This is the current release of the guideline.

All clinical reports and 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

Prevention
Treatment

Family Practice
Infectious Diseases
Internal Medicine
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

To offer guidance regarding antiviral treatment and prophylaxis to clinicians caring for children during yearly influenza epidemics and to provide resources for information on antiviral treatment in the event of an influenza pandemic

• Children with moderate to-severe influenza infection who may benefit from a decrease in the duration of symptoms
• High-risk children who have not yet received immunization and during the 2 weeks after immunization
• Unimmunized family members and health care professionals with close contact with high-risk unimmunized children or infants who are younger than 6 months
• Unimmunized staff and children in an institutional setting

Antiviral therapy and prophylaxis for influenza with oseltamivir, zanamivir, amantadine, or rimantadine

Treatment

• Duration of influenza-attributable symptoms
• Incidence of acute otitis media
• Level of viral shedding

Prevention

• Protective efficacy
• Number of symptomatic cases of influenza

Searches of Electronic Databases

Not stated

Not stated

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Not applicable

Review

Not stated

Not stated

Not applicable

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

Not stated

Not applicable

Dosing Recommendations for Antiviral Agents for Treatment and Prophylaxis of Influenza

^a Amantadine and rimantadine should only be used for prophylaxis in winter seasons during which a majority of influenza A virus strains isolated are adamantine-susceptible; the adamantanes should not be used for primary therapy because of the rapid emergence of resistance. However, for those requiring adamantine therapy, a treatment course of approximately 7 days is suggested, or 24 to 48 hours after the disappearance of signs and symptoms.

^b For prophylaxis, antiviral drugs should be continued for the duration of known influenza A in the community because of the potential for repeated and unknown exposures or until immunity can be achieved after immunization.

Indications for Therapy and Prophylaxis

Therapy

• Influenza infection of any severity in high-risk children (see definition of "high-risk" below) regardless of immunization status
• Any otherwise healthy child with moderate-to-severe influenza infection who may benefit from the decrease in duration of clinical symptoms documented to occur with therapy

Prophylaxis

• High-risk children during the 2 weeks after influenza immunization, if influenza is active in the community
• High-risk children for whom influenza vaccine is contraindicated
• Family members or health care providers who are unimmunized and are likely to have ongoing, close exposure to (1) high-risk, unimmunized children or (2) infants who are younger than 6 months
• Control of influenza outbreaks for unimmunized staff and children in a closed institutional setting with high-risk pediatric residents (e.g., extended-care facilities)
• As a supplement to immunization among high-risk children
• Postexposure prophylaxis in a family setting
• High-risk children and their family members and close contacts, as well as health care workers, when circulating strains of influenza virus in the community are not matched with vaccine strains

Infants And Children at High Risk of Complications From Influenza Include Those with:

• Ages between 6 and 24 months (no antiviral agent is currently approved for infants younger than 12 months)
• Asthma or other chronic pulmonary diseases such as cystic fibrosis
• Hemodynamically significant cardiac disease
• Immunosuppressive disorders or therapy
• Human immunodeficiency virus (HIV) infection
• Sickle cell anemia and other hemoglobinopathies
• Diseases requiring long-term aspirin therapy, such as rheumatoid arthritis or Kawasaki disease
• Chronic renal dysfunction
• Chronic metabolic disease such as diabetes mellitus
• Neuromuscular disorders, seizure disorders, or cognitive dysfunction that may compromise the handling of respiratory secretions

None provided

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

Appropriate use of antiviral therapy and prophylaxis for influenza in children

• Anti-viral resistance, especially with amantadine and rimantadine
• The most common adverse drug effects noted were gastrointestinal tract disturbances, with vomiting in 14% of oseltamivir-treated children, compared with 8% of children who were given placebo.
• Unpublished safety data on oseltamivir were recently reviewed by the U.S. Food and Drug Administration (FDA) on the basis of reports of neuropsychiatric events associated with patients treated for influenza with oseltamivir. Accurate data on the incidence of these events are not available, but they seem to be in the range of 1 in 10,000 to 100,000 treatment courses. On the basis of the FDA review, it is not known whether the spontaneous reports of neuropsychiatric behavior reflect a true adverse event caused by oseltamivir, perhaps with a greater incidence in populations with a certain genetic background; a result of central nervous system (CNS) infection caused by influenza virus; or a combination of both drug and virus in the CNS. There are no reports of neuropsychiatric events in adults or children receiving oseltamivir prophylaxis for influenza infection.
• Reported adverse effects in otherwise healthy children and adults were similar between those treated with zanamivir and those given placebo. However, concerns by the FDA regarding bronchospasm and decreased pulmonary function after inhalation of zanamivir in patients with underlying reactive airways disease, including asthma and chronic obstructive pulmonary disease, prompted warnings about the use of zanamivir in this population. Potential risks and benefits should be carefully weighed before treatment of these children. Monitoring of respiratory function should be considered if treatment is given.
• The most commonly occurring (5 to 10%) adverse events of amantadine treatment are nausea, lightheadedness, and insomnia. Those that occur infrequently (1 to 5%) include anxiety, nervousness, irritability, dry mouth, headache, fatigue, and diarrhea. The incidence of CNS adverse effects is twofold higher in those taking amantadine than in those taking rimantadine. Gastrointestinal adverse effects are equivalent between the 2 agents. These effects are dosage related and are usually mild, resolving when the agent is discontinued. Serious adverse effects have been reported in adults and are often associated with either high plasma drug concentrations in patients with renal insufficiency or in those with an underlying psychiatric or seizure disorder.
• No differences in adverse-event rates were noted between children treated with rimantadine and those treated with acetaminophen. In controlled studies in adults, no drug-attributable adverse effects occurred in more than 5% of the study subjects with the most commonly reported events being insomnia and dizziness.

• The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
• No prospective human data currently exist on which to base recommendations for treatment of infections caused by potential H5N1 pandemic influenza virus strains.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

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

2007 Apr

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Infectious Diseases

Committee on Infectious Diseases, 2006-2007: Joseph A. Bocchini, Jr, MD, Chairperson; Robert S. Baltimore, MD; Henry H. Bernstein, DO; John S. Bradley, MD; Michael T. Brady, MD; Penelope H. Dennehy, MD; Margaret C. Fisher, MD; Robert W. Frenck, Jr, MD; David W. Kimberlin, MD; Sarah S. Long, MD; Julia A. McMillan, MD; Lorry G. Rubin, MD

Liaisons: Richard D. Clover, MD, American Academy of Family Physicians; Marc A. Fischer, MD, Centers for Disease Control and Prevention; Richard L. Gorman, MD, National Institutes of Health; Douglas R. Pratt, MD, Food and Drug Administration; Anne Schuchat, MD, Centers for Disease Control and Prevention; Benjamin Schwartz, MD, National Vaccine Program Office; Jeffrey R. Starke, MD, American Thoracic Society; Jack Swanson, MD, Practice Action Group

Ex Officio: Larry K. Pickering, MD, Red Book Editor; Carol J. Baker, MD, Red Book Associate Editor

Consultant: Edgar O. Ledbetter, MD

Staff: Alison Siwek, MPH

Not stated

This is the current release of the guideline.

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

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 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.