Hand, foot and mouth disease in Vietnam: a guide for parents

Hand, foot and mouth disease is one of the few childhood illnesses where Vietnam genuinely differs from where most of our patients come from. In Britain or Australia it is a nuisance. A few days of spots, a grumpy toddler, back to nursery the following week. In Vietnam and across the wider region it is also that, in the overwhelming majority of children — but the local mix of viruses includes one strain that occasionally attacks the nervous system, and the country runs seasonal outbreaks large enough that the health ministry tracks them.

So the advice here is calibrated differently. Not more alarming, but more watchful, and specific about which signs change the plan. This page cannot tell you what your child has. Blistering rashes in small children have several causes. Sorting them is an examination, not a reading exercise.

Signs that mean hospital tonight

The complications affect the brain, the heart and the lungs. They typically appear on the second to fifth day of illness, often while the rash itself looks unremarkable. If you see any of the following, ring 115 or take the child to the nearest hospital straight away rather than waiting for a clinician to come out:

• Sudden jerks or startles of the limbs during sleep, especially repeated ones — this is the single most important early sign
• Walking or sitting unsteadily, or a tremor of the hands that was not there yesterday
• Persistent vomiting, or refusing every kind of fluid for hours
• Unusual drowsiness, difficulty waking, or a stare that does not focus
• Any seizure, or twitching of the face
• Breathing fast, grunting, or a chest that is pulling in between the ribs
• A racing heart at rest, cold mottled hands, or skin that has gone grey or blotchy
• Continuous crying that cannot be settled, or a startle response to being touched
• A high temperature that will not come down over a couple of days

The limb jerks during sleep are worth repeating because parents dismiss them as dreaming. In an outbreak here, that symptom in a feverish child with mouth ulcers is the one Vietnamese paediatricians act on immediately. It is the reason to go in rather than ring back in the morning.

What it looks like in the usual case

It opens like any viral illness. A temperature, a flat mood, an appetite that disappears, sometimes a sore throat. Within a day or two the mouth comes up. Small ulcers appear on the tongue, the inside of the cheeks, the gums and the back of the throat. They are what makes the child miserable. Eating hurts, drinking hurts, and swallowing saliva hurts.

Then the hands and feet. Small flat red spots that often become oval blisters, sitting on the palms, the soles, the sides of the fingers and toes, and frequently around the buttocks and the nappy area as well. In small babies the spots can be widespread enough to be mistaken for chickenpox, though chickenpox favours the trunk and these favour the extremities.

Fever usually runs two to three days. The ulcers are at their worst somewhere around day three and settle over a week. Most children are back to themselves inside seven to ten days.

Two viruses, two different risks

Most cases worldwide are coxsackievirus A16. It behaves the way the paragraphs above describe, and almost never does anything else. Enterovirus 71 produces an identical rash and carries the small additional risk of brainstem encephalitis, which is the complication the warning list above is built around.

Both circulate in Vietnam. You cannot tell them apart by looking. That is the whole reason the watching matters. The rash does not predict the risk; the clinical course over the first few days does. Laboratory typing exists but it comes back after the decisions have had to be made.

Put that in proportion. Severe cases are a small minority of a very common illness, and the great majority of children here get through it with cold drinks and a few bad nights. Knowing the signs is not the same as expecting them.

Getting fluid into a child whose mouth hurts

This is the practical heart of the illness. Children with hand, foot and mouth disease rarely get dehydrated because they are losing fluid. They get dehydrated because swallowing is painful and they stop taking it in. The job is to make drinking hurt less rather than to persuade harder.

• Cold works. Chilled water, cold milk, ice lollies, frozen fruit puree, ice cream. Cold is mildly anaesthetic on an ulcer and children accept it when they refuse everything warm
• Avoid anything acidic or salty — orange and other citrus juices, tomato, crisps, and the salty broths that usually tempt a sick child. They sting badly and one bad mouthful will end the attempt
• Small amounts, very often, beats a glass every few hours. A syringe or a spoon works when a cup is refused, and a straw sometimes bypasses the sorest part of the mouth
• Oral rehydration salts are worth offering but many children reject the taste when their mouth is raw. Milk and water that go down beat the ideal solution that does not
• Give the usual paracetamol at the dose on the packet before meals rather than after them, so that eating lands in the window where it hurts least
• Soft, bland, cool food: yoghurt, rice porridge gone cold, mashed banana, custard. Nobody needs a balanced diet for a week

Counting wet nappies is the measurement that works

Thirst and appetite are unreliable in a child with a painful mouth, and so is how miserable they seem. Urine output tracks hydration honestly. It is the one Vietnamese paediatric wards ask about first.

Six or more wet nappies a day in a baby, or a toilet-trained child passing urine every few hours, means the drinking is working. A dry stretch across several hours, dark and strong-smelling urine, no tears when crying, a dry mouth and tongue, or a sunken soft spot on a baby's head means it is not. That is the point to have the child seen, rather than to try harder at home.

How it spreads, and nurseries

The virus is in saliva, in the fluid inside the blisters, and in stools. It stays in stools for weeks after the child is well. That is why outbreaks in nurseries are so hard to stop. A child is most infectious in the first week.

One hygiene point catches people out. Enteroviruses are non-enveloped, so alcohol hand gel is substantially less effective against them than it is against the viruses the gel bottle was bought for. Soap and running water, for long enough, is what works. Toys, cot rails, door handles, tablet screens and swimming pool surrounds are the surfaces that matter.

Vietnamese nurseries and kindergartens generally exclude children until the blisters have dried and the fever has gone. Hotel kids clubs will ask. Pools are best avoided while blisters are open, for everyone else's sake.

Adults are not exempt

Parents catch it. Adults often have it worse than the child they caught it from — a brutal sore throat, ulcers that make eating a chore for several days, spots on the hands, and in some people fingernails and toenails that lift and shed some weeks later. The nail thing is harmless and grows back. But it is alarming if nobody warned you.

One group needs a different conversation. Infection in late pregnancy can be passed to a newborn, and newborn infection is managed cautiously. If you are pregnant and have been around a child with it, that is a reason to mention it to whoever is looking after the pregnancy rather than to worry quietly.

Season, and reading the local picture

Vietnam typically sees two annual peaks. Broadly spring into early summer, then a second rise after the school year restarts in autumn. Those are tendencies rather than a timetable. Some years are much larger than others. Provincial health departments and the Ministry of Health publish case counts, and nurseries usually know before the statistics do.

What a visit at your accommodation involves

• An examination that distinguishes this from chickenpox, a strep throat, herpetic mouth infection and the other look-alikes, which is not a judgement to make from a photograph
• A hydration assessment with an actual figure on it, rather than an impression
• A plain statement on the neurological signs, with a written list to keep beside the bed overnight
• Advice on pain timing that makes drinking achievable, which is usually what turns the day around
• A view on nursery, flights and pools, which parents ask about more than anything else
• A referral and a call ahead if the child needs a paediatric ward rather than a visit, said directly
• An itemised invoice and a report in English for an insurer, including the days of illness

The summary for a tired parent

Cold things, small and often, nothing acidic, and count the wet nappies. Soap rather than hand gel. Most children are fine in a week. Jerky startles during sleep, unsteady walking, persistent vomiting or fast breathing mean the nearest hospital that night, and 115 if the child is hard to rouse.