Q&A: Identifying and preparing for monkeypox in children
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The CDC released clinical considerations for monkeypox in children and adolescents after announcing the first two pediatric cases in the United States.
We spoke with Kristina A. Bryant, MD, hospital epidemiologist at Norton Children’s Hospital and professor of pediatrics in the division of pediatric infectious diseases at the University of Louisville, regarding symptoms, misconceptions and ways to protect children against monkeypox.
Healio: Did it surprise you to hear that cases of monkeypox had been reported in children?
Bryant: No. Rare cases have been reported in kids in Europe, and as cases in adults continue to climb in the U.S., it makes sense that we would eventually see cases in children.
Healio: What symptoms should pediatricians and providers look out for?
Bryant: Classic monkeypox begins with fever, swollen lymph nodes and flu-like symptoms including headache and malaise. Rash usually appears 1 to 4 days after the onset of fever, typically with macular lesions that evolve into papules then vesicles and finally pustules. Pustular lesions are deep seated and well circumscribed, and they are usually the same size and in the same stage of development on a given body site. In this outbreak though, not all patients have had the usual prodromal symptoms before the rash. We have also heard a lot about patients with rash that begins in the perianal or genital area, highlighting the importance of a comprehensive skin exam. I think the most challenging thing for pediatricians and other frontline care providers is that the rash of monkeypox can look like chickenpox or hand, foot and mouth disease or even molluscum. All of these are much more common causes of rash in children than monkeypox. We can’t test every child with a vesicular or pustular rash, so it is important to ask about epidemiologic risk factors for monkeypox.
Healio: Is your institution planning anything to prepare for a possible pediatric case of monkeypox?
Bryant: We have educated clinicians about the signs and symptoms of monkeypox, disseminated information about testing protocols and developed infection control protocols for both the ambulatory and inpatient settings.
Healio: In general, what is the outlook for children who contract monkeypox?
Bryant: Most people who have contracted monkeypox in the current outbreak have mild, self-limited disease. Some people are at risk for more severe disease though, and that includes children, especially those aged younger than 8 years, immunocompromised people and anyone with an underlying skin disease, such as eczema or atopic dermatitis. Fortunately, there are medications available to treat people at risk for developing severe disease. The CDC has reported that the two children diagnosed with monkeypox in the U.S. are receiving antiviral medication and are doing well.
Are there any prominent misconceptions regarding monkeypox, and what should providers keep in mind about them?
Bryant: One important misconception is that that monkeypox is a disease that affects only men who have sex with men. This virus can infect anyone. The other thing to point out is that people are contagious until the scabbed lesions fall off and healthy skin forms underneath. This is different than chickenpox, for example.
What is the best way to protect children?
Bryant: The Jynneos vaccine is a vaccine that can be given as post-exposure prophylaxis to individuals who have had a high-risk exposure to monkeypox. Although it is approved only for individuals 18 years or older, it can be offered to children aged younger than 18 years through an expanded access investigation new drug protocol held by the CDC. Public health experts may recommend the vaccine for children who have had a household or another type of close exposure to monkeypox. Information about monkeypox should also be provided to teenagers as part of routine sexual health counseling. They need to know that monkeypox is not a sexually transmitted disease but can be spread through close, intimate contact, including sex. Having multiple or anonymous sex partners may increase the chances for exposure to monkeypox.
References:
CDC. Clinical considerations for monkeypox in children and adolescents. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pediatric.html. Accessed July 27, 2022.
Sun LH, Nirappil. First cases of monkeypox in children in U.S. confirmed. Washington Post. June 22, 2022. Accessed June 27, 2022.
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