With the beginning of summer well underway, I have seen many kiddos in the office with a very typical summer rash. It’s a rash that usually appears on the hands, feet, and around the mouth, giving it the name Hand, Foot, and Mouth Disease (HFMD). It’s caused by a group of enteroviruses that are common in the summer months. While this big group of viruses can cause more serious illnesses, this presentation of illness is typically mild and commonly infects infants and toddlers. While it can affect older children and adults, it is less common and these individuals typically have milder symptoms of the disease, if any. 

The most common symptom of HFMD is the rash for which the disease is named. The rash usually begins as tiny little red dots that get bigger and then look like small blisters. The areas that are typically affected include the skin around the mouth, mucous membranes inside the mouth (including tongue/back of throat), hands (including the palms) and feet (including the soles), as well as buttock and diaper area.

Other symptoms of HFMD include fever, runny nose and sore throat. Like all other viruses, treatment involves supportive care and caring for symptoms, including the use of fever-reducing medications as well as pain control. While rash is typically not bothersome or painful, the lesions in the mouth can cause sore throat or mouth pain. There is no particular treatment necessary for the rash, as it will typically self-resolve within two weeks. It is important to watch for any spots that look like they are oozing or not healing well because secondary bacterial infections can occur. If you have any worries, call your pediatrician as we can usually diagnose this by examining your child and getting a history of the symptoms. 

For starters:

1. No, it's not that cattle disease with a similar name. Heehee. 
2. Yes, it's super contagious. 
3. Nope - no reason to freak out. We see it all the time. You probably had it when you were a kid.
4. Go get some popsicles. I'm gonna prescribe them.

Hand Foot and Mouth Disease (HFM from here on out) is caused by a virus. What does that mean? Come on - I know you're sick of hearing me say it - that means no antibiotics needed! Woo hoo! This is a virus which your strong kiddo can clear on his own!

Most of the time this happens in kids under 5. They catch it from day care or school classmates. Usually they catch it by getting oral secretions or fecal secretions in their mouth or airway from a buddy. I'll let your imagination run wild on the methods kids go through to experience this fun transfer of germs. It's really contagious.

People with HFM are most contagious during the first week of their illness. However, they may be contagious for weeks after symptoms go away. Some people, especially adults, may not develop any symptoms, but they can still spread the viruses to others.

This is a common SUMMER virus! But can happen any time of year.

Soon after catching it (like 3-5 days), kids start with a fever and a new rash. The fever is usually low (under 101) but can be high at times. Sometimes they have a runny nose, or other cold symptoms.

The rash is unique. They're red spots with/without thick bubbles of fluid.

Usually, they're on or in the mouth, and on the palms of the hands and soles of the feet. Hence the name. However, I joke with parents that it should be called "Hand-Foot-Mouth-Butt-Arms-Legs" because you can see the spots in other places, too.

HFM is commonly mistaken for other things. Often, parents worry about chicken pox. Remember - chicken pox is itchy and tender. HFM is not. People also mistake these for bug bites - again, not itchy like bug bites are.

The mouth sores hurt. They're typically the main complication I see with HFM - they hurt so much kids don't want to eat or drink. The eating I don't mind -but it's important that they drink. Load up on popsicles. All my "sugar rules" go out the door when a kiddo has HFM. Sometimes if it's really bad we will prescribe a mouthwash for pain.

Something else you should know - more than one strain of virus causes this bad boy. So kids can get it more than once. And if an older child/adult catches it? It can be more troublesome/painful than in a younger person.

It'll go away on its own. This can typically take 7-10 days. The fevers usually last just a couple of those days. Kids typically are just fine. It's actually adults that can experience the worst of it!

Hope this helps!

Hugs,

Dr. Diane

Pamela Sherman, M.D., is a highly specialized and skilled orthopedic hand surgeon at Cook Children’s who has more than 3,000 hand patient visits per year. In order for her patients to be successful after her surgeries she relies on highly specialized rehab therapists called hand therapists. A hand therapist can be a licensed physical or occupational therapist. To become a hand therapist requires many hours of training beyond the basic education of a physical or occupational therapist. The hand therapists at Cook Children’s work closely with Dr. Sherman in her outpatient clinics to provide collaborative and comprehensive care to the patients and families.

Hand therapy is the art and science of evaluating and treating injuries and conditions of the upper extremity (shoulder, arm, elbow, forearm, wrist, and hand). The Cook Children’s SPORTS program is staffed with hand therapists at three locations across Tarrant County whose expertise is treating children with an injury or condition that affects the arm or hand.  The hand therapists work with the kids  from birth to 21 years to assess their needs and develop a treatment plan that allows them to return to their normal activities. 

Injuries of the hand are quite common, but steps can be taken to prevent some of them from happening.  Here are a few tips to help prevent hand and arm injuries:

1. Wear protective gear, such as elbow pads and wrist guards, during sports activities.
2. Make sure children do not play near treadmills or other exercise equipment.  Be sure to turn off the equipment and/or unplug them from the power source.  
3. Supervise children when using knives or sharp scissors. 
4. When using a game controller, put pillows in your lap to rest your arms on. 
5. Take regular breaks when performing a repetitive task.  This can help prevent overuse injuries.
6. Change positions often if you are going to be holding an object for an extended amount of time.
7. Review your body mechanics and posture when performing a task.

About the author

Cara Smith, PT, CHT, is a certified hand therapist and the Hand Therapy Program coordinator for the SPORTS program at Cook Children's. Cook Children's offers hand rehabilitation services for all ages, diagnoses and stages of care. We help rehabilitate children/adolescents with a wide variety of congenital conditions and traumatic injuries.

For more information, call 817-347-2925. Cook Children's hand rehabilitation services are under the direction of our Sports Performance Orthopedic Rehabilitation Team Specialists (SPORTS). 

Cook Children's offers three SPORTS Rehab locations for hand therapy:

750 Mid Cities Blvd., Suite 130, Hurst, TX 76054

1919 8th Ave., Fort Worth, TX 76110

801 Matlock Rd., Mansfield, TX 76063

Ball sports and games have many benefits for kids besides being a lot of fun. Playing ball helps kids develop skills:

Increased coordination with both hands

How?

o Stand in one place and dribble a basketball.

o Run while dribbling a ball.

o Playing/bumping a volleyball.

Increased hand eye coordination

How?

o Playing catch.

o Batting practice.

o Playing mini golf.

o Playing a racquet sport like tennis or ping pong.

Improved balance

How?

o Kicking a ball while standing in place.

o Kicking a ball while running.

o Jumping and reaching to catch a throw.

There are great ball options for kids of all ages and abilities. 

For kids 3 and under

Once babies can sit on their own, they can begin to roll a medium sized ball. As they grow, they will begin to use two hands to attempt to catch by pulling a ball closet to their body. Kicking is something that we should start to see with toddlers. At first your little one will walk into a ball to move it forward. As your child matures they will begin to lift one leg to kick. This requires balance and is a good challenge for toddlers and preschoolers. As their balance improves they will be able to the kick the ball harder and farther and in a straight line.

For grade school kids

At this age, kids are ready to be challenged with balls of different shapes and sizes like soccer balls, footballs, baseballs and tennis balls. These balls can be thrown and caught, but also can be used in more complex ways as part of a game. A great way to get this age group active is to create a game that they can play with friends.

For the preteen and teenagers

If your child is not yet involved in a team sport, it is important to continue to encourage them to be active with their friends, including games that include ball skills.

Sports are beneficial whether played on formal teams or as part of pick-up game with friends. Sports not only challenge your child physically, but encourage them to work on things like taking turns and being a good sport. Activities like soccer, baseball, and basketball require children to coordinate their own movements with the movements of other children in order to be successful. Teamwork and compromise are great skills for all kids to work on and will benefit them in many areas of their life.

So whether it is on their own, with siblings and friends, or as part of a team, encourage your kids to be active this summer and get involved with ball games. Remember that all kids should be getting at least one hour of physical activity a day and they will need lots of water when playing outside in the Texas summers. 

About the author

Kate Mcgee, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

Why is it important for my child to be treated for a finger injury?

Just because your child’s finger may not look like it is broken, it is still important to have it looked at by a professional. The bones of the hand are quite small, and fragile. But, the bones aren’t the only thing in the hand that can be injured. There are also several ligaments and tendons in the hand that are at risk for injury. A ligament connects bones to other bones and their job is to support the bones and joints, and in some cases, prevent certain movements. If a ligament is injured and not allowed to heal, it can cause the bones to be unstable which can lead to further injury.

When should I get help for my child that has injured their hand or finger?

• If your child’s finger looks like it is out of place.
• If there is any bruising, swelling, or pain that lasts more than a couple of days.
• If your child is unable to bend or straighten the finger.
• If your child is favoring that hand or finger and doesn’t want to use it in everyday activities.

If your child injures their finger and it looks to be out of place, you should seek immediate attention from a medical professional. Do not try to put the finger back into place on your own. You could cause further damage.

“Do you have any information on a little older child who has dysgraphia? He is 11 ½ years old, he is also a left-handed writer and eater, but does most sports right handed. To add confusion, his right foot, left foot dominance is somewhat equal. I would appreciate any information you can share.”

Kim Greenberg, M.O.T., O.T.R., an occupational therapist for Cook Children’s and works in the specialty clinics in Arlington and Mansfield, gave us some insight into dysgraphia.

Development of grasp

The growing curiosity of toddlers’ hands happens before we know it. They begin by watching their hands open and close, then playing with their hands in front of their eyes, eventually reaching for different rattles and toys, and soon pulling on mommy’s hair.

Crawling is also an essential developmental skill that builds upper body strength; especially building the hand muscles of the thumb, pointer, and middle fingers, as these are the fingers that will ultimately hold writing tool.

As children’s eye-hand coordination continue to progress, they will become increasingly curious and independent with holding their own bottle, cup, spoon and fork. Eventually, children will show interest in holding crayons and scribbling on paper. At first, a child may show a full fisted grasp pattern, and not show a preference to use either hand. I often recommend that parents do not force hand dominance. Therapists often recommend that a utensil or writing tool be placed in a neutral midline position in front of their child.

Hand dominance

Whichever hand children initiate using will typically become their dominant hand. Once children show their hand preference, parents may encourage their child to then develop their feeding and pre-writing skills. When children turn 6 years of age or begin kindergarten, they will have established their hand dominance of being either right-handed or left-handed.

Dysgraphia

Then there is the subject of dysgraphia, or “difficulty with handwriting.” Handwriting is a complex process. It involves a combination of many systems to include visual-motor, eye-hand coordination, motor planning, learning and memorizing the shapes and forms of letters and numbers. To complicate matters, there are also many types of handwriting curriculums. When a child has a diagnosis of dysgraphia, I often ask their parents to attempt to write using their non-dominant hand, as this is how it feels to our children as they begin to write. Now more then ever, there are more pressures on our children to be enrolled in pre-school and pre-kindergarten programs that force them to write when they’re simply not developmentally ready.

Sports

I have also worked with children who demonstrate a hand dominance for feeding and writing, and a different hand dominance for playing sports or a musical instrument. The fact remains that we live in a right-sided dominant world. I often educate my parents to support their child no matter what their natural hand dominance.

As a child begins playing sports or a musical instrument, a qualified coach or teacher will understand how hand and foot dominance affect the skills of the child. A “switch hitter” is often the most valuable position in baseball. A parent should feel empowered to tell their child’s coach and teachers of their child’s natural dominance, and that a child should be taught in a positive manner that develops his skill and confidence.

Conclusion

Most importantly, I would like to stress that even with the most proficient grasp pattern, a child may still demonstrate dysgraphia, or poor handwriting legibility.

In this instance, a child should be evaluated by an occupational therapist, either from a reputable outpatient clinic, such as the Rehab facilities at Cook Children’s or from an occupational therapist through his or her school district.

Kim Greenberg, M.O.T., O.T.R.

About the author

Kim Greenberg, M.O.T., O.T.R., an occupational therapist for Cook Children’s and works in the specialty clinics in Arlington and Mansfield. Cook Children's Healthcare System provides a full spectrum of occupational therapy including inpatient,outpatient, and home health.

Oosthuizen said he was closing the bathroom door Tuesday morning at the place his family is staying for this week's Crowne Plaza Invitational at Colonial. Sophia was on the other side.

"Her finger was on the side of the hinges," Oosthuizen said. "It nearly cut off the finger completely."

Oosthuizen rushed his daughter to the emergency room at Cook Children's, which is located in Fort Worth and is the primary charity for the Crowne Plaza Invitational.

At the hospital, they met with Dr. Pamela Sherman, an orthopedic surgeon and hand specialist. She explained that it was important to repair the nail bed on Sophia's finger and give the new nail a chance to grow in order to save the finger. Dr. Sherman then performed the surgery.

"It was a scary moment," Oosthuizen said. "It was Sophia's first time under anesthesia. You never know what's going to happen.

"Dr. Sherman was great. ... She told us it's important to have the proper people doing it, and they have some of the best there."

Sophia will go to Cook Children's on Sunday for a check-up before the Oosthuizens return home.

Louis Oosthuizen is grateful for the attention his daughter received at Cook Children's.

"If I'm in doubt ever to have any surgery or something for my kids, I'll fly in to see them," Oosthuizen said. "The way they handled it, the way they spoke to us and treated the kids -- it was amazing to us.

"I didn't even know there were hospitals like that."