Hand, Foot, and Mouth Disease (HFMD) is a common viral infection that frequently circulates in child care and school settings. The illness, caused most often by coxsackieviruses, typically presents with fever, a sore throat, and a characteristic rash of small blisters on the hands, feet, and inside the mouth. Determining when a child can return to a group setting requires clear, practical guidance. The decision to allow re-entry is based on criteria balancing the child’s recovery with the need to limit community spread, focusing primarily on the acute symptoms that pose the highest transmission risk.
How Long Is HFMD Contagious?
Hand, Foot, and Mouth Disease is highly contagious, and a child is generally most infectious during the first week of the illness. This period of peak contagiousness often starts even before the trademark rash appears, sometimes beginning a day or two before the onset of any symptoms. Transmission occurs through respiratory droplets from coughing or sneezing, direct contact with the fluid from the blisters, and the fecal-oral route.
The body continues to shed the virus long after the acute symptoms resolve. Viral particles can be found in the respiratory tract for up to three weeks and may be shed in the stool for weeks to even months. Because of this prolonged shedding, keeping a child home until the virus is completely eliminated is not practical and would result in unnecessarily long exclusions. Therefore, exclusion policies focus on the abatement of the most infectious and unmanageable symptoms, rather than the complete end of all viral shedding.
The Standard Criteria for School Return
The decision for a child to return to school or daycare hinges on the resolution of the most disruptive symptoms. The most widely adopted guideline requires the child to be fever-free for a full 24 hours without the assistance of fever-reducing medication. This criterion ensures the child is past the initial, most symptomatic phase of the viral infection.
The state of the characteristic blistered sores is the second major consideration for re-entry. The Centers for Disease Control and Prevention (CDC) advises that the lesions should be healing, and many institutions require that any blisters be dried out or crusted over. Open or draining sores contain infectious fluid and must be fully resolved before a return to the group setting. The combination of being fever-free and having a controlled rash indicates the child is recovering and the risk of acute transmission is significantly lower.
Managing Active Symptoms That Require Exclusion
Even if the fever has resolved, several active symptoms require continued exclusion from school or child care. A child must be well enough to participate in normal classroom activities, which is often compromised by the pain of the mouth sores. Painful oral lesions can make swallowing difficult, leading to a refusal to eat or drink and placing the child at risk for dehydration.
Excessive or uncontrolled drooling caused by the mouth sores also poses a significant risk for the spread of the virus through secretions. If a child cannot manage the secretions, they should remain home because this increases the likelihood of contaminating shared surfaces and toys. Any signs of general malaise, extreme lethargy, or indications of dehydration suggest the child is still too ill for a group setting and may need medical attention. These symptoms suggest the illness is still active and disruptive, regardless of the 24-hour fever rule.
Local Policies and Preventing Secondary Spread
While public health agencies provide standard recommendations, return policies can vary based on local school districts, state health departments, or individual child care centers. Some daycares, particularly those caring for infants who are more likely to put items in their mouths, may maintain stricter requirements regarding the complete resolution of skin lesions. Parents should proactively communicate with their specific institution to confirm the exact exclusion criteria before sending their child back to the classroom.
Once a child has returned to the group setting, preventative hygiene measures remain important to minimize the risk of secondary spread. Frequent and thorough handwashing with soap and water is essential after toileting and before eating. Surfaces and shared items, such as toys and doorknobs, should be regularly cleaned and disinfected. Adhering to these hygiene practices helps contain the ongoing, lower-level viral shedding that continues for several weeks.