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My Take on Influenza Treatment in the Pediatric Population

Paul G. Auwaerter, MD

Sherrilyn and Ken Fisher Professor of Medicine
Clinical Director
Division of Infectious Diseases
Johns Hopkins University School of Medicine
Baltimore, Maryland

Dr Auwaerter: consulting fees: EMD Serono, Verily; contracted research: Humanigen; other financial or material support: Johnson & Johnson.

View ClinicalThoughts from this Author

Released: August 5, 2021

When to Treat Influenza in Pediatric Patients: Factors to Consider
With high attack rates, particularly in schools, children are one of the main reasons adults get very ill with influenza. There has been only one reported pediatric death related to influenza in the 2020-2021 flu season. I think one of the most significant factors in why we have seen so little influenza in the previous respiratory season is that schools were closed. Children also had reduced socialization and were adhering to social mitigation strategies against SARS-CoV-2. Children with influenza, especially those who can be treated early, will symptomatically improve and therefore get back to school faster, potentially allowing parents and guardians to get back to work. This is important for many families, and I think is a compelling reason to treat influenza in pediatric patients. While I do not prescribe antivirals for most children with influenza because they will usually get better without them, I think it is reasonable to factor in the social aspects and other potential for complications, as influenza can occasionally be a devastating illness in children—especially in those at risk for complications. Pediatricians need to educate parents and older children with these risk factors to call at the first signs of significant respiratory illness when influenza viruses are circulating in the community so that timely antiviral therapy can be initiated.

Prescriber Options for Treating Influenza Depend on the Population
Oseltamivir is approved for children as young as 2 weeks of age and is even used in neonates. It has a long track record for safety, although I find that children are more prone to the nausea that oseltamivir is known to cause. One item that sometimes comes up when I am speaking to parents is whether oseltamivir can precipitate neuropsychiatric complications. This concern originated from descriptions of adolescents in Japan who developed irritability, anxiety and depression while taking oseltamivir. Upon further study, it appears that these symptoms were more of a manifestation of the acute illness exacerbating some psychiatric stressors rather than a precipitating effect of the oseltamivir.

Baloxavir is another oral option for adolescents that is FDA approved for children 12 years and older. It can be given as a single-dose regimen based on its long half-life, so this is an especially attractive option in the population where adherence and supervision may be a concern. Baker and colleagues showed that children aged 1 to 12 years treated with baloxavir demonstrated reasonable efficacy, but the FDA chose not to approve this indication at this time. I believe this may be largely because children’s immune systems cannot clear the virus as quickly. With these more prolonged periods of viral shedding, we see more generation of influenza variants that are a natural consequence of baloxavir use. The clinical impact of these variants is not yet fully elucidated, but I think we will continue to monitor the generation of these variants in the older populations and expect that the complete picture will become more apparent in the future.

Zanamivir is an additional agent to treat influenza type A and B infections in patients aged 7 years and older that is probably overlooked due to accessibility concerns. It is the most potent of the neuraminidase inhibitors and health care providers have considered it in the past when oseltamivir resistance is a concern. I find it helpful for pediatric patients with pill aversion. However, it is important to remember that zanamivir is contraindicated in patients with underlying respiratory diseases such as asthma, one of our most common rationales for prescribing antivirals in children.

Looking to the Future
Influenza variants are a concern and to date their full impact is not completely understood. I think antiviral therapy in general is moving towards more combination therapy, not only for the clinical benefits but also for reducing resistance. We have seen these benefits in other infections such as HIV and although influenza is an acute infection, I think that over time we will likely evolve to a multi-modality approach to help with some of these resistance concerns. This is one more reason that newer classes of antivirals such as endonuclease inhibitors are a welcome addition to our armamentarium.

I hope you find this information useful in making treatment decisions for your pediatric patients with influenza.

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