Pediatric Monkeypox Calls – Recommended Nurse Response

Realistic education and reassurance about monkeypox risk in children to help worried parents.
September 12, 2022

At this time, there are just a very small number of children in the US with confirmed monkeypox. Monkeypox remains an extremely rare disease in pediatrics (less than 1% of total cases). With the current outbreak, most cases are occurring in adult men.

Calls about rashes can account for up to 10% of all pediatric calls. Of those calls, 99.9% will be rashes not caused by monkeypox. If the child does not have household, child care, or other direct contact with a person who has confirmed monkeypox, their rash is not due to monkeypox.

The main role of the triage nurse at this time is to reassure anxious parents that their children are safe and are highly unlikely to have monkeypox unless they have known exposure to it.

Pediatric Nurse Telephone Triage Protocol Updates

We have added monkeypox triage questions and care advice to the following 5 nurse triage protocols:

Rash or Redness – Localized
Rash or Redness – Widespread
Penis-Scrotum Symptoms – After Puberty
Vaginal Symptoms or Discharge – After Puberty
STI Exposure or Questions

Triage Questions Added

The following two triage questions were added to each of the protocols listed above:

Discuss with PCP and Callback by Nurse Within 1 Hour / Go to ED Now (or PCP Triage)

[1] Monkeypox rash suspected (unexplained rash often starting on the face or genital area, then spreading quickly to the arms and legs) AND [2] known monkeypox exposure in last 21 days. (Note: exposure means close contact with person who has a confirmed diagnosis of monkeypox)

See in Office Today / Call PCP within 24 Hours

[1] Monkeypox rash suspected by TRIAGER (unexplained rash often starting on the face or genital area, then spreading quickly to the arms and legs) AND [2] no known monkeypox exposure in last 21 days. Exception: classic HFMD, hives, insect bites, etc.

Care Advice / Background Information Added

Here is the advice that was added (Background Information for Office Hours, Care Advice for After Hours):

Reassurance and Education – Monkeypox in Children

Monkeypox is extremely rare in children.
Of all cases in the US, only 1 per 1000 has occurred under age 17 years. Even less common in younger children.
Children mainly get monkeypox if someone in their home has monkeypox.
Most worries about children catching monkeypox are not warranted.

Monkeypox Rash Appearance

Initial symptoms are fever, headache, muscle ache and swollen lymph nodes. These symptoms last 1 to 5 days. Small sores may appear in the mouth.
A rash appears about 1 to 3 days after the start of the fever. Sometimes people get the rash first and afterwards other symptoms.
The rash usually starts on the face, sometimes on the genital area. It spreads quickly within 24 hours to the arms and legs, even the palms and soles.
Each monkeypox sore is about 0.5 cm to 1 cm wide. Each sore progresses through the following stages: small red spot (macule), small red bump (papule), small water blister (vesicle), small cloudy blister (pustule). Then, the sore crusts over and the scab falls off. The entire process takes about 2 weeks.
The rash is usually the same size and at the same stage on different areas of the body, unlike chickenpox.

Monkeypox Disease – Basics

Monkeypox is a rare disease caused by the monkeypox virus.
DIAGNOSIS: Suspected by appearance of rash and monkeypox contact. Diagnosis confirmed by lab test on fluid from monkeypox sore. Most testing done through public health department.
INCUBATION PERIOD: Symptoms usually start between 1 to 2 weeks after exposure. Range is from 4 to 21 days.
CONTAGIOUS PERIOD: A person can spread monkeypox from the time symptoms start until all the monkeypox sores have crusted over and fallen off (usually 7 to 14 days).
SPREAD: Monkeypox spreads from person-to-person by direct skin contact. For example, spread can occur during intimate contact and sex. Most current cases occur in adult men who have sex with other men.
ISOLATION IS NEEDED: To protect others, stay at home (isolate) until all of the scabs have fallen off the monkeypox spots and the skin is healing. Avoid close contact with others in your home.
TREATMENT: Symptoms are treated with home remedies and OTC meds. Prescription medicines are not needed for most healthy people.
OUTCOME: Most healthy people do not develop any complications. Death rate is less than 1 percent.

The above guidance was written by Dr. Barton Schmitt and the Pediatric Editorial Team at Schmitt-Thompson Clinical Content, authors of the gold standard Schmitt-Thompson nurse telephone triage protocols used within ClearTriage. It reflects knowledge of monkeypox within children as of September 2022 and identifies changes that were made to the nurse triage protocols in ClearTriage on September 12th.

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