What is the difference between fifth disease and sixth disease?
You get a call from childcare: your child has red spots. Or you suddenly discover a strange rash on your toddler's body at home. Two of the most common viral childhood illnesses with skin rashes are fifth disease (erythema infectiosum) and sixth disease (exanthema subitum). Although the names are confusingly similar, they are completely different viruses with their own distinct course. And that's precisely where the problem lies: parents and childcare workers often misjudge the contagiousness and the right time to return.
Fifth disease is caused by parvovirus B19. The hallmark is the 'slapped cheek' appearance: bright red, warm cheeks that look like your child has been hit, while the area around the mouth stays pale. After that, a patchy pink rash pattern spreads across the arms, torso, and legs. The rash can come and go for weeks, especially with heat or physical exertion. With sixth disease, everything revolves around the HHV-6 virus. Here you first see three to five days of high fever — sometimes up to 40°C — while your child otherwise seems remarkably well. Precisely when the fever suddenly drops, the characteristic rash appears: small pink spots that start on the torso and spread to the neck and face.
How contagious is your child and when does the incubation period begin?
There's a crucial difference here that directly impacts childcare policy. With fifth disease, your child is most contagious before the cheeks turn red. That sounds contradictory, but it explains why outbreaks at daycare centers are so difficult to prevent. The incubation period is four to fourteen days. Once the rash is visible, the risk of infection is essentially over — except for children with weakened immunity or certain blood disorders.
With sixth disease, contagiousness runs parallel to the fever phase. The incubation period is five to fifteen days. The child is contagious from before the fever until shortly after it subsides. Here too, the rule applies: once the spots appear, contagiousness drops sharply.
Just as with chickenpox at childcare, the caregiver mainly looks at how your child feels and whether there's still fever. The visible phase of both illnesses is often already the end of the contagion story — an insight that surprises many parents.
What exactly does the RIVM say about returning to childcare?
The RIVM guideline for childcare is clear, but requires nuance. For fifth disease, the rule is: children with the visible rash may simply go to the daycare center (kinderdagverblijf/KDV) or after-school care (BSO). They are no longer contagious to those around them. However, there is one important exception: pregnant women. For them, parvovirus B19 can be risky, especially in the first trimester. Childcare locations must inform pregnant staff members or pregnant parents about an outbreak, so they can contact their midwife or gynecologist.
For sixth disease, the RIVM advises that children may return to childcare as soon as they are fever-free and feel well enough. The rash itself is not a reason to stay home. This is comparable to how you approach RSV in babies and toddlers, where you also look at general wellbeing and the absence of fever.
Yet in practice, you see that childcare locations are sometimes more cautious than the guideline prescribes. This relates to their own illness policy, group composition, and sometimes pressure from other parents. It helps to know your childcare's illness policy well in advance.
Why are fifth disease and sixth disease often confused?
The numbering refers to a historical sequence of described childhood illnesses with rash — not to severity or frequency. The first through fourth diseases (including measles and rubella) have become rare due to vaccination programs. As a result, fifth and sixth disease now come to light more often, but awareness of their differences hasn't grown accordingly.
Parents recognize the confusing signals: both often start innocently, both cause rash, and with both your child seems reasonably recovered between phases. The difference lies in the chronology. Remember this rule of thumb: fifth = cheeks first, then body; sixth = fever first, then rash. No fever beforehand? Think fifth. Fever that suddenly stops? Think sixth.
When do you call the doctor and when do you keep your child home?
Fifth and sixth disease are generally harmless and resolve on their own. Still, there are times when you should seek medical advice. Call your doctor for fifth disease if your child becomes pale, extremely tired, or if you're concerned about blood values — this virus can temporarily slow blood cell production. With sixth disease, it's wise to contact them if the fever lasts longer than five days, if your child won't drink, is lethargic, or if the rash looks different than expected (for example, bruises or bleeding spots).
Regarding keeping your child home: follow the RIVM advice, but also be practical. A child with fifth disease who is playing happily and has no fever may go to childcare. A child with sixth disease who has just become fever-free but is still listless and irritable might benefit from a recovery day at home. Fever in babies and toddlers remains the most important measure for childcare or staying home.
What does this mean for pregnant staff and parents in the group?
This is the underexposed chapter of both illnesses. With fifth disease, the risk for pregnant women is greatest, because parvovirus B19 can cross the placenta and in rare cases cause fetal anemia. The RIVM advises pregnant women who haven't been previously infected to consult their care provider after direct contact with an infected child. Good news: most adults are already immune due to an unnoticed infection in childhood.
With sixth disease, the risk for pregnant women is negligible. The HHV-6 virus can cause problems in newborns, but that occurs in a completely different context than toddler care.
Childcare locations would be wise to proactively communicate with pregnant team members during a fifth disease outbreak. As a parent, you can also be alert to this yourself — it prevents unnecessary anxiety when everyone is informed in time.
How do you handle childcare policy in practice?
Despite clear RIVM guidelines, you see large differences between locations. Some daycare centers enforce a strict 'no rash' policy, others follow professional advice strictly. The best approach is transparent communication. Report what the doctor or Municipal Health Service (GGD) has said, ask about their specific protocol, and discuss together what is appropriate.
On Kiddie.nl, when comparing childcare locations, you can look not only at pedagogical vision and GGD reports, but also inquire how a location handles illness and return. That prevents surprises at the moment when your child is already better and you need to get back to work.
Conclusion: trust the facts, not the fear
Fifth and sixth disease are part of childhood and are almost always harmless for healthy children. The biggest problem isn't the illness itself, but the confusion around it. Knowing that your child with the visible rash of fifth disease is no longer contagious, or that sixth disease is only truly over when the fever is gone, helps you act more purposefully. Discuss your childcare's policy with them, inform pregnant contacts about fifth disease, and if in doubt? A call to your doctor or GGD always gives more certainty than Googling late into the night.