HFMD - Checking for ulcers

Hand, foot and mouth disease (HFMD) is a common and contagious viral infection that can affect children as well as adults.

It hit epidemic levels in Singapore in early 2012, with over three times as many cases in the first 18 weeks of 2012 as compared to the same period in 2011.

In the week of 29 April to 5 May alone, there were 1,468 cases reported, according to latest statistics published by the Ministry of Health. This is slightly fewer than the week prior, in which 1,590 cases were reported – a four-year high.


Given such numbers, it is no wonder that parents are worried. The best way we can be equipped to fight against the spread of HFMD is to learn more about the condition, keep abreast of the news of outbreaks in our neighbourhood and be prepared in the event that our children are infected.

What is HFMD?

HFMD is an illness caused by intestinal viruses, with the commonest being Coxsackie virus and Enterovirus 71. While most cases of HFMD are mild and self-resolving, serious complications involving the nervous system, lungs and heart can occasionally occur, although quite rarely. Such complications are usually due to the Enterovirus 71 strain.

Who gets affected?

Both adults and children can be affected but the younger ones, particularly those under the age of five, are most susceptible.

What are the symptoms?

A person with HFMD usually has the following symptoms:
• Fever
• Sore throat
• Rash (flat or raised red spots) or small blisters on the palms of hands, soles of feet, or buttocks
• Ulcers on the inside of the mouth or sides of the tongue
• Poor appetite
• Lethargy

The incubation period is three to five days, with symptoms usually starting three days to a week after being infected. Symptoms can last a week to 10 days.

Don’t confuse HFMD with…

Foot-and-mouth disease (FMD), sometimes called hoof-and-mouth disease, which is a disease in cattle, sheep, and swine. The two are caused by different viruses and are not related. Humans do not get the animal disease, and animals do not get the human disease.

While most clinicians are able to diagnose HFMD just by reviewing the symptoms, it should be noted that this has occasionally turned out to be a misdiagnosis. The child might present similar symptoms but actually be suffering from other conditions. Strep throat, Herpangina, Herpetic gingivostomatitis, Aphthous stomatitis and Stevens-Johnson’s syndrome are some conditions which need to be differentiated from HMFD.

How is HFMD spread?

The virus is spread from person to person by direct contact with the nasal discharge, saliva, and fluid from inside the blisters of an infected person, and can also linger in faeces for up to several weeks after infection.

Minimise the risk of HFMD transmission

• Wash the hands with soap before eating and after going to the toilet
• Cover the mouth and nose when coughing or sneezing and throw the tissue away immediately
• Clean and disinfect toys or appliances which are contaminated by nasal or oral secretions thoroughly
• Do not share toothbrushes, towels, or rinsing mugs
• Do not share eating utensils, drinking straws, food or drinks


Minimise the spread of HFMD with regular hand washing

When should I bring my child to the doctor?

The Ministry of Health (MOH) advises parents to consult a doctor early if your child shows symptoms of HFMD. Also be alert to any change in your child’s normal behaviour. Should they refuse to eat or drink to extremes, have persistent vomiting or drowsiness, bring them immediately to the A&E Departments of either NUH or KKH, whichever is closer to your home.

Since 1 October 2000, medical practitioners are required to notify MOH of all clinical cases of HFMD. Childcare centres, kindergartens and schools are also required to report HFMD outbreaks to the relevant authorities. If confirmed positive for HFMD, a mandatory 10-day quarantine is imposed on patients.

Getting over it

The good news is that HFMD is usually mild and self-limiting. It is a viral disease that just has to run its course. As such, treatment with antibiotics is not effective and should not be prescribed.

Although there is no specific treatment or vaccine, individual symptoms can be treated. Give your child medications as prescribed by your paediatrician or GP; these may include paracetamol to relieve fever and pain from the ulcers.

What to do with my child?

Ensure that your child gets plenty of rest at home. Observe the mandatory 10-day quarantine period, even if your child does not have to attend school. Although energy levels vary between different children, each child will go through a period where they will tire easily and feel lethargic. Rest is essential for a quicker recovery.

Eating and drinking

One major problem in children with HFMD is the pain of eating and drinking, due to the ulcers in their mouths. Swallowing can be difficult, so ensuring that your child gets enough nutrients and liquids may be a huge challenge.

Try a soft diet – porridge, pureed fruit, soft cereals – but if your child refuses even these, ice-cream, jelly and frozen yoghurt may do the trick.

Most important, of course, is staying hydrated. Encourage your child to drink plenty of fluids – juices, soups and broths included. Indulge in requests for iced water, and ignore the horrified disapproval of the child’s grandparents. If dehydration occurs, the child may have to be hospitalised so that liquids can be administered intravenously.

Four-year-old Ruth was diagnosed with HFMD in April and has since recovered. Her mother, Zoe, shares, “During days two to four, Ruth hardly ate, except for ice-cream. Milk stings the ulcers a lot too, so most children will generally reject milk. She did like iced water a lot and I gave her as much as she liked. While fruit juices were recommended, they were mostly too acidic to be soothing. Yoghurts were also too sour and caused even more stinging.”

Running its course

A child infected with HFMD is contagious throughout the duration of the illness. Children with HFMD should stay at home, especially to avoid contact with other children. Do not allow them to attend school, childcare, playgroup, kindergarten and other classes.

Also avoid crowded public places such as shopping malls, playgrounds, buses and trains until the fluid in the blisters has dried and the 10-day quarantine period is over.

Proper hygiene should also be practised at home so as to prevent transmission to other family members. If you have other children who are not infected, it may be best to have them stay with grandparents or other relatives if possible. Also refrain from sending them to school until enough time has passed to ensure that they have not been infected as well.

Zoe suggests: “Try to wear a mask and gloves around your child if your child requires a lot of soothing and hugging.”

Will my child get it again?

Once recovered, the chance that your child will have a recurrence of HFMD is slim, although not impossible. A child with a healthy immune system will form antibodies to whichever virus caused the infection. If a child is exposed to the same strain of virus, they will probably not be re-infected. However, they are still susceptible, in varying degrees, to other viruses.

For more information about HFMD, see the HPB and MOH pages on the disease.