ACEP Monkeypox Field Guide

Children and Adolescents

• Monkeypox should be considered when children or adolescents present with a rash that could be 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 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 exposure to people with suspected or confirmed monkeypox may be eligible for post-exposure prophylaxis (PEP) with vaccination, immune globulin, or antiviral medication.

For Additional information see CDC guidance on Clinical Considerations for Monkeypox in Children and Adolescents.

People with HIV

• People with advanced HIV or who are not virologically suppressed with antiretroviral therapy can be at increased risk of severe disease related to monkeypox virus infection.
• Post-exposure prophylaxis and antiviral treatments are available for persons exposed to monkeypox or with monkeypox virus infection. Vaccination with JYNNEOS is considered safe for people with HIV, and antiviral treatments have few interactions with antiretroviral therapy.

These considerations are based upon limited evidence available to date about monkeypox virus infection in patients with HIV. The approaches outlined below are intentionally cautious until additional data become available.

For Additional information see CDC guidance on Clinical Considerations for Treatment and Prophylaxis of Monkeypox Virus Infection in People with HIV.

Pregnant or Breastfeeding

Pregnancy

• Data regarding monkeypox infection in pregnancy are limited. It is unknown if pregnant people are more susceptible to Monkeypox virus or if infection is more severe in pregnancy.
• Monkeypox virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth.
• Adverse pregnancy outcomes, including spontaneous pregnancy loss and stillbirth, have been reported in cases of confirmed monkeypox infection during pregnancy. Preterm delivery and neonatal monkeypox infection have also been reported. The frequency and risk factors for severity and adverse pregnancy outcomes are not known.
• Pregnancy loss, stillbirth, preterm birth, and congenital infection have been reported in cases of Variola virus infection during pregnancy.

Breastfeeding

• Separation (e.g., separate rooms) of a patient with monkeypox from their newborn is the best way to prevent transmission to the newborn. Full-time rooming in with a newborn is not recommended during a patient’s infectious period.
• The patient should be counseled about the risk of transmission and the potential for severe disease in newborns. If the patient chooses to have contact with the newborn during the infectious period, strict precautions should be taken, including the following:
  • There should be no direct skin-to-skin contact.
  • During contact the newborn should be fully clothed or swaddled and after contact occurs the clothing or blanket should be removed and replaced.
  • Gloves and a fresh gown should be worn by the patient at all times, with all visible skin below the neck covered.
  • Soiled linens should be removed from the area.
  • The patient should wear a well-fitting source control (e.g. medical mask) during visit.
• These precautions should be continued until criteria for discontinuing isolation have been met (i.e., all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed).
• Discharge planning should take into account the duration of isolation, ability to strictly adhere to recommended isolation precautions, and availability of alternative caregivers.
• It is unknown if Monkeypox virus is present in breast milk. Breast milk expressed from a patient who is symptomatic or isolated should be discarded while breastfeeding is delayed. To avoid inadvertently exposing an infant to the Monkeypox virus, a healthy caregiver can feed pasteurized donor human milk or infant formula. People who are breastfeeding should talk with their healthcare provider to determine if their lesions have healed and they can resume direct breastfeeding or feed expressed breast milk.

For Additional information see CDC guidance on Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding.