Clinical Considerations for Monkeypox in Children and Adolescents in the U.S.

Overview

Children and adolescents in the United States can become infected with MPXV through contact with people or animals with monkeypox or with contaminated materials. This includes:

• Close, skin-to-skin contact such as might occur during cuddling, caregiving, or bed-sharing
• Transmission across the placenta in utero or contact during the birthing process
• Contact with body fluids and respiratory secretions of patients with monkeypox or with contaminated fomites
• In adolescents, sexual contact

Historically, monkeypox has been documented in children and adolescents in endemic countries in West and Central Africa and in periodic outbreaks linked to travel to these countries. There have also been cases associated with imported animals from Africa, including a 2003 outbreak in the United States associated with pet prairie dogs.

The United States has seen more than 36,000 monkeypox cases from the clade II outbreak that began in 2022. Cases of monkeypox among children and adolescents have been very rare (<0.01% of all reported cases as of June 1, 2024). A 2022 report described the epidemiologic and clinical features of 83 cases of infection in U.S. children and adolescents:

• 16 cases among children <5 years
• 12 cases in children 5-12 years
• 55 cases in adolescents 13-17 years

Most adolescents (89%) were male. The most common mode of exposure for children <12 years of age was close physical contact with an adult household member with monkeypox, while for adolescents the most common exposure was through male-to-male sexual contact.

Signs

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. Historical reports of clade I or II MPXV infections in children and adolescents describe a rash often accompanied by fever, chills, sweats, lymphadenopathy, sore throat, headache, or myalgias.

However, in the United States, cases since the ongoing outbreak began in 2022 have not always presented with fever and lymphadenopathy. 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.

In an MMWR report:

• Distribution of the rash in children was predominantly on the trunk and face, and none of the children <12 years of age had anogenital lesions.
• In contrast, most adolescents presented with anogenital lesions.
• More than 11% of 83 children and adolescents were hospitalized, with no patients requiring intensive care.
• 22% were treated with tecovirimat.
• All patients recovered without sequalae.
• There were 4 infants <1 year of age and no neonates <4 weeks of age.

Information about the disease course in neonates and young infants in the ongoing clade II outbreak is limited to case reports and series, which have included low rates of complications and only 1 report of perinatal transmission. There was 1 severe case of adenovirus and monkeypox virus (MPXV) coinfection where it is unclear which pathogen contributed more to the disease course.

Very few neonates and infants developed monkeypox, so it’s unclear whether the youngest children could have more severe illness. Consult public health officials when considering therapeutics, including antivirals, for young children, particularly if they’re under 6 months of age.

Other potential diagnoses

Monkeypox rash may be confused with other rash illnesses that are commonly considered in children, including classic varicella (chickenpox) and varicella zoster (shingles); hand, foot, and mouth disease; measles; scabies; molluscum contagiosum; herpes; syphilis; allergic skin rashes; drug eruptions; and a variety of congenital infections.

Co-infections with monkeypox are possible. When indicated based on clinical presentation, evaluation for 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.

Testing

The recommendations for monkeypox testing are similar for children and adults. Tests should be ordered when monkeypox is suspected based on clinical presentation and epidemiologic criteria.

CDC is available for consultation for complex cases, including those that appear atypical or questionable, and can perform additional testing. Email poxvirus@cdc.gov or contact the CDC Emergency Operations Center at 770-488-7100.

Patient management

As with adults, children and adolescents with monkeypox should be closely monitored throughout their illness and provided with supportive care and pain control.

• Treatment decisions closely align with guidance for adults.
• Pay particular attention to keeping skin lesions covered.
• Try to prevent children from scratching lesions or touching their eyes after touching lesions to avoid auto-inoculation and more severe illness.
• Consult an ophthalmologist to perform a careful ocular exam.
  • If there is involvement near or in the eye, consider tropical trifluridine eye drops in consultation with ophthalmology.
• Encourage optimal fluid intake, particularly in people with extensive skin involvement who may have additional fluid losses.

While most cases of monkeypox resolve without treatment, you may consider clinical treatment for children and adolescents who have the following clinical manifestations:

• Severe disease, including disseminated rash, a large number of lesions that are confluent, hemorrhagic or necrotic lesions, severe lymphadenopathy that can cause airway obstruction, involvement of multiple organ systems and associated comorbidities (for example, pulmonary involvement with nodular lesions, encephalitis, ocular disease, myocarditis, neurologic involvement), sepsis, or if the disease requires hospitalization.
• Involvement of anatomic areas which might result in serious sequelae that include scarring or strictures.

You may also consider treatment for those at higher risk for severe disease:

• Children under 1 year of age
• Children and adolescents experiencing severe immunodeficiency or immunocompromise
• Adolescent girls who are pregnant or breastfeeding
• Children and adolescents with a condition affecting skin integrity

CDC offers a clinical consultation service (email poxvirus@cdc.gov), or healthcare providers may contact the CDC Emergency Operations Center [EOC] at (770) 488-7100) where CDC can provide additional guidance to clinicians with patient management questions.

Treatment

Tecovirimat

Tecovirimat is currently a first-line treatment for MPXV infection in people with severe disease or who are at risk for severe disease, including for children and adolescents. To facilitate access to tecovirimat, CDC holds an expanded access IND (EA-IND) protocol for the treatment of non-variola orthopoxvirus infections, including monkeypox, in adults and children who meet eligibility criteria.

Contact poxvirus@cdc.gov or call the CDC Emergency Operations at 770-488-7100 with additional questions or to request tecovirimat.

Dosing

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.

In the absence of an oral tecovirimat suspension formulation, IV tecovirimat may be considered for children weighing less than 13 kilograms based on clinical assessment of risk/benefit and if determined appropriate by the treating clinician.

For information on weight-based dosing of tecovirimat, see the EA-IND protocol. The protocol includes instructions for opening capsules and mixing with food or liquid for infants and children who require less than a 200 mg dose, which differs from the FDA-approved TPOXX (tecovirimat) labeling.

Monitor renal function in patients less than 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.

Other treatments

Other treatments including vaccinia immune globulin (VIG) and antiviral medications might be considered in addition to tecovirimat or as an alternative when children and adolescents are ineligible or have a contraindication for tecovirimat. These treatments should be reserved for unusual circumstances, such as very severe infections, disease progression or recrudescence (initial improvement followed by worsening) despite tecovirimat treatment, or when tecovirimat is unavailable.

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 take into account the level of risk from the patient's exposure and the individual patient's risk of severe disease. Vaccination, immune globulin, and antiviral medication can be used as monkeypox PEP. For most people, vaccination is preferred. For infants under 6 months of age, Vaccinia Immune Globulin Intravenous (VIGIV) should be considered in lieu of JYNNEOS vaccine.

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.

JYNNEOS vaccine

JYNNEOS contains a non-replicating modified vaccinia Ankara-Bavarian Nordic (MVA-BN) strain. While JYNNEOS has not been studied specifically for children or adolescents, the same MVA-BN in the JYNNEOS vaccine has been used in studies against other diseases including tuberculosis, measles, and Ebola. These studies included children as young as 4 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 children in the United States during the ongoing clade II outbreak with no known serious adverse events to date.

JYNNEOS is available for use as post exposure prophylaxis (PEP) for children and adolescents under 18 years determined to be at high risk for MPXV infection under the Emergency Use Authorization (EUA) issued by the US Food and Drug Administration on August 9, 2022. In the ongoing clade II outbreak, children as young as 4 months have been vaccinated with JYNNEOS as PEP after a known exposure. However, VIGIV should be considered in lieu of JYNNEOS vaccine for infants <6 months.

JYNNEOS has also been administered to children in the United States during the ongoing clade II outbreak without any serious adverse events to date. 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. The intradermal route of administration is not recommended for people <18 years, as there are no data with this route of administration in people <18 years. For more information, review EUA Fact Sheet for Healthcare Providers Administering JYNNEOS Vaccine.

Sexually active adolescents

Adolescents at risk for monkeypox may receive the JYNNEOS vaccine before an exposure. Additionally, PEP vaccine should be offered to sexually active adolescents who were exposed to MPXV.

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 in infants under 6 months of age.

Antivirals

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

When considering isolation and infection control for children hospitalized with suspected or confirmed monkeypox, take the following into account:

• The child's age and caregiving needs
• Family and caregiver preferences
• 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 women or immunocompromised people). The presence of caregivers in the hospital provides immeasurable benefit to children.

At home

At home, isolation and infection control measures can prevent the spread of monkeypox to others. Families should take extra care to ensure all children avoid close contact with people who have monkeypox.. Household members with monkeypox should keep all their lesions covered. Children who have a household member who has monkeypox should be considered for PEP. If children must come into contact with someone with monkeypox, they must avoid touching the patient's rash and sharing items like towels, bedding, dishes, and cups. Both the patient and the child(ren) should also wear well-fitting masks or respirators.

If a child or adolescent develops monkeypox follow all regular isolation and infection control measures.

Additional considerations

Breastfeeding a child who has monkeypox

Make recommendations about whether an infant or child with monkeypox may directly breastfeed from an uninfected caregiver on a case-by-case basis. Considerations include 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. Consider PEP with the JYNNEOS vaccine for the uninfected caregiver.

Neonates born to women with suspected, probable, or confirmed monkeypox

Early bathing is recommended for neonates born to women with suspected, probable, or confirmed monkeypox. Perform bathing using soap and water prior to the neonate receiving procedures, vaccines, and medications (e.g., Vitamin K).

Consider PEP for neonates born to women with suspected, probable, or confirmed monkeypox. You can determine specific treatments after consultation with public health authorities.

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

Closely monitor neonates born to women with suspected, probable, or confirmed monkeypox for the development of signs consistent with monkeypox 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.