This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics. Committee on Infectious Diseases. Policy statement--recommendations for prevention and control of influenza in children, 2010-2011. Pediatrics 2010 Oct;126(4):816-26.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Influenza

To update recommendations for routine use of trivalent seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children

All children and adolescents 6 months of age and older during the 2011-2012 influenza season, including the following groups for whom special outreach efforts should be made:

• All children, including infants born prematurely, 6 months of age and older with conditions that increase the risk of complications from influenza
• All household contacts and out-of-home care providers of
  • Children with high-risk conditions
  • Children younger than 5 years
• All health care personnel (HCP)
• All women who are pregnant, considering pregnancy, or breastfeeding during the influenza season

Prevention

1. Immunization with trivalent inactivated influenza vaccine or live-attenuated influenza vaccine, based on specified criteria
2. Development of improved strategies for planning, communication, and administration of vaccines to achieve the immunization of all children 6 months and older

Treatment

Antiviral therapy and prophylaxis with oseltamivir or zanamivir

PubMed, Medline, and Cochrane databases were reviewed. The search built on previous searches conducted for prior versions of the guideline, incorporating new information affecting influenza. All relevant information concerning influenza infection and prevention was included.

Not stated

Not applicable

Not stated

This American Academy of Pediatrics (AAP) policy statement was prepared in parallel with the Centers for Disease Control and Prevention (CDC) recommendations and reports. Much of this statement is based on literature reviews, analyses of unpublished data, and deliberations of CDC staff in collaboration with the Advisory Committee on Immunization Practices (ACIP) Influenza Working Group, with liaison from the AAP.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not applicable

Introduction

The American Academy of Pediatrics (AAP) recommends annual trivalent seasonal influenza immunization for all children and adolescents 6 months of age and older during the 2011–2012 influenza season. Special outreach efforts should be made to the following groups:

• All children, including infants born prematurely, 6 months of age and older with conditions that increase the risk of complications from influenza
• All household contacts and out-of-home care providers of
  • Children with high-risk conditions, and
  • Children younger than 5 years.
• All health care personnel (HCP)
• All women who are pregnant, considering pregnancy, or breastfeeding during the influenza season

Key Points Relevant for the 2011-2012 Influenza Season

1. All people 6 months of age and older should receive trivalent seasonal influenza vaccine each year, especially those who are at high risk of influenza complications (e.g., children with chronic medical conditions such as asthma, diabetes mellitus, immunosuppression, or neurologic disorders). In the United States, more than two-thirds of children younger than 6 years and almost all children older than 6 years spend significant time in child care and school settings outside the home. Exposure to groups of children increases the risk of infectious diseases. Children younger than 2 years are at an increased risk of hospitalization and complications attributable to influenza. School-aged children bear a large influenza disease burden and have a significantly higher chance of seeking influenza-related medical care compared with healthy adults. Therefore, reducing influenza transmission among children who attend child care or school should decrease the burden of childhood influenza and transmission of influenza to household contacts and community members. Most egg-allergic children can now receive influenza vaccine safely.
2. Annual trivalent seasonal influenza vaccine is recommended for household members and out-of-home care providers of children and adolescents at high risk of complications of influenza and healthy children younger than 5 years, especially infants younger than 6 months. Pediatric offices should consider serving as an alternate venue for parents and other adults who care for children to receive influenza vaccine, if this approach is acceptable to both the pediatrician and the adult to be immunized. Clinicians should still encourage adults to have a medical home and communicate their immunization status to the primary care provider. Immunization of close contacts of children at high risk of influenza-related complications is intended to reduce their risk of contagion (i.e., "cocooning"). The concept of cocooning is particularly important for helping to protect infants younger than 6 months, because they are too young to be immunized with influenza vaccine. The risk of influenza-associated hospitalization in healthy children younger than 24 months has been shown to be greater than the risk of hospitalization in previously recognized high-risk groups such as the elderly. Children 24 through 59 months of age have had increased rates of outpatient visits and antimicrobial use.
3. The 2009 pandemic influenza A (H1N1) virus emerged in March 2009 and was associated with 2 significant waves of influenza activity during 2009 and 2010, as defined by the World Health Organization. This virus strain disproportionately affected the pediatric population compared with the usual seasonal influenza strains. It was 1 of 3 circulating influenza viruses during the 2010–2011 influenza season, and it is expected to circulate again during the 2011–2012 influenza season in combination with 1 or more of the other seasonal influenza strains. During the 2010–2011 season, influenza A (H3N2) was the predominant circulating strain, but weekly virus subtype activity varied regionally.
4. Although the number of hospitalizations for younger persons and outpatient visits for influenza-like illness overall was lower during the 2010–2011 season compared with the influenza A (H1N1) pandemic period, at least 114 laboratory-confirmed influenza-associated pediatric deaths were recorded during the 2010–2011 season. Seventy-one deaths were associated with influenza A virus subtypes: 30 influenza A (2009 H1N1), 21 influenza A (H3N2), and 20 undetermined subtypes. Forty-three deaths were associated with influenza B viruses. More than half of all hospitalized pediatric patients (51.8%) did not have any known underlying conditions (see Figure 1 in the original guideline document). Although children with certain conditions are at higher risk of complications, substantial proportions of seasonal influenza morbidity and mortality occur among healthy children.
5. The recommended trivalent vaccine for the 2011–2012 influenza season contains the following 3 virus strains: 
   • A/California/7/2009 (H1N1)–like antigen (derived from 2009 pandemic influenza A [H1N1] virus)
   • A/Perth/16/2009 (H3N2)–like antigen
   • B/Brisbane/60/2008–like antigen.
6. On the basis of ongoing global surveillance data, for only the fourth time in 25 years there is no need to change any of the influenza vaccine strains (see Figure 2 in the original guideline). The number of trivalent seasonal influenza vaccine doses to be administered this year depends on the child's age at the time of the first administered dose and his or her vaccine history (see Figure 3 in the original guideline document):
   • Infants younger than 6 months are too young to be immunized with influenza vaccine.
   • Children 9 years of age and older need only 1 dose.
   • Children 6 months through 8 years of age should receive 2 doses of vaccine if they did not receive any dose of vaccine last season. The second dose should be administered at least 4 weeks after the first dose.
   • Children 6 months through 8 years of age who received at least 1 dose of the 2010–2011 trivalent seasonal influenza vaccine last season need only 1 dose of the 2011–2012 influenza vaccine this season.

   In most influenza seasons, children who received influenza vaccine for the first time the previous season but who received only 1 dose are recommended to receive 2 doses of vaccine in the current season, because the first vaccine dose primes the immune system, but no significant protection against disease is achieved until 1 week after the second dose. However, because the vaccine strains for the 2011–2012 season are unchanged from last season, 1 dose this season coupled with the 1 dose of last season will provide adequate protection (see Figure 4 in the original guideline document). Previous recommendations for 2 doses of vaccine will resume for seasons in which 1 or more of the vaccine strains change.

7. Optimal protection is achieved through annual immunization. Antibody titers wane to 50% of their original levels 6 to 12 months after vaccination. Because the vaccine strains for the 2011–2012 season are unchanged from last season, a repeat dose this season is critical for maintaining protection in all populations.
8. As soon as the trivalent seasonal influenza vaccine is available locally, health care personnel (HCP) should be immunized, publicize vaccine availability to parents and caregivers, and begin immunization of all children 6 months of age and older, especially children at high risk of complications from influenza. HCP endorsement plays a major role in vaccine uptake. A strong correlation exists between HCP endorsement of influenza vaccine and patient acceptance. Providers should continue to offer vaccine through the vaccine expiration date. Protective immune responses persist throughout the influenza season, which can have >1 disease peak and often extends into March or later. Prompt initiation of influenza immunization and continuance of immunization throughout the influenza season, regardless of whether influenza is circulating (or has circulated) in the community, are critical components of an effective immunization strategy. This approach provides ample opportunity to administer a second dose of vaccine, because children younger than 9 years might require 2 doses to confer optimal protection.
9. HCP, influenza campaign organizers, and public health agencies should collaborate to develop improved strategies for planning, communication, and administration of vaccines.
   • Plan to make trivalent seasonal influenza vaccine easily accessible for all children. Examples of such action include creating walk-in influenza clinics, extending office hours beyond routine times during peak vaccination periods, considering how to immunize parents and adult caregivers at the same time in the same office setting as children, and working with other institutions (e.g., schools, child care centers, and religious organizations) or alternative care sites, such as emergency departments, to expand venues for administering vaccine while providing appropriate documentation of immunization for the child's medical home.
   • Concerted efforts among the aforementioned groups, plus vaccine manufacturers, distributors, and payers, also are necessary to appropriately prioritize distribution to the primary care office setting, especially when vaccine supplies are delayed or limited.
   • Vaccine safety, effectiveness, and indications must be communicated properly to the public. HCP should act as role models by receiving influenza immunization annually and recommending annual immunizations to both their colleagues and patients.
10. The neuraminidase inhibitors oseltamivir (Tamiflu [Roche Laboratories, Nutley, NJ]) and zanamivir (Relenza [GlaxoSmithKline, Research Triangle Park, NC]) are the only antiviral medications routinely recommended for chemoprophylaxis or treatment during the 2011–2012 season. All strains of influenza currently anticipated to circulate are susceptible to neuraminidase inhibitors but have high rates of resistance to amantadine and rimantadine (see Table 1 in the original guideline document). Resistance characteristics may change rapidly; clinicians should verify susceptibility information at the start of the influenza season and monitor it during the season through either the AAP Web site (www.aap.org  or http://aapredbook.aappublications.org/flu ) or the Centers for Disease Control and Prevention (CDC) Web site (www.cdc.gov/flu/index.htm ).
11. As the 2011–2012 influenza season unfolds, it is critically important for HCP to be aware of new or changing recommendations from the CDC or their local and state health departments. Up-to-date information can be found on the AAP Web site (www.aap.org  or http://aapredbook.aappublications.org/flu ) and the CDC Web site (www.cdc.gov/flu/index.htm ).

Current Recommendations

Trivalent seasonal influenza immunization is recommended for all children 6 months of age and older. Healthy children 2 years of age and older can receive either trivalent inactivated vaccine (TIV) or live-attenuated influenza vaccine (LAIV). Particular focus should be on the administration of TIV for all children and adolescents who have underlying medical conditions associated with an increased risk of complications from influenza, including:

• Asthma or other chronic pulmonary diseases, including cystic fibrosis
• Hemodynamically significant cardiac disease
• Immunosuppressive disorders or therapy
• Human immunodeficiency virus (HIV) infection
• Sickle cell anemia and other hemoglobinopathies
• Diseases that require long-term aspirin therapy, including juvenile idiopathic arthritis or Kawasaki disease
• Chronic renal dysfunction
• Chronic metabolic disease, including diabetes mellitus
• Any condition that can compromise respiratory function or handling of secretions or can increase the risk for aspiration, such as neurodevelopmental disorders, spinal cord injuries, seizure disorders, or neuromuscular abnormalities

Although universal immunization for all people 6 months of age and older is recommended for 2011–2012, particular immunization efforts with either TIV or LAIV should be made for the following groups to prevent transmission of influenza to those at risk, unless contraindicated:

• Household contacts and out-of-home care providers of children younger than 5 years and at-risk children of all ages (healthy contacts 2–49 years of age can receive either TIV or LAIV)
• Any female who is pregnant, considering pregnancy, or breastfeeding during the influenza season (TIV only). Studies have found that infants born to immunized women have better influenza-related health outcomes. However, data suggest that no more than one-half of pregnant women receive seasonal influenza vaccine, although both pregnant women and their infants are at higher risk of complications. In addition, there is limited evidence that influenza vaccination in pregnancy might decrease the risk of preterm birth.
• HCP or health care volunteers. Despite the recent AAP recommendation for mandatory influenza immunization for all HCP, many HCP remain unvaccinated. As of January 2010, the CDC estimated that only 62% of HCP received the seasonal vaccine and only 37% received the 2009 H1N1 monovalent vaccine. HCP frequently come into contact with patients at high risk of influenza illness in their clinical settings, so it is paramount that HCP protect themselves against influenza to remain influenza free, to prevent disease transmission to patient populations at high risk, and to avoid lost workplace productivity.
• Close contacts of immunosuppressed people

Use of Antiviral Medications

Antiviral resistance can emerge quickly from one season to the next. If local or national influenza surveillance data indicate a predominance of a particular influenza strain with a known antiviral-susceptibility profile, then empiric treatment can be directed toward that strain. For example, during the 2010–2011 season, only 1.3% of influenza viruses tested were resistant to oseltamivir, and none were resistant to zanamivir. High levels of resistance to amantadine and rimantadine persist, and these drugs should not be used in the upcoming season unless resistance patterns change significantly (see Table 1 in the original guideline document).

• Oseltamivir is available in capsule and oral-suspension formulations. The manufactured liquid formulation has a concentration of 6 mg/mL. Oral suspensions in 12 mg/mL concentrations will remain available until supplies run out. If the commercially manufactured oral suspension is not available, the capsule might be opened and the contents mixed with a sweetened liquid by retail pharmacies to a final concentration of 15 mg/mL (see Table 4, footnote "a" in the original guideline document).
• Current treatment guidelines (see Table 4 in the original guideline document) are applicable to infants and children with suspected influenza when known virus strains are circulating in the community or when infants or children are confirmed to have seasonal influenza.
• Continuous monitoring of the epidemiology, change in severity, and resistance patterns of influenza strains might lead to new guidance.

Treatment should be offered to:

• Any child hospitalized with presumed influenza or with severe, complicated, or progressive illness, regardless of influenza immunization status
• Influenza infection of any severity in children at high risk of complications of influenza infection (see Table 5 in the original guideline document)

Treatment should be considered for:

• Any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her provider if treatment can be initiated within 48 hours of illness onset

Earlier treatment provides more optimal clinical responses, although treatment after 48 hours of symptoms in the child with moderate-to-severe disease or with progressive disease might still provide some benefit. Dosages for antiviral agents for both treatment and chemoprophylaxis in children can be found in Table 4 in the original guideline document and on the CDC Web site (http://www.cdc.gov/flu/professionals/antivirals/index.htm ). Children younger than 1 year are at increased risk of influenza-related complications. Although there are no antiviral medications licensed by the Food and Drug Administration for this age group and the 2009 H1N1 pandemic Emergency Use Authorization has expired, recommendations for use of oseltamivir in this young age group can still be followed and are provided in Table 4 in the original guideline document.

Clinical judgment (based on underlying conditions, disease severity, time since symptom onset, and local influenza activity) is an important factor in treatment decisions for pediatric patients who present with influenza-like illness. Antiviral treatment should be started as soon as possible after illness onset and should not be delayed while waiting for a definitive influenza test result. Currently available rapid antigen tests have low sensitivity, particularly for the 2009 pandemic influenza A (H1N1) virus strain and should not be used to rule out influenza. Negative results from rapid antigen tests should not be used to make treatment or infection-control decisions.

People with suspected influenza who present with an uncomplicated febrile illness typically do not require treatment with antiviral medications unless they are at higher risk of influenza complications, especially in situations with limited antiviral medication availability. Should there be a shortage of antiviral medications, local public health authorities might provide additional guidance about testing and treatment. Rapid antigen tests are not helpful in the management of children with suspected influenza.

Recommendations for chemoprophylaxis during an influenza outbreak:

• For children at high risk of complications for whom influenza vaccine is contraindicated
• For children at high risk during the 2 weeks after influenza immunization
• For family members or HCP who are unimmunized and are likely to have ongoing, close exposure to:
  • Unimmunized children at high risk; or
  • Infants and toddlers who are younger than 24 months
• For control of influenza outbreaks for unimmunized staff and children in a closed institutional setting with children at high risk (e.g., extended-care facilities)
• As a supplement to immunization among children at high risk, including children who are immunocompromised and might not respond to vaccine
• As postexposure prophylaxis for family members and close contacts of an infected person if those people are at high risk of complications from influenza
• For children at high risk and their family members and close contacts, as well as HCP, when circulating strains of influenza virus in the community are not matched with trivalent seasonal influenza vaccine strains, on the basis of current data from the CDC and local health departments

These recommendations apply to routine circumstances, but it should be noted that guidance might change on the basis of updated recommendations from the CDC in concert with antiviral availability, local resources, clinical judgment, recommendations from local or public health authorities, risk of influenza complications, type and duration of exposure contact, and change in epidemiology or severity of influenza.

Chemoprophylaxis should not be considered a substitute for immunization. Influenza vaccine should always be offered when not contraindicated, even when influenza virus is circulating in the community. Antiviral medications currently licensed are important adjuncts to influenza immunization for control and prevention of influenza disease, but indiscriminate use might promote resistance and/or limit availability (see Table 1 in the original guideline document). Providers should inform recipients of antiviral chemoprophylaxis that risk of influenza is lowered but still remains while taking medication, and susceptibility to influenza returns when medication is discontinued. For recommendations about treatment and chemoprophylaxis against influenza, see Table 4 in the original guideline document. Updates will be available at www.aapredbook.org/flu  and www.cdc.gov/flu/professionals/antivirals/index.htm .

The following clinical algorithms are available in the original guideline document:

• The number of 2011-2012 seasonal influenza vaccine doses recommended for children 6 months through 8 years of age
• Precautions for administering influenza vaccine to presumed egg-allergic recipients

The type of evidence supporting the recommendations is not specifically stated.

Appropriate influenza vaccination and use of antiviral therapy and prophylaxis for influenza in children

Children Who Should Not Be Vaccinated with Trivalent Inactivated Vaccine (TIV)

• Infants younger than 6 months
• Children who have a moderate-to-severe febrile illness, on the basis of clinical judgment of the provider
• Children who are known to have experienced Guillain-Barré syndrome (GBS) within 6 weeks after a previous influenza vaccination; whether influenza vaccination specifically might increase the risk for recurrence of GBS is unknown; the decision not to immunize should be thoughtfully balanced against the potential morbidity and mortality associated with influenza for that individual child.

Children Who Should Not Be Vaccinated with Live-Attenuated Influenza Vaccine (LAIV)

• Children younger than 2 years
• Children who have a moderate-to-severe febrile illness
• Children with copious nasal congestion that would impede vaccine delivery
• Children who are known to have experienced GBS within 6 weeks after a previous influenza vaccination; whether influenza vaccination specifically might increase the risk of recurrence of GBS is unknown; the decision not to immunize should be thoughtfully balanced against the potential morbidity and mortality associated with influenza for that individual child.
• Children who have received other live-virus vaccines within the previous 4 weeks; however, other live-virus vaccines can be given on the same day as LAIV.
• Children with asthma, children with other chronic disorders of the pulmonary or cardiovascular systems, or children 2 through 4 years of age with a history of recurrent wheezing or a medically attended wheezing episode in the previous 12 months
• Children with chronic underlying medical conditions including metabolic disease, diabetes mellitus, renal dysfunction, and hemoglobinopathies
• Children who have known or suspected immunodeficiency disease or who are receiving immunosuppressive or immunomodulatory therapies
• Children who are receiving aspirin or other salicylates
• Any female who is pregnant or considering pregnancy
• Children with any condition that can compromise respiratory function or handling of secretions or can increase the risk for aspiration, such as neurodevelopmental disorders, spinal cord injuries, seizure disorders, or neuromuscular abnormalities.

Vaccine Implementation

These updated recommendations for prevention and control of influenza in children will have considerable operational and fiscal effect on pediatric practice. Therefore, the American Academy of Pediatrics (AAP) has developed implementation guidance on supply, payment, coding, and liability issues; these documents can be found at www.aapredbook.org/implementation .

Not applicable: The guideline was not adapted from another source.

American Academy of Pediatrics

The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Committee on Infectious Diseases

Committee on Infectious Diseases, 2011-2012: Michael T. Brady, MD, Chairperson; Carrie L. Byington, MD; H. Dele Davies, MD; Kathryn M. Edwards, MD; Mary P. Glode, MD; Mary Anne Jackson, MD; Harry L. Keyserling, MD; Yvonne A. Maldonado, MD; Dennis L. Murray, MD; Walter A. Orenstein, MD; Gordon E. Schutze, MD; Rodney E. Willoughby, MD; Theoklis E. Zaoutis, MD

Former Committee Member: Margaret C. Fisher, MD

Liaisons: Marc A. Fischer, MD, Centers for Disease Control and Prevention; Bruce Gellin, MD, National Vaccine Program Office; Richard L. Gorman, MD, National Institutes of Health; Lucia Lee, MD, Food and Drug Administration; R. Douglas Pratt, MD, Food and Drug Administration; Jennifer S. Read, MD, National Vaccine Program Office; Joan Robinson, MD; Canadian Paediatric Society; Jane Seward, MBBS, MPH, Centers for Disease Control and Prevention; Jeffrey R. Starke, MD, American Thoracic Society; Jack Swanson, MD, Committee on Practice Ambulatory Medicine; Tina Q. Tan, MD, Pediatric Infectious Diseases Society

Ex Officio: Carol J. Baker, MD, Red Book Associate Editor; Henry H. Bernstein, DO, Red Book Associate Editor; David W. Kimberlin, MD, Red Book Associate Editor; Sarah S. Long, MD, Red Book Associate Editor; H. Cody Meissner, MD, Red Book Associate Editor; Larry K. Pickering, MD, Red Book Editor

Consultant: Lorry G. Rubin, MD

Contributors: J. Dennis O'Dell, MD, Medical Home Expert; Stuart T. Weinberg, MD, Partnership for Policy Implementation; Kathryn E. Fay, BA, Research Assistant, Children's Hospital at Dartmouth; John M. Kelso, MD, Section on Allergy and Immunology

Staff: Jennifer Frantz, MPH

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics. Committee on Infectious Diseases. Policy statement--recommendations for prevention and control of influenza in children, 2010-2011. Pediatrics 2010 Oct;126(4):816-26.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site .

Print copies: Available from American Academy of Pediatrics, 141 Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

None available

None available

This NGC summary was completed by ECRI Institute on May 15, 2007. The information was verified by the guideline developer on May 23, 2007. This summary was updated by ECRI Institute on March 10, 2008 following the U.S. Food and Drug Administration (FDA) advisory on Tamiflu (oseltamivir phosphate). This summary was updated by ECRI Institute on April 9, 2008 following the U.S. Food and Drug Administration (FDA) advisory on Relenza (zanamivir). This summary was updated by ECRI Institute on May 16, 2008. The updated information was verified by the guideline developer on May 20, 2008. This NGC summary was updated by ECRI Institute on April 7, 2009. The updated information was verified by the guideline developer on April 23, 2009. This summary was updated by ECRI Institute on November 12, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Afluria (influenza virus vaccine). This NGC summary was updated by ECRI Institute on March 30, 2011. This summary was updated by ECRI Institute on July 15, 2011 following the U.S. Food and Drug Administration advisory on Tamiflu (oseltamivir phosphate). This NGC summary was updated by ECRI Institute on January 6, 2012.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.