Enteroviruses in Children: Symptoms, Prevention, and Treatment

Enteroviruses (EVs) are among the most common pathogens affecting children worldwide. They are part of a large group of RNA viruses, including the coxsackieviruses, echoviruses, and polioviruses, responsible for a wide range of illnesses. While most infections are mild, some strains can lead to severe health complications, including meningitis, myocarditis, and even paralysis. For healthcare professionals, understanding the transmission, prevention, and treatment of enteroviruses is critical in protecting children.

In this article, we’ll explore in detail the epidemiology, symptoms, transmission, treatment, and strategies to safeguard children from these viruses. This comprehensive guide is designed for pediatricians, family physicians, and other healthcare professionals responsible for child health.

Understanding Enteroviruses

Enteroviruses are non-enveloped RNA viruses classified under the family Picornaviridae. Over 100 different serotypes of enteroviruses have been identified, but the most common types responsible for human disease include the polioviruses, coxsackieviruses (A and B), echoviruses, and enterovirus D68 (EV-D68).

• Poliovirus is historically the most notorious enterovirus, though thanks to global vaccination efforts, it is on the brink of eradication.
• Coxsackievirus is notorious for causing hand, foot, and mouth disease (HFMD) in children. It can also lead to severe complications like myocarditis or pericarditis.
• Enterovirus D68 is of particular concern, as it has been associated with outbreaks of severe respiratory illness and acute flaccid myelitis (AFM), a polio-like syndrome.

The majority of enterovirus infections occur during the late summer and fall, though they can circulate year-round in tropical climates. Children under five years old, immunocompromised individuals, and those living in densely populated environments are at the highest risk.

Symptoms of Enteroviral Infections

The clinical manifestations of enterovirus infections vary widely, from mild to life-threatening, depending on the viral strain and host immune response.

1. Mild Respiratory Illnesses
   • Symptoms include fever, runny nose, cough, sneezing, sore throat, and muscle aches.
   • This presentation is most commonly caused by EV-D68, which is often mistaken for the common cold but can lead to more severe respiratory complications in some children.
2. Hand, Foot, and Mouth Disease (HFMD)
   • HFMD is a well-known syndrome, predominantly caused by Coxsackievirus A16 and Enterovirus 71.
   • It presents as a fever, painful sores in the mouth, and a characteristic rash on the hands, feet, and buttocks.
   • The condition is usually mild, but can sometimes lead to severe complications, including viral meningitis or encephalitis.
3. Viral Meningitis and Encephalitis
   • Meningitis and encephalitis caused by enteroviruses are typically less severe than bacterial forms but still require prompt treatment.
   • Symptoms include severe headache, neck stiffness, photophobia, nausea, and altered mental status.
   • The most common enteroviruses associated with these conditions include Coxsackievirus A and B, and echoviruses.
4. Acute Flaccid Myelitis (AFM)
   • AFM is a rare but serious condition associated with enterovirus D68.
   • It manifests as sudden muscle weakness, loss of muscle tone, and reflexes, predominantly affecting the limbs.
   • AFM shares many similarities with poliomyelitis and can cause permanent paralysis.
5. Myocarditis and Pericarditis
   • Enteroviruses, especially Coxsackievirus B, are a leading cause of myocarditis and pericarditis in children.
   • Symptoms include chest pain, fatigue, and shortness of breath, which may progress to heart failure if untreated.

Transmission of Enteroviruses

Enteroviruses are highly contagious and can spread through multiple routes:

• Fecal-Oral Route: This is the primary route of transmission, especially for polioviruses and HFMD-related viruses. Poor hand hygiene after using the toilet or changing diapers can lead to the ingestion of viral particles.
• Respiratory Droplets: Respiratory viruses like EV-D68 can spread through droplets when an infected person sneezes or coughs.
• Contact with Contaminated Surfaces: Enteroviruses can survive on surfaces for days. Children touching contaminated surfaces, toys, or sharing personal items (like utensils) can become infected.

Given the various transmission routes, enterovirus outbreaks are common in schools, daycare centers, and other settings where children interact closely.

Diagnosis

Identifying an enterovirus infection can be challenging due to the wide range of clinical presentations and overlapping symptoms with other viral illnesses. Key diagnostic steps include:

• Clinical Assessment: Based on symptomatology, age, and epidemiology (e.g., seasonality, contact with infected individuals), a physician may suspect an enterovirus infection.
• Viral Culture and PCR: Throat swabs, stool samples, or cerebrospinal fluid (in cases of meningitis or encephalitis) can be tested using viral culture or polymerase chain reaction (PCR) to confirm the presence of enterovirus.
• Serological Testing: In rare cases, serology can be used to detect antibodies against specific enterovirus strains.

Treatment of Enterovirus Infections

Currently, there is no specific antiviral treatment for most enterovirus infections. Treatment focuses on symptom management and supportive care:

1. Symptomatic Care
   • Fever and Pain Management: Acetaminophen or ibuprofen can be used to manage fever, body aches, and headaches.
   • Hydration: Especially important in cases of HFMD, where oral sores can make drinking painful.
   • Rest: Encouraging bed rest allows the body to recover and strengthens the immune response.
2. Respiratory Support
   • Children with severe respiratory symptoms, particularly those infected with EV-D68, may require oxygen therapy or even mechanical ventilation in extreme cases.
3. Intravenous Immunoglobulin (IVIG)
   • For severe cases, particularly those involving myocarditis or AFM, IVIG therapy may be considered. However, its efficacy is still under research.
4. Antivirals (in Development)
   • While there are no FDA-approved antiviral treatments specifically targeting enteroviruses, experimental treatments, such as pleconaril, are under investigation.

Preventing Enterovirus Infections in Children

Prevention is the most effective strategy for controlling enteroviral infections. As healthcare professionals, providing parents with guidance on preventive measures is essential in reducing the incidence of these infections.

1. Hand Hygiene
   • Proper handwashing with soap and water for at least 20 seconds is one of the most effective ways to prevent the spread of enteroviruses.
   • Alcohol-based hand sanitizers can be used when soap and water are not available, although they are less effective against non-enveloped viruses like enteroviruses.
2. Environmental Cleaning
   • Regularly disinfecting frequently touched surfaces, such as toys, doorknobs, and countertops, reduces the likelihood of transmission via contaminated surfaces.
3. Avoiding Close Contact
   • Children with symptoms of an enterovirus infection should be kept at home to prevent the spread of the virus to others.
   • It is also advisable to avoid close contact with infected individuals, especially in cases of respiratory infections like those caused by EV-D68.
4. Polio Vaccination
   • Vaccination is the most effective method of preventing poliovirus infections. Ensure that all children follow the polio vaccination schedule recommended by the CDC (Centers for Disease Control and Prevention) or WHO (World Health Organization) guidelines.
   • The inactivated polio vaccine (IPV) is administered in four doses, typically at 2 months, 4 months, 6–18 months, and a booster at 4–6 years.
5. Monitoring Outbreaks
   • Healthcare providers should stay informed about local enterovirus outbreaks. Public health authorities often issue alerts during seasonal spikes in EV-D68 or HFMD cases.
   • During outbreaks, parents should be encouraged to limit their children’s exposure to crowded places like daycare centers or playgrounds.
6. Education
   • Parents, caregivers, and school staff should be educated about the signs and symptoms of enterovirus infections and the importance of early detection.
   • Promote the "cover your cough" campaign to minimize the spread of respiratory droplets, a common transmission route for enteroviruses.

The Role of Public Health in Enterovirus Control

Public health surveillance and timely reporting of enterovirus infections play a critical role in outbreak prevention and control. Healthcare professionals should ensure that severe cases of enteroviral infections (such as myocarditis, meningitis, and AFM) are reported to public health authorities. This enables proper tracking and response strategies, including informing the public about preventive measures and vaccination campaigns.

Research into new vaccines, especially for non-polio enteroviruses like EV-D68 and Coxsackieviruses, is ongoing and holds the promise of further reducing the global burden of enteroviral diseases in children.

Conclusion

Enteroviruses represent a significant health risk to children, particularly those under five years old. While many enteroviral infections are mild, healthcare professionals must remain vigilant about severe cases that can lead to life-threatening complications, such as myocarditis, viral meningitis, and acute flaccid myelitis.

The cornerstone of prevention lies in educating parents about proper hand hygiene, environmental cleaning, and vaccination, as well as recognizing early signs of infection. Healthcare professionals must also stay informed about local outbreaks and new developments in antiviral treatments and vaccines.

By staying proactive and educating both caregivers and the public, we can significantly reduce the impact of enteroviral infections in children and safeguard their health.