Update 8/4/22: The U.S. has declared the monkeypox outbreak to be a public health emergency. Read more here.
AAP experts are answering pediatricians’ most frequently asked questions about how to prevent, recognize, test for and treat monkeypox. Children have not played a significant role in the current outbreak with only two cases reported by the Centers for Disease Control and Prevention (CDC), but some may be at risk for severe disease if they are infected.
What is the risk for children?
The risk of children getting infected with monkeypox virus is low. As of Aug. 3, two pediatric cases have been confirmed in the United States (<0.1% of all cases). Children and adolescents are more likely to be exposed to monkeypox if they live in or recently traveled to a community with higher rates of infection.
Are some children at increased risk?
Infants, young children (under 8 years of age), children with eczema and other skin conditions, and children with immunocompromising conditions may be at increased risk of severe disease when they contract monkeypox.
What are the symptoms of monkeypox in children?
Rash is the most common monkeypox symptom, and it can look similar to rashes seen more commonly in children, including rashes caused by chickenpox, herpes, allergic skin rashes, and hand, foot and mouth disease.
The rash typically begins as maculopapular lesions and progresses to vesicles, pustules and scabs. Other common symptoms include fever, lymphadenopathy, fatigue and headache, although these symptoms are not always present.
For more information, see https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html.
How is monkeypox spread?
Monkeypox can spread to others through close, personal, often skin-to-skin contact, including:
- Direct contact with monkeypox rash, scabs or body fluids from a person with monkeypox, including sexual contact.
- Touching objects, fabrics (clothing, bedding or towels) and surfaces that have been used by someone with monkeypox.
- Contact with respiratory secretions.
Unlike some other rashes, monkeypox remains contagious until the scabs fall off and new skin has formed. For more information, see https://www.cdc.gov/poxvirus/monkeypox/transmission.html.
When should I consider testing a child for monkeypox?
If a child has a suspicious rash, pediatricians and other pediatric clinicians should test the patient if there is a history of close, personal contact with someone who has a confirmed or probable case or travel (https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html) that puts them at risk.
Testing is available through state public health authorities and at some commercial labs. Requirements for specimen collection and shipping may differ by laboratory, and clinicians should confirm requirements before obtaining a sample from the skin lesions.
If I think a child might have monkeypox, what precautions should I recommend to the family/caregiver?
Monkeypox remains contagious until the rash is fully resolved (scabs fall off and new skin has formed), which can take up to two to four weeks. While contagious, the following precautions should be taken:
- Children with monkeypox should cover their skin lesions.
- Parents/caregivers should encourage children not to scratch skin lesions or touch their eyes.
- Children with monkeypox should avoid contact with other people and pets. If possible, one person should be the caregiver of a child with monkeypox and should avoid skin-to-skin contact with the rash.
- Children who are at least 2 years of age who have monkeypox should wear a well-fitting mask when interacting with a caregiver, and the caregiver should wear a respirator or well-fitting mask and gloves when skin contact with the child may occur, and when handling bandages or clothing.
- Children should not return to school or child care while contagious. The decision to end isolation and return to school or child care should be made in collaboration with local or state public health authorities.
Is there any treatment for monkeypox for children?
Yes. Treatment is available, particularly for those who have severe disease, are at risk for severe monkeypox disease, (e.g., those who are younger than 8 years of age, those with immunocompromising conditions, those who have a history of certain skin conditions), those who have accidental implantation or lesions in certain anatomical areas (e.g., eyes, mouth, genitalia, anus) and children and adolescents with complications from monkeypox.
Tecovirimat is the first-line treatment and is being used under an investigational protocol. The CDC recently streamlined the process to obtain it. It is available in both oral and intravenous forms.
Is there a vaccine indicated for use in children and how do I obtain it for my patients?
There currently is no monkeypox vaccine available for administration to all children. However, a vaccine is available to children under 18 years who have been exposed to monkeypox. JYNNEOS vaccine may be recommended for children under 18 years for post-exposure prophylaxis under a single patient expanded access investigational new drug (IND) protocol through the CDC. Clinicians should discuss use of vaccine in a child as post-exposure prophylaxis with the state or local health department and CDC.
How can I protect myself and members of the practice team from monkeypox?
Currently, vaccination is not recommended for most health care workers. The CDC recommends that people whose jobs (clinical or research laboratories and certain health care and public health team members) may expose them to orthopoxviruses, such as monkeypox, receive either JYNNEOS or ACAM2000 vaccine. For more information, see https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html.
Health care workers should utilize the following personal protective equipment when caring for a patient with suspected or confirmed monkeypox infection: gown, gloves, eye protection and N95 (or comparable) respirator.
Is post-exposure prophylaxis recommended for health care workers who have been exposed to monkeypox?
Health care workers who have unprotected, high-risk contact with patients with monkeypox may be eligible for post-exposure prophylaxis in consultation with public health authorities. Post-exposure prophylaxis involves receipt of vaccine, optimally within four days of exposure. Transmission of monkeypox virus from patients to health care workers has not occurred to date in this outbreak, lending support to the recommendation for post-exposure prophylaxis as the primary means for protecting health care workers.
What is the guidance for newborns in hospitals who may have been exposed to monkeypox during and after delivery?
Infants born to someone with suspected or confirmed monkeypox should undergo early bathing and post-exposure prophylaxis. While the optimal strategy for post-exposure prophylaxis of newborns has not been defined, vaccinia immune globulin should be considered. Infants also should stay in a separate room and not have direct contact with parent(s) or caregivers infected with monkeypox. Breastfeeding should be delayed during the isolation period, and breastmilk should be pumped and discarded.