Again?”,

Coxsackievirus is a virus and yes children can catch it more than once. The reason for this is that there are a few strains of Coxsackievirus. The different strains are labeled Group A Coxsackieviruses or Group B Coxsackiviruses. (1) A child can catch Coxsackievirus more than once because each time they are exposed to a different strain. The symptoms for each strain may vary a little bit. For example, Coxsackievirus A16 usually results in Hand Foot Mouth Disease which is a virus where children develop lesions in their mouth, on their feet and on their hands, hence the name; Hand Foot Mouth Disease. A child who is infected with Coxsackievirus A24 tends to get conjunctivitis. (1)

The signs and symptoms of Coxsackievirus include painful vesicles and ulcers in the mouth, fever, diarrhea and vesicular lesions on the palms of the hands and soles of the feet. (2) Sometimes these lesions may appear on the extremities and in the diaper area. (3). Infections with the Group B Coxsackievirus tend to be more serious and may result in sepsis in infants, myocarditis, pericarditis (inflammation of the lining of the heart) and Central Nervous System infections.

The Coxsackievirus is spread via the fecal-oral route and via the respiratory route. (1) Therefore diligent hand washing and appropriate disposal of diapers is necessary to prevent spread of the disease. Coxsackievirus actually can be shed from the stool for several weeks after the onset of the infection. Once the stool gets on a person's hand they can spread the germ by putting their hand in their mouth.

It is important that children with Cocksackievirus do not share food because the germ can be spread this way too. Coxsackievirus tends to spread quickly in children because they tend to put toys in their mouth, share toys and because they stool in their in diapers. (1) The incidence of Coxsackievirus tends to be higher in the summer and early fall.

The treatment for Coxsackievirus includes supportive care. (4) Many children with Coxsackievirus refuse to eat or drink because the mouth lesions are so painful. Giving children ice pops and sherbet helps because the coldness temporarily relieves pain. It is a good idea to avoid orange juice or acidic food which may irritate the lesions. Soft foods such as pudding and Jello are a good choice. Crackers or pretzels may scratch the mouth and throat area and irritate the lesions.

Children that refuse to eat and drink because of the pain are at risk for developing dehydration. Therefore it is very important to control the pain in order to prevent dehydration. You can give your child pain relieving medication such as Tylenol thirty minutes before a feeding. Tylenol should not be given more frequently than every four hours.

For children over 1 year old, there’s a mixture you can prepare that can help take away the sting of the mouth lesions. Measure equal parts Benadryl and Maalox and mix together well. For example, add one teaspoon of Benadryl with one teaspoon of Maalox. Coat the lesions on the child’s lips, tongue and inside of the mouth with this mixture. Using a Q-tip may help. This will temporarily take away the pain. Even though this is a topical application, the medication is absorbed therefore it is important not to use too much. To make sure that your child doesn’t get too much Benadryl, you should not give a 33 pound child more than 2 teaspoons of the mixture (which contains 1 tsp of Benadryl) in a 6 hour period.

If your child has Coxsackievirus and you cannot get him to eat or drink it is important to look for signs of dehydration. The signs of dehydration include decreased urine output(children should urinate at least 6 times in a twenty four hour period), dry oral mucosa (inside of the mouth), sunken eyeballs, lack of tears, sunken anterior fontanelle (soft spot), poor skin turgor (dry non-elastic skin), weight loss, increased heart rate, lethargy, irritability and change in temperature (5). If your child demonstrates signs of dehydration it is important to have her evaluated by a health care professional.

(1)American Academy of Pediatrics. Enterovirus Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:198-99.
(2) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990: 478-479.
(3)Nield L, Kamat D. Diaper Dermatitis: From “A” to “Pee”. Consultant For Pediatricians. 2006. June:373-380.
(4)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:379-382.
(5) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:406-410.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Sick Children