The Centers for Disease Control and Prevention (CDC) has released new guidance on recognizing and caring for children and adolescents with monkeypox.
“Pediatricians should know about monkeypox, be prepared to answer parents’ questions but recognize that it’s incredibly rare,” said Kristina Bryant, M.D., FAAP, a member of the AAP Committee on Infectious Diseases.
There have been two pediatric cases among more than 3,500 cases in the U.S., according to the CDC. The agency’s new guidance covers prevention, symptoms, management, treatment, vaccines, infection control and breastfeeding.
Rash is the most common monkeypox symptom, and Dr. Bryant said it can look similar to more common rashes like those caused by chickenpox, herpes, allergic skin rashes, and hand, foot and mouth disease.
The monkeypox rash typically begins as maculopapular lesions then progresses to vesicles, pustules and scabs. Other common symptoms include fever, lymphadenopathy, fatigue and headache, although these do not always appear.
Clinicians should use their judgment on testing and consider the patient’s history of contact with someone who has a confirmed or probable case, close contact with men who have sex with men (MSM) or travel that puts them at risk. Clinicians should contact their jurisdictional health department when they suspect a patient has monkeypox.
Children with monkeypox should cover their skin lesions and keep from scratching them or touching their eyes, according to the guidance. Most infections are mild. Children and adolescents may need treatment if they have severe disease or complications or if they are at risk of severe disease. Children at higher risk include those who are under 8 years or have immunocompromising conditions or certain skin conditions.
Tecovirimat is the first-line treatment and is being used under investigational protocol. The CDC recently streamlined the process to obtain it. It is available in both oral and intravenous forms.
Unlike some other rashes, monkeypox remains contagious until the scabs fall off and new skin has formed, according to Dr. Bryant, hospital epidemiologist at Norton Children’s Hospital in Louisville, Ky., and professor of pediatrics at the University of Louisville.
The CDC recommends children with immunocompromising conditions avoid close contact with someone who has monkeypox and wear a well-fitting mask or respirator if contact can’t be avoided. People with monkeypox should avoid contact with other people and pets while contagious. If possible, one person should be the caregiver of a child with monkeypox and should avoid skin-to-skin contact with the rash. Children over 2 years who have monkeypox should wear a well-fitting mask when interacting with a caregiver, and the caregiver should wear gloves when handling bandages or clothing.
Children and adolescents exposed to monkeypox may be eligible for post-exposure prophylaxis (PEP). Clinicians should consult their health department regarding pediatric use of PEP products such as vaccination, immune globulin and antiviral medication. The two-dose Jynneos vaccine can be used in children and adolescents under a single patient expanded access investigational new drug protocol, but supply is limited. The ACAM2000 vaccine also can be used under investigational protocol but is associated with adverse events and is contraindicated for children under 12 months and children and adolescents with certain underlying conditions.
Babies born to someone with suspected or confirmed monkeypox should undergo early bathing, and PEP should be considered, according to the CDC. They also should stay in a separate room and not have direct contact with the person who is infected. Breastfeeding should be delayed during the isolation period, and mothers should be encouraged to pump and discard milk.
“We just don’t really know if this virus is transmitted in breastmilk,” Dr. Bryant said. “This is the guidance right now being very cautious, and as we get more data then the guidance could evolve.”
If a child has monkeypox, the decision to breastfeed from an uninfected caregiver should be made on a case-by-case basis.
At the other end of the pediatric age spectrum are teens and young adults who should be educated about the impact the outbreak is having on men who have sex with men.
“Our teenagers should receive information about monkeypox, particularly those who are teenage MSM,” Dr. Bryant said. “They need to know about this virus and how to protect themselves.”