Clinical Considerations for Monkeypox in Children and Adolescents

Key points

• Monkeypox should be considered when children or adolescents present with a rash that is consistent with the disease, especially if epidemiologic criteria are present.
• Young children, children with eczema and other skin conditions, and children with immunocompromising conditions may be at increased risk of severe disease.
• Treatment should be considered on a case-by-case basis for children and adolescents with suspected, probable, or confirmed monkeypox who are at risk of severe disease or who develop complications of monkeypox. Tecovirimat is the first-line medication to treat monkeypox, including in children and adolescents.
• Children and adolescents with close contact to people with suspected, probable, or confirmed monkeypox may be eligible for post-exposure prophylaxis (PEP) with vaccination, immune globulin, or antiviral medication

Monkeypox in children and adolescents

Historically, monkeypox has been documented in children and adolescents living in areas where monkeypox infections occur more commonly. Once illness occurs, the clinical presentation is expected to be similar to illness in adults. However, it is not known whether children are more susceptible to monkeypox than adults or whether clinical outcomes differ from those in adults. In the current global outbreak, monkeypox has only been known to spread by people from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. However, monkeypox virus has been detected in some samples taken from people who reported no symptoms. CDC will continue to monitor case data and available science for new or changing information about transmission. Monkeypox can also be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth.

While data about monkeypox in children are limited, there is evidence from patients infected with Clade I of Monkeypox virus (previously called the Congo Basin clade) that the disease is more likely to be severe in children under 8 years of age. Additionally, anyone with immunocompromising conditions or certain skin conditions, such as eczema, is at risk of severe monkeypox disease. The 2022 Multinational Monkeypox Outbreak is caused by the Clade IIb virus (previously called the West African clade), which typically causes less severe disease than Clade I. Data on potential complications of infections with Clade II in children are currently lacking. Rarely, monkeypox can result in complications including encephalitis, cellulitis, pneumonia, sepsis, abscess, airway obstruction due to severe lymphadenopathy, keratitis, and corneal scarring. CDC continues to monitor for these outcomes and will update this document as more information becomes available.

Signs and symptoms

Similar to infections in adults, the most common sign of monkeypox in children and adolescents is a rash that progresses from maculopapular lesions to vesicles, pustules, and finally scabs. Before the 2022 Multinational Monkeypox Outbreak, fever and lymphadenopathy were commonly associated with monkeypox; however, during the current outbreak, these have not always occurred. Other symptoms may include fatigue and headache. Difficulty swallowing or cough may occur when oropharyngeal lesions are present. Intraocular lesions, eyelid swelling, or eyelid crusting may occur when there are lesions near or in a patient’s eye, which can occur when a patient touches these sites with their hand after touching a lesion. (See Clinical Recognition for key characteristics of monkeypox and pictures of lesions.)

The rash of monkeypox may be confused with other rash illnesses that are commonly considered in children, including varicella (chickenpox); hand, foot, and mouth disease; measles; scabies; molluscum contagiosum; herpes; syphilis (including congenital syphilis); allergic skin rashes; and drug eruptions. Co-infections with monkeypox are possible. When indicated based on clinical presentation, evaluation for more common etiologies other than monkeypox should be done at the time of testing for monkeypox, particularly when no epidemiologic link to a person with monkeypox has been identified.

The recommendations for testing for monkeypox are similar for children and adults. Tests should be performed on people for whom monkeypox is suspected based on clinical presentation and epidemiologic criteria. If testing is indicated, lesions should be vigorously swabbed and sent for testing according to the guidance on Preparation and Collection of Specimens.

Positive diagnostic results from testing of lesion material for Orthopoxvirus or Monkeypox virus DNA in people without epidemiologic criteria or known risk factors, or with atypical presentations, should be verified. Molecular tests (e.g., real-time PCR tests) are highly specific and sensitive; however, when epidemiologic criteria are absent or unknown and the Ct value is high (generally ≥34), CDC recommends re-extraction and retesting of the specimen. CDC can be consulted for complex cases, including those that appear atypical or questionable, and can perform additional viral specific- and clade-specific PCR testing and anti-orthopoxvirus serologic testing. For more information, see HAN Archive – 00471 | Health Alert Network (HAN) (cdc.gov) and Orthopoxvirus Testing Challenges for Persons in Populations at Low Risk or Without Known Epidemiologic Link to Monkeypox — United States, 2022 | MMWR (cdc.gov).

Patients with suspected monkeypox should be assessed for contact with people or animals having a rash or diagnosed with monkeypox. Clinicians should contact their jurisdictional health department (Jurisdictional Contacts) as soon as monkeypox is suspected.

Management of monkeypox

As with adults, children and adolescents with monkeypox should be closely monitored throughout their illness and likely will benefit from supportive care and pain control. Decisions about treatment for children closely align with treatment plans for adults (see Interim Clinical Guidance for the Treatment of Monkeypox). For the pediatric population, particular attention should be paid to keeping skin lesions covered and preventing children from scratching lesions or touching their eyes, which may result in auto-inoculation and more severe illness. For information about skin care for individuals with monkeypox lesions, please see Monkeypox: Caring for the Skin. If there are lesions near or in the eye, an ophthalmologist should be consulted and a careful ocular exam performed. Optimal fluid intake should be encouraged, particularly in persons with extensive skin involvement who may have additional fluid losses.

When considering treatment for a child or adolescent with monkeypox, clinicians should consult their jurisdictional health department. Jurisdictional health departments can facilitate consultation with CDC for additional guidance, as needed.

While most cases of monkeypox resolve without treatment, treatment should be considered, based on guidance for clinical treatment for people of all ages, for people who have the following clinical manifestations:

• Severe disease
• Involvement of anatomic areas which might result in serious sequelae that include scarring or strictures.

Treatment should also be considered for people who are at high risk for severe disease:

• Children under 8 years of age
• People experiencing severe immunocompromise
• People who are pregnant or breastfeeding
• People with a condition affecting skin integrity

Treatment

Tecovirimat

Under an expanded access Investigational New Drug (EA-IND) protocol  [1 Mb, 22 pages], tecovirimat (TPOXX) is currently being used as the first-line treatment for infection with Monkeypox virus for people with severe disease or who are at risk for severe disease, including for children and adolescents. For more specific information about tecovirimat use for adult and pediatric patients, see Guidance for Tecovirimat Use Under Expanded Access Investigational New Drug Protocol during 2022 U.S. Monkeypox Outbreak.

Data on the effectiveness of tecovirimat to treat people with monkeypox are not yet available, but studies using a variety of animal species have shown that tecovirimat can effectively treat disease caused by orthopoxviruses. Evidence for the efficacy of tecovirimat for monkeypox treatment comes from animal studies that suggest a potential for reduction in mortality and a case study that suggests tecovirimat may limit the duration of illness and viral shedding. Prior to the 2022 Multinational Monkeypox Outbreak, tecovirimat was used in a 28-month-old child with no adverse effects attributed to the drug, but no clinical studies have been conducted in pediatric populations. When considering the use of tecovirimat, clinicians and patients should understand the lack of tecovirimat effectiveness data to date in people with monkeypox and the potential for development of resistance to tecovirimat.

Oral tecovirimat dosing is most practical for children who weigh at least 13 kilograms (approximately 28 pounds), can take capsules or the contents of a capsule mixed with soft food, and are able to eat a fatty meal to ensure optimal drug absorption. Because of the challenge of accurate dosing for children under 13 kilograms, IV therapy can be considered for this group when tecovirimat is indicated. For information on weight-based dosing of tecovirimat, see the EA-IND protocol  [1 MB, 22 pages]. The protocol includes instructions for opening capsules and mixing with food  [295 KB, 2 pages] or liquid for infants and children who require less than a 200 mg dose, which differs from the FDA-approved tecovirimat labeling.

Monitoring of renal function is recommended in pediatric patients < 2 years of age, given theoretical concerns that renal immaturity in young pediatric patients may result in higher exposure of hydroxypropyl-β-cyclodextrin, an ingredient in IV tecovirimat. Animal studies have shown potential for nephrotoxicity at very high exposure levels of hydroxypropyl-β-cyclodextrin. For more information, see Expanded Access IND Protocol: Use of Tecovirimat (TPOXX®) for Treatment of Human Non-Variola Orthopoxvirus Infections in Adults and Children (cdc.gov) [1 MB, 22 pages].

Other treatments

Other treatments might be considered in addition to tecovirimat or as an alternative; these should be reserved for unusual circumstances, such as very severe infections, disease progression despite tecovirimat treatment, or when tecovirimat is contraindicated or unavailable. Use of these treatments should be in consultation with infectious disease specialists, pharmacists, state and local health departments, and CDC.

Vaccinia immune globulin, licensed for treatment of vaccinia virus vaccine complications, may be used for treatment of severe monkeypox infection, though it is unknown whether children will benefit from treatment. Vaccinia immune globulin is available from the US Strategic National Stockpile and can be given through an existing expanded access Investigational New Drug (EA IND).

The use of the antiviral medications cidofovir [ 828KB, 6 Pages] and brincidofovir [ 670KB, 21 Pages] may also be considered, but these should be used with caution due to potential toxicity.

For additional information on current therapeutic recommendations, see Treatment Information for Healthcare Professionals.

Post-exposure prophylaxis (PEP)

Data on PEP to prevent monkeypox in children are limited. The only vaccine that is authorized and recommended for use in children or adolescents for PEP is the JYNNEOS vaccine. PEP should not be withheld from children or adolescents who are otherwise eligible. Decisions about whether to offer PEP should consider the level of risk from the patient’s exposure and the individual patient’s risk of severe disease. Prophylactic modalities that can be administered include vaccination, immune globulin, and antiviral medication. For almost all patients, vaccination is the modality that should be administered. Immune globulin or antivirals may also be considered for infants under 6 months of age, given their immature immune systems and possible decreased responses to vaccination.

When considering prophylactic modalities for a child or adolescent, clinicians should first consult their jurisdictional health department (Jurisdictional Contacts). Jurisdictional health departments can facilitate consultation with CDC for guidance regarding PEP modalities, when needed, and for assistance with the associated EA IND processes, if applicable.

Vaccines and other options for monkeypox PEP in children and adolescents are reviewed below. For detailed information on vaccines for monkeypox, see Considerations for Monkeypox Vaccination.

Vaccines

JYNNEOS

JYNNEOS contains a non-replicating Vaccinia virus. While JYNNEOS has not been studied specifically for children or adolescents, the same non-replicating Vaccinia virus in the JYNNEOS vaccine has been used in studies against other diseases including tuberculosis, measles, and Ebola. These studies included children as young as 5 months old, and no serious safety concerns were reported. In the United Kingdom in 2018–2019, JYNNEOS was administered to a few young children, including infants, following exposures to monkeypox, with no known adverse events. JYNNEOS has also been administered to some children in the United States during the current outbreak without any adverse events to date.

JYNNEOS is available for use as PEP for children and adolescents under 18 years determined to be at high risk for monkeypox infection under the Emergency Use Authorization (EUA) issued by the US Food and Drug Administration on August 9, 2022. In the current outbreak, CDC has recommended vaccination with JYNNEOS as PEP after a known exposure for children as young as 5 months. Prior to administration in people younger than age 6 months, clinicians should first contact their jurisdictional health department.

Vaccination with JYNNEOS for children and adolescents aged <18 years should be administered via subcutaneous injection as two doses (0.5mL each) given four weeks apart, ideally with the first dose given within four days of exposure. For more information, review EUA Fact Sheet for Healthcare Providers Administering  Jynneos Vaccine.

ACAM2000

Up until the early 1970s, a precursor to ACAM2000 was administered to children in the United States to prevent smallpox, an infection caused by another orthopoxvirus. That vaccine and ACAM2000 contain a replicating Vaccinia virus and are associated with adverse events caused by uncontrolled viral replication, such as progressive vaccinia and eczema vaccinatum. Many adverse events were more common in young children, particularly post-vaccinial encephalitis in those under age 12 months, and immunocompromised individuals.

ACAM2000 is contraindicated in children under 12 months of age and in children and adolescents with the following conditions:

• Congenital or acquired immune deficiency disorders, including those taking immunosuppressive medications and people living with HIV (regardless of immune status)
• Atopic dermatitis/eczema or a history of atopic dermatitis/eczema or other acute or exfoliative skin conditions
• Pregnancy
• Cardiac disease
• Eye disease treated with topical steroids

ACAM2000 is allowed for use against monkeypox under an EA IND. It can be used following risk-benefit discussions and a review of any conditions that could increase the patient’s risk for adverse events. Clinicians considering the use of ACAM2000 should also take into account the risk of accidental inoculation, autoinoculation, and myopericarditis, which may be greater among children and adolescents compared to adults. They should also take into consideration whether the child or adolescent resides in a home with immunocompromised individuals (both adults and children), pregnant individuals, and people with skin conditions including eczema; these people are at risk for serious infection with Vaccinia virus, which can infect them if the vaccinated person does not keep the vaccination site covered.

Vaccinia immune globulin

Vaccinia immune globulin is approved for treatment of smallpox vaccine complications. Its effectiveness as monkeypox PEP is unknown. However, vaccinia immune globulin is available through an EA IND for potential prevention of monkeypox. Particularly for infants under 6 months of age, vaccinia immune globulin can be offered as an alternative PEP modality.

Antivirals as PEP

Antiviral medications, primarily tecovirimat, can be considered for monkeypox PEP in unusual circumstances, such as when vaccine is contraindicated due to an allergy to vaccine components. The effectiveness of antiviral medications as monkeypox PEP is unknown.

Infection control

Pediatric inpatient care

For children hospitalized with suspected or confirmed monkeypox or for hospitalized children with monkeypox exposure, isolation and infection control procedures should take into consideration the child’s age and caregiving needs, family and caregiver preferences, and individual patient and caregiver factors, including the patient’s course of illness, the extent and location of lesions, the ability to cover lesions, and the risk to caregivers (e.g., pregnant or immunocompromised persons). The presence of caregivers in the hospital provides immeasurable benefit to children.

For detailed recommendations on isolation and infection control in healthcare settings, see Infection Control: Healthcare Settings.

In homes

Isolation and infection control measures can prevent the spread of Monkeypox virus to others. Extra care should be taken to ensure children with immunocompromising conditions avoid close contact with people who have monkeypox. If unavoidable, then children over 2 years of age should wear a well-fitting mask or respirator when interacting with members of the household who have monkeypox. If a child or adolescent develops monkeypox, they should avoid contact with uninfected people and pets until the rash has resolved, the scabs have fallen off, and a fresh layer of intact skin has formed. When possible, whether in the hospital or at home, limit the number of caregivers to one person. Caregivers should cover areas of broken skin with bandages to the extent possible and avoid direct skin-to-skin contact with the rash. During interactions with caregivers, children over 2 years of age with monkeypox should wear well-fitting source control (e.g., a medical mask) when possible. Caregivers assisting with changing bandages or clothes covering the rash should wear gloves to avoid infection. Gloves should be disposed of after each use, followed by handwashing. If any clothing (whether on the caregiver or the child) comes into contact with the rash, it should be immediately laundered.

Additional considerations

Breastfeeding a child who has monkeypox

Decisions about whether an infant or child with monkeypox may directly breastfeed from an uninfected caregiver should be considered on a case-by-case basis through weighing the benefits of breast milk with any uncertain risks of the child transmitting infection to the caregiver, particularly to a caregiver who is immunocompromised or at risk for severe infection.

Neonates born to individuals with suspected or confirmed monkeypox

Early bathing is recommended for neonates born to individuals with suspected or confirmed monkeypox. Bathing can be performed using soap and water and should occur prior to the neonate receiving procedures, vaccines, and medications (e.g., Vitamin K).

PEP should be considered for neonates born to individuals with suspected or confirmed monkeypox. The specific therapeutic that is administered should be determined after consultation with public health authorities.

Caregivers or family members who do not have suspected or confirmed monkeypox can provide routine care to an uninfected neonate who is born to a person with monkeypox.

Neonates born to individuals with suspected or confirmed monkeypox should be closely monitored for the development of signs consistent with monkeypox, including fever, lymphadenopathy, rash, or any new signs or symptoms of illness, for 21 days following birth or the last close contact with a person with monkeypox during their infectious period. Monitoring should include at least daily temperature checks and full skin exams, which can be performed by a caregiver or healthcare provider.

For detailed recommendations, see Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding.