This is the current release of the guideline.

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.

Introduction

The American Academy of Pediatrics (AAP) recommends annual influenza immunization for the following groups:

1. All children, both healthy and with high-risk conditions, aged 6 months through 18 years
2. Household contacts and out-of-home care providers of:
   • Children with high-risk conditions
   • Healthy children younger than 5 years of age
3. Any female who will be pregnant during influenza season
4. Health care professionals

Key Points Relevant for the 2008–2009 Influenza Season

1. The recommended age range of children for annual influenza immunization has been expanded to include all children 6 months through 18 years of age, which means vaccinating:
   • All children at higher risk for influenza complications (e.g., those with chronic medical conditions or immunosuppression)
   • All healthy children 6 through 59 months of age
   • All children 5 through 18 years of age, if feasible, in the 2008–2009 influenza season, but it should be routine no later than the 2009–2010 season

   This expansion targets all school-aged children, the population that bears the greatest disease burden and is at significantly higher risk of needing influenza-related medical care compared with healthy adults. In addition, reducing influenza transmission among school-aged children will, in turn, reduce transmission of influenza to household contacts and community members.

2. Household members and out-of-home care providers of all children at high risk and adolescents and of all healthy children younger than 5 years also should receive influenza vaccine each year. Immunization of the close contacts of children at high risk is intended to reduce the risk of exposure to influenza for these young children, who are at serious risk of influenza infection, hospitalization, and complications. The risk of influenza-associated hospitalization in healthy children younger than 24 months has been shown to be equal to or greater than the risk in previously recognized high-risk groups. Children 24 through 59 months of age experience increased morbidity as a result of influenza illness, with increased rates of outpatient visits and antibiotic use. Infants younger than 6 months are too young to be immunized. Influenza vaccine has not been approved for use in infants younger than 6 months.
3. All children 6 months through 18 years of age, especially those at high risk of complications from influenza, should be identified, and their parents should be informed, when possible, that annual influenza immunization is due.
4. On the basis of global surveillance of circulating influenza strains, all 3 strains in the 2008–2009 influenza vaccines are different from last year's strains.
5. The number of influenza vaccine dose(s) to be administered is age dependent (see Figure 1 in the original guideline document):
   • Children 9 years and older who have not received the influenza vaccine previously need only 1 dose in their first season of immunization.
   • In contrast, any child younger than 9 years receiving an influenza vaccine for the first time should receive a second dose at least 4 weeks after the first.
   • Children younger than 9 years who received only 1 dose of influenza vaccine in the first season they were vaccinated should receive 2 doses of influenza vaccine the following season. This recommendation applies only to the influenza season that follows the first year that a child younger than 9 years receives influenza vaccine.

6. The antiviral medications recommended for chemoprophylaxis or treatment (ie, oseltamivir or zanamivir) have not changed for the 2008–2009 influenza season. Health care professionals should not prescribe amantadine or rimantadine for influenza treatment or chemoprophylaxis because of widespread resistance to these antiviral medications that continues to exist among some circulating influenza A virus strains. Amantadine and rimantadine are not effective against influenza B strains. Although oseltamivir resistance has been reported, it is still very limited; therefore, current antiviral treatment recommendations have not changed.
7. Influenza vaccine should be offered to all children as soon as vaccine is available. Immunization efforts should continue throughout the entire influenza season, even after influenza activity has been documented in a community. Influenza season often extends well into March and beyond (see Figure 2 in the original guideline document), and there may be more than 1 peak of activity in the same season. Thus, immunization through May 1 can still protect recipients during that particular season and also provide ample opportunity to administer a second dose of vaccine to children who require 2 doses in that season.
8. Health care professionals, influenza campaign organizers, and public health agencies should cooperate to develop plans for expanding outreach and infrastructure to achieve the target immunization of all children 6 months through 18 years of age, beginning no later than the 2009–2010 influenza season. Concerted effort among the aforementioned groups, plus vaccine manufacturers, distributors, and payers, also is necessary to appropriately prioritize administration of influenza vaccine whenever vaccine supplies are delayed or limited.

Current Recommendations

Influenza immunization is recommended for all children 6 months through 18 years of age. Healthy children aged 2 through 18 years can receive either trivalent inactivated influenza vaccine (TIV) or live-attenuated influenza vaccine (LAIV). Immunization efforts should continue to focus on (see Figure 1 in the original guideline document):

1. Use of TIV (not LAIV) for all children and adolescents with underlying medical conditions, 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 requiring 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 cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders

2. Household contacts and out-of-home care providers of children younger than 5 years and at-risk children of all ages. Healthy contacts 2 through 49 years of age can receive either TIV or LAIV.
3. Any female who will be pregnant during influenza season (TIV only).
4. Health care professionals

In addition, immunization with either TIV or LAIV is recommended for the following people to prevent transmission of influenza to those at risk, unless contraindicated:

• Healthy contacts and caregivers of other children or adults at high risk of complications from influenza infection
• Close contacts of immunosuppressed people
• Health care professionals or volunteers

A clinical algorithm, "Influenza algorithm for determining recommended 2008–2009 influenza immunization actions for children," is provided in the original guideline document.

The type of evidence supporting the recommendations is not specifically stated. Much of this statement is based on literature reviews, analyses of unpublished data, and deliberations of Centers for Disease Control and Prevention (CDC) staff in collaboration with the Advisory Committee on Immunization Practices Influenza Working Group, with liaison from the American Academy of Pediatrics.

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

2007 Apr (revised 2008 Nov)

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Infectious Diseases

Committee on Infectious Diseases, 2008-2009: Joseph A. Bocchini, Jr, MD, Chairperson; John S. Bradley, MD; Michael T. Brady, MD; Henry H. Bernstein, DO; Carrie L. Byington, MD; Penelope H. Dennehy, MD; Margaret C. Fisher, MD; Robert W. Frenck, Jr, MD; Mary P. Glode, MD; Henry L. Keyserling, MD; David W. Kimberlin, MD; Walter A. Orenstein, MD; Lorry G. Rubin, MD

Liaisons: Beth P. Bell, MD, Centers for Disease Control and Prevention; Robert Bortolussi, MD, Canadian Paediatric Society; 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; R. Douglas Pratt, MD, Food and Drug Administration; Benjamin Schwartz, MD, National Vaccine Program Office; Jeffrey R. Starke, MD, American Thoracic Society

Contributors: J. Dennis O'Dell, MD, Medical Home Expert; Stuart T. Weinberg, MD, Partnership for Policy Implementation (PPI)

Consultants: Edgar O. Ledbetter, MD; H. Cody Meissner, MD

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

Staff: Alison Siwek, MPH

Not stated

This is the current release of the guideline.

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.

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 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.