“Slapped cheek” is one of those illnesses that seems to come around a couple of times a year. This May, wastewater samples in Northern California have confirmed the presence of the virus; that tracks. Dr. Ted has been seeing a lot of it this week.
This virus is also known as fifth disease. It got that name back in the 1880s. At the time, childhood diseases that caused rashes were assigned a number. This was number 5 out of 6.
For those of you who like to collect trivial facts, the original numerical list includes:
First Disease: Measles (Rubeola)
Second Disease: Scarlet Fever
Third Disease: Rubella (German Measles)
Fourth Disease: Dukes’ Disease (Also known as Filatow-Dukes’ disease or Staphylococcal Scalded Skin Syndrome; rarely used today)
Fifth Disease: Erythema Infectiosum (Parvovirus B19)
Sixth Disease: Roseola Infantum (Exanthem subitum)
You might hear it occasionally referred to by its medical terms, but most people just call it slapped cheek.
Just like Hand Foot Mouth (another one of those viruses that sometimes makes parents question why they signed up for this parenting gig), slapped cheek is a contagious rite of passage.
Most people get it while they are still children and thus have immunity as adults. The majority of cases happen in kids between 4-14 years of age. While it can occur at any age, the infection is highly prevalent in this group because the virus spreads easily in close-contact settings like schools and daycares.
It spreads through respiratory secretions, but can also be carried through infected blood.
Unless you had a memorable case of it, many people don’t actually know whether they have had it or not. You can check with the grandma or grandpa, but I bet they don’t remember either. The symptoms may have been mild enough that no one paid much attention.
Common Symptoms
This illness can be quite variable. Some kids don’t seem too impaired while others clearly feel miserable. The mild cases can present with a child who has a red chapped cheek for a day or so, and that’s it! The common denominator (hence the name) is one or both cheeks usually appear very red and irritated.
Red cheeks aren’t definitive. Some kids look flushed when they have a fever no matter what. This diagnosis often has some guessing involved.
For some patients, the red cheeks are followed by a lacy, mottled rash that works its way up and down the body. This rash tends to cover the arms and legs more than the trunk. Of course there are exceptions; some kids don’t read the textbooks and present in their own unique way. People with more moderate cases often have high fevers. Kids tend to be pretty fussy.
That’s a lot of symptoms to think about, but how does it look most of the time?
About 20-30% of children may have no symptoms at all.
Early on, around 50-60% develop mild cold-like symptoms such as congestion, runny nose, headache, sore throat, or low energy.
Fever occurs in roughly 20-40% of cases and is usually low-grade, although some kids run higher fevers.
The classic bright red slapped cheek rash develops in most symptomatic children and is followed by the lacy body rash in roughly 70-80% of cases. Mild itching can happen but is less common.
Fussiness and fatigue are also common, especially in younger kids, though thankfully most children continue to drink fluids and bounce back fairly quickly.
On the whole, even though the title sounds alarming, most kids with Parvovirus B19 don’t usually look terribly sick (we see you readers who are waving your hands around; some kids are indeed truly wretched).
Rare symptoms
In rare severe cases it can cause very painful or swollen joints (polyarhropathy). This is much more common in older kids or adults. In even more rare cases, it can also cause the body to temporarily stop making new red blood cells. This can lead to anemia. If the patient seems suddenly paler than usual, or low energy, it is worth checking in with your doctor.
People with sickle cell disease, other types of long lasting anemia, or weakened immune systems are more at risk for these complications.
Rebound Symptoms
One confusing thing about slapped cheek is that it often comes in phases. Many kids start with a few days of mild fever, fussiness, congestion, or low energy that seems to improve. Then, about a week later the famous red cheeks or lacy rash show up. Some children even seem to get a second round of low-grade fevers or feel crummy again during this stage. Doctors call this a ‘biphasic’ illness, which is just a fancy way of saying it can feel like the illness comes in two waves. Thankfully, the second phase is usually milder and more about the rash than serious illness.
The good news is that this is not one of the viruses that you can get multiple times! Once you’ve been infected, your body is generally protected for life.
Treatment
There is no real treatment for slapped cheek beyond symptomatic care. Treat the fevers and/or fussiness as needed with Tylenol/Ibuprofen and tepid baths. Make sure your child gets plenty of fluids and rest.
Modern medicine doesn’t have any magic wand for this. However, just because you think your child might have slapped cheek, don’t exclude the possibility of an illness that would benefit from treatment. In general, if you have a miserable kid with a mystery fever that isn’t responding to standard medications, it is usually worth having them checked out. It might be something like strep throat.
In any event, even if the only thing you get out of a visit to the doctor is assurance that there is nothing more serious going on, sometimes that is worth it.
Pregnancy
Frankly, the issue about slapped cheek that is the biggest concern, is that it can be dangerous to a fetus.
If a woman is infected for the first time in the early stages of pregnancy there is an increased chance of miscarriage.
If you are pregnant and may have been exposed, take a deep breath and remember that most women (to the tune of 60-70%) had this as a child and are therefore not at risk.
If you have a child with slapped cheek, obviously, try to minimize exposure to anyone who is expecting. However, if you are the pregnant one, it is not reasonable to try to isolate yourself from your own child. The fact is, they were likely contagious before you had a diagnosis.
Just to be on the safe side, talk to your OB about getting a blood test to check your immunity.
Incubation and Reducing Spread
The incubation period is thought to be about 4-14 days after the exposure, with most symptoms starting after 6-11 days. In other words, if you come into your doctor’s office and walk out with a red cheek, you didn’t get it there; that would be way too soon.
The kids are most contagious at the very beginning of the illness when the main symptom is probably simple fussiness. You figure it is a simple cold or teething. By the time the rash is in full throttle and you’re pretty certain you’re dealing with slapped cheek, they are probably not very contagious anymore.
Our best daycare, camp, and school guidelines are to keep a child home if they are fussy or have a fever. If you have a happy child with a red cheek, it seems unreasonable to expect you to stay home from work. Chances are, once one of the kids in daycare shows up with it, everyone has already been exposed.
Case Study: Nurse Judy’s 27 month old grandson Coby.
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Coby presented with a fever on Thursday evening.
Murphy’s Law had a good handle on this one, since daddy was out of town for the three day weekend, so mama Lauren had the 5 year old (who was a champion), a sick toddler, and a large dog to deal with as a single parent.
His fever went as high as 102.5. It responded to Tylenol and Motrin. When the medication was on board, he seemed pretty okay. When the meds wore off he was very ‘fragile and pitiful’.
Night times were tough.
He had mild congestion, a cough and red cheeks. The cough started as a bark and morphed into a looser hack after a few days. His voice was pathetically hoarse, so croup was one of the diagnoses that we were considering.
Coby is very verbal for his age, and was able to tell his mom that something in his mouth was hurting him. She didn’t notice any sores.
(It is worth noting that kids under 5 with a sore throat will often complain that their ‘mouth’ hurts).
When the fever was lingering for 3 days, Lauren took him into urgent care and came out with the diagnosis “some virus.”....in other words, treat the symptoms and check back in if something changes or it doesn’t go away in a couple more days.
She was given an oral steroid to start if the croupy cough was causing any distress. She didn’t need to start it.
The red cheeks became more significant on Monday.
Checking in with other kids in day care confirmed a cascade of viral stuff, some kids had mild fevers, others with congestion.
So, was it slap cheek? Maybe.
Viral syndromes often remain a mystery.
The key is:
Are you worried about your kid, or do you mostly feel sorry for them? In Coby’s case it was the latter.
