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Guideline Summary
Guideline Title
Recommendations for prevention and control of influenza in children, 2013–2014.
Bibliographic Source(s)
Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2013-2014. Pediatrics. 2013 Oct;132(4):e1089-104. [3 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2011-2012. Pediatrics. 2011 Oct;128(4):813-25.

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.

Scope

Disease/Condition(s)

Influenza

Guideline Category
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Allergy and Immunology
Family Practice
Infectious Diseases
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

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

Target Population

All people, including all children and adolescents, 6 months of age and older during the 2013–2014 influenza season

Note: See the "Major Recommendations" field for specific populations in whom antiviral treatment and chemoprophylaxis are recommended.

Interventions and Practices Considered

Prevention

  1. Immunization with trivalent or quadrivalent 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

*Note: The trivalent vaccine for the 2013–2014 season contains an A/California/7/2009 (H1N1) pdm09-like virus (same as 2012–2013), an A/Texas/50/2012 (H3N2) virus (antigenically like the 2012–2013 strain), and a B/Massachusetts/2/2012-like virus (a B/Yamagata lineage like 2012–2013 but a different virus). The new quadrivalent influenza vaccines include an additional B virus (B/Brisbane/60/2008-like virus [B/Victoria lineage]). In addition, 2 trivalent influenza vaccines manufactured using new technologies that do not use eggs will also be available during the 2013–2014 season: cell culture-based inactivated influenza vaccine (ccIIV3) and recombinant influenza vaccine (RIV3).

Major Outcomes Considered
  • Incidence and prevalence of influenza in infants, children, and adolescents
  • Incidence and prevalence of hospitalization from influenza in infants, children, and adolescents
  • Incidence and prevalence of influenza-related death in infants, children, and adolescents
  • Adverse effects of influenza vaccine administration

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

PubMed was the primary database used for all literature searches, which focused on the past 12–18 months (since the previous policy statement). The search focused primarily on children, 18 years of age and younger. Search terms included: influenza, immunization, live-attenuated influenza vaccine, inactivated influenza vaccine, vaccine, children, pediatrics.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

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.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

Introduction

The American Academy of Pediatrics (AAP) recommends annual seasonal influenza immunization for all people, including all children and adolescents, 6 months of age and older during the 2013–2014 influenza season. In addition, special effort should be made to vaccinate people in the following groups:

  • All children, including infants born preterm, who are 6 months of age and older with conditions that increase the risk of complications from influenza (e.g., children with chronic medical conditions, such as asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression, or neurologic and neurodevelopmental disorders).
  • Children of American Indian/Alaskan Native heritage.
  • All household contacts and out-of-home care providers of:
    • Children with high-risk conditions; and
    • Children younger than 5 years, especially infants younger than 6 months
  • All health care personnel (HCP)
  • All women who are pregnant, are considering pregnancy, have recently delivered, or are breastfeeding during the influenza season

Key Points Relevant for the 2013–2014 Influenza Season

  1. Annual seasonal influenza vaccine is recommended for all people, including all children and adolescents, 6 months of age and older during the 2013–2014 influenza season. It is important that household contacts and out-of-home care providers of children younger than 5 years, especially infants younger than 6 months and children of any age at high risk of complications of influenza (e.g., children with chronic medical conditions, such as asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression, or neurologic and neurodevelopmental disorders) receive annual influenza vaccine. In the United States, more than two-thirds of children younger than 6 years and almost all children 6 years and older spend significant time in child care and school settings outside the home. Exposure to groups of children increases the risk of contracting infectious diseases. Children younger than 2 years are at an increased risk of hospitalization and complications attributable to influenza. School-age 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 virus transmission among children who attend child care or school has been shown to decrease the burden of childhood influenza and transmission of influenza virus to household contacts and community members of all ages.
  2. The 2012–2013 influenza season was moderately severe, with a higher percentage of outpatient visits for influenza-like illness, higher rates of hospitalization, and more deaths attributed to pneumonia and influenza compared with the 2011–2012 influenza season. As of August 10, 2013, 158 laboratory-confirmed influenza-associated pediatric deaths were reported to the Centers for Disease Control and Prevention (CDC) during the 2012–2013 influenza season. Influenza A (H3N2) viruses predominated overall, but influenza B viruses and, to a lesser extent, A (H1N1) pdm09 (pH1N1) viruses also were reported in the United States. Eighty-two of the 158 deaths were associated with influenza B viruses, 32 deaths were associated with influenza A (H3) viruses, and 4 deaths were associated with pH1N1 viruses. Thirty-seven deaths were associated with an influenza A virus for which the subtype was not determined, 1 death was associated with an undetermined type of influenza virus, and 2 deaths were associated with both influenza A and B viruses. The majority of pediatric deaths were among children who had not been immunized against influenza. Among children hospitalized with influenza and for whom medical chart data were available, approximately 44% did not have any recorded underlying condition, whereas 23% had underlying asthma or reactive airway disease (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.
  3. Both trivalent and quadrivalent influenza vaccines are licensed and available in the United States for the 2013–2014 season. Neither vaccine formulation is preferred over the other. The trivalent vaccine contains an A/California/7/2009 (H1N1) pdm09-like virus (same as 2012–2013), an A/Texas/50/2012 (H3N2) virus (antigenically like the 2012–2013 strain), and a B/Massachusetts/2/2012-like virus (a B/Yamagata lineage like 2012–2013 but a different virus). The new quadrivalent influenza vaccines include an additional B virus (B/Brisbane/60/2008-like virus [B/Victoria lineage]). In addition, 2 trivalent influenza vaccines manufactured using new technologies that do not use eggs will also be available during the 2013–2014 season: cell culture-based inactivated influenza vaccine (ccIIV3) and recombinant influenza vaccine (RIV3).
  4. The number of seasonal influenza vaccine doses to be administered in the 2013–2014 influenza season depends on the child's age at the time of the first administered dose and his or her vaccine history (see Figure 2 in the original guideline document):
    • Influenza vaccines are not licensed for administration to infants younger than 6 months of age.
    • Children 9 years and older need only 1 dose.
    • Children 6 months through 8 years of age receiving the seasonal influenza vaccine for the first time should receive a second dose this season at least 4 weeks after the first dose.
    • Children 6 months through 8 years of age who received seasonal influenza vaccine before the 2013–2014 influenza season
      • Need only 1 dose of vaccine, if they previously received 2 or more doses of seasonal vaccine since July 1, 2010
      • Need 2 doses of vaccine, if they have not previously received 2 or more doses of seasonal vaccine since July 1, 2010
      • Need only 1 dose of influenza vaccine if there is clear documentation of having received at least 2 seasonal influenza vaccines from any previous season and at least 1 dose of a pH1N1-containing vaccine, which could have been in 1 of the seasonal vaccines (2010–2011, 2011–2012, or 2012–2013) or as the monovalent pH1N1 vaccine from 2009–2010
    • Vaccination should not be delayed to obtain a specific product for either dose. Any available, age-appropriate trivalent or quadrivalent vaccine can be used. A child who receives only 1 of the 2 doses as a quadrivalent formulation is likely to be less primed against the additional B virus.
  5. Pediatric offices should consider serving as alternate venues for providing influenza immunization to parents and other adults who care for children, if this approach is acceptable to both the pediatrician and the adult to be immunized. There are important medical liability issues and medical record documentation requirements that need to be addressed before a pediatrician begins immunizing adults (see details at www.aapredbook.org/implementation External Web Site Policy). Pediatricians are reminded to document the recommendation for adult immunization in the vulnerable child's medical record. In addition, adults should still be encouraged to have a medical home and communicate their immunization status to their 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 to help protect infants younger than 6 months, because they are too young to be immunized with influenza vaccine. Infants younger than 6 months of age can also be protected through vaccination of their mothers during pregnancy with transplacental transfer of antibodies. The risk of influenza-associated hospitalization in healthy children aged 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, during influenza season. Children 24 through 59 months of age have shown increased rates of outpatient visits and antimicrobial use associated with influenza-like illnesses.
  6. As soon as the seasonal influenza vaccine is available locally, HCP should be immunized, parents and caregivers should be notified about vaccine availability, and immunization of all children 6 months and older, especially children at high risk of complications from influenza, should begin. HCP endorsement plays a major role in vaccine uptake. A strong correlation exists between HCP endorsement of influenza vaccine and patient acceptance. Prompt initiation of influenza immunization and continuance of immunization throughout the influenza season, whether or not influenza is circulating (or has circulated) in the community, are critical components of an effective immunization strategy. Giving the vaccine promptly and early during the influenza season is not felt to pose a significant risk that immunity might wane before the end of the season. The seasonal vaccine is not perfect, but it still is the best strategy available for preventing illness from influenza. It is moderately effective in reducing the risk for outpatient medical visits caused by circulating influenza viruses by approximately one-half to two-thirds in most people. Even a moderately effective influenza vaccine has been shown to reduce illness, antibiotic use, doctor visits, time lost from work, hospitalizations, and deaths.
  7. Providers should continue to offer vaccine until the vaccine expiration date because influenza is unpredictable. Protective immune responses persist throughout the influenza season, which can have >1 disease peak and often extends into March or later. Although most influenza activity in the United States tends to occur in January through March, influenza activity can occur in early fall (i.e., October and November) or late spring (e.g., influenza circulated through the third week in May during the 2012–2013 season). This approach also provides ample opportunity to administer a second dose of vaccine because children aged <9 years may require 2 doses to confer optimal protection. In addition, with international travel so common, there is potential exposure to influenza at virtually all times of the year.
  8. HCP, influenza campaign organizers, and public health agencies should collaborate to develop improved strategies for planning, communication, and administration of vaccines.
    • Plan to make seasonal influenza vaccine easily accessible for all children. Examples include creating walk-in influenza clinics; extending hours beyond routine times during peak vaccination periods; administering influenza vaccine during both well and sick visits; considering how to immunize parents, adult caregivers, and siblings 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. If a child or adult receives influenza vaccine outside of his or her medical home, such as at a pharmacy or other retail-based clinic, appropriate documentation of immunization must be provided to the medical home.
    • Concerted efforts among the aforementioned groups, plus vaccine manufacturers, distributors, and payers, also are necessary to prioritize distribution appropriately to the primary care office setting and patient-centered medical home before other venues, especially when vaccine supplies are delayed or limited.
    • Vaccine safety, effectiveness, and indications must be properly communicated to the public. HCP should act as role models by receiving influenza immunization annually as well as recommending annual immunizations to both colleagues and patients. Influenza immunization programs for HCP benefit the health of employees, their patients, and members of the community. Beginning in 2012, as an immunization core measure, the Centers for Medicare and Medicaid Services, the US federal agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program, began requiring hospitals and certain other inpatient facilities to screen for a history of influenza vaccination and to administer influence vaccine to all unimmunized hospitalized patients 6 months and older between October and March unless contraindicated or the patient or family refuses.
  9. Antiviral medications also are important in the control of influenza but are not a substitute for influenza immunization. The neuraminidase inhibitors oral oseltamivir (Tamiflu; Roche Laboratories, Nutley, NJ) and inhaled zanamivir (Relenza; GlaxoSmithKline, Research Triangle Park, NC) are the only antiviral medications routinely recommended for chemoprophylaxis or treatment of influenza during the 2013–2014 season. Intravenous preparations of oseltamivir, zanamivir, and peramivir are not currently approved by the US Food and Drug Administration (FDA) and are not routinely available. However, with consultation with infectious diseases specialists, experimental intravenous antiviral medications could be considered for some critically ill children, especially those who are immunocompromised. Recent viral surveillance and resistance data indicate that the majority of currently circulating influenza viruses likely to cause 2013–2014 seasonal influenza in North America continue to be sensitive to oseltamivir and zanamivir. In contrast, amantadine and rimantadine should not be used because circulating influenza A viruses have sustained high levels of resistance to these drugs, and they are not effective against influenza B viruses. Resistance characteristics may change rapidly; pediatricians should verify susceptibility data at the start of the influenza season and monitor it during the season. Up-to-date information can be found on the AAP Web site (www.aap.org External Web Site Policy or www.aapredbook.org/flu External Web Site Policy), through state-specific AAP chapter Web sites, or on the CDC Web site (www.cdc.gov/flu/index.htm External Web Site Policy).

Current Recommendations

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

  • 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 of aspiration, such as neurodevelopmental disorders, spinal cord injuries, seizure disorders, or neuromuscular abnormalities

Although universal immunization for all people 6 months and older is recommended for the 2013–2014 influenza season, particular immunization efforts with either IIV 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 of age and at-risk children of all ages (healthy contacts 2 through 49 years of age can receive either IIV or LAIV).
  • Any woman who is pregnant, is considering pregnancy, has recently delivered, or is breastfeeding during the influenza season (IIV only). Studies have shown that infants born to immunized women have better influenza-related health outcomes. However, according to Internet panel surveys conducted by the CDC, only 47% of pregnant women reported receiving an influenza vaccine during the 2011–2012 season, even though both pregnant women and their infants are at higher risk of complications. In addition, data from some studies suggest that influenza vaccination in pregnancy may decrease the risk of preterm birth as well as giving birth to infants who are small for gestational age. Pregnant women can safely receive the influenza vaccine during any trimester.
  • Children and adolescents of American Indian/Alaskan Native heritage
  • HCP or health care volunteers. Despite the recent AAP recommendation for mandatory influenza immunization for all HCP, many HCP remain unvaccinated. As of November 2012, the CDC estimated that only 62.9% of HCP received the seasonal influenza vaccine. The AAP recommends mandatory vaccination of HCP, because they frequently come into contact with patients at high risk of influenza illness in their clinical settings.
  • Close contacts of immunosuppressed people

Use of Antiviral Medications

Oseltamivir remains the antiviral drug of choice for the management of influenza infections. Zanamivir is an acceptable alternative but is more difficult to administer. 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 known antiviral susceptibility profile, then empirical treatment can be directed toward that strain.

  • Current treatment guidelines for antiviral medications (see Table 3 in the original guideline document) are applicable to both 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.
  • Oseltamivir is available in capsule and oral-suspension formulations. The commercially manufactured liquid formulation has a concentration of 6 mg/mL. If the commercially manufactured oral suspension is not available, the capsule may be opened and the contents mixed with simple syrup or Oral-Sweet SF (sugar-free) by retail pharmacies to a final concentration of 6 mg/mL (see Table 3, footnote a, in the original guideline document).
  • Continuous monitoring of the epidemiology, change in severity, and resistance patterns of influenza strains may lead to new guidance.

Treatment should be offered for the following:

  • Any child hospitalized with presumed influenza or with severe, complicated, or progressive illness attributable to influenza, regardless of influenza immunization status
  • Influenza infection of any severity in children at high risk of complications of influenza infection (see Table 4 in the original guideline document)

Treatment should be considered for the following:

  • 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 pediatrician; the greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset.

Treatment with oseltamivir for children with presumed serious, complicated, or progressive disease, irrespective of influenza immunization status and/or even if illness began >48 hours before admission, continues to be recommended. Earlier treatment provides optimal clinical responses. However, treatment after 48 hours of symptoms in adults and children with moderate-to-severe disease or with progressive disease has been shown to provide some benefit and should be strongly considered.

Dosages for antiviral agents for both treatment and chemoprophylaxis in children can be found in Table 3 in the original guideline document and on the CDC Web site (http://www.cdc.gov/flu/professionals/antivirals/index.htm External Web Site Policy). Children younger than 2 years are at an increased risk of hospitalization and complications attributable to influenza. The FDA recently licensed oseltamivir down to 2 weeks of age. Given its known safety profile, oseltamivir can be used to treat influenza in both term and preterm infants from birth.

Clinical judgment (on the basis of 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 pH1N1 virus strain, and should not be used to exclude influenza infection. Although negative results from rapid antigen tests should not be used to make treatment or infection-control decisions, positive results are helpful because they may reduce additional testing to identify the cause of the child's influenza-like illness. Nucleic-acid-based molecular diagnostic techniques (e.g., polymerase chain reaction–based) are more widely available and have greater sensitivity than antigen tests for influenza infection.

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 (e.g., children with chronic medical conditions such as asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression, or neurologic and neurodevelopmental disorders), especially in situations with limited antiviral medication availability. Should there be a shortage of antiviral medications, local public health authorities will provide additional guidance about testing and treatment.

Decisions on whether to administer antiviral agents for chemoprophylaxis should take into account the exposed person's risk of influenza complications, vaccination status, the type and duration of contact, recommendations from local or public health authorities, and clinical judgment. Optimally, postexposure chemoprophylaxis should only be used when antiviral agents can be started within 48 hours of exposure. Early treatment of high-risk patients without waiting for laboratory confirmation is an alternative strategy.

Although immunization is the preferred approach to prevention of infection, chemoprophylaxis during an influenza outbreak, as defined by the CDC, is recommended:

  • For children at high risk of complications from influenza 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
    • Unimmunized 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 may 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 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 may 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 is not recommended for infants younger than 3 months, unless the situation is judged critical, because of limited safety and efficacy data in this age group.

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 there are toxicities associated with antiviral agents, and indiscriminate use might limit availability. Pediatricians should inform recipients of antiviral chemoprophylaxis that risk of influenza is lowered but remains while taking the medication, and susceptibility to influenza returns when medication is discontinued. For recommendations about treatment and chemoprophylaxis against influenza, see Table 3 in the original guideline document. Updates will be available at www.aapredbook.org/flu External Web Site Policy and http://www.cdc.gov/flu/professionals/antivirals/index.htm External Web Site Policy.

Clinical Algorithm(s)

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

  • Number of 2013–2014 seasonal influenza vaccine doses for children 6 months through 8 years of age
  • Precautions for administering IIV to presumed egg-allergic individuals

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention and control of influenza in children

Potential Harms
  • The most common adverse events after inactivated influenza vaccine (IIV) administration are local injection site pain and tenderness. Fever may occur within 24 hours after immunization in approximately 10% to 35% of children younger than 2 years but rarely in older children and adults. Mild systemic symptoms, such as nausea, lethargy, headache, muscle aches, and chills, may occur after administration of trivalent inactivated influenza vaccine (IIV3).
  • The most common adverse events with trivalent IIV (IIV3) are redness, induration, swelling, pain, and itching, which occur at the site of administration; although all adverse events occur at a slightly higher rate with the intramuscular (IM) formulation of IIV3, the rate of pain was similar between intradermal (ID) and IM. Headache, myalgia, and malaise may occur and tend to occur at the same rate as that with the IM formulation of IIV3.
  • In children, the most common injection site adverse reactions with quadrivalent inactivated influenza vaccine (IIV4) were pain, redness, and swelling. The most common systemic adverse events were drowsiness, irritability, loss of appetite, fatigue, muscle aches, headache, arthralgia, and gastrointestinal tract symptoms. These events were reported with comparable frequency among participants receiving the licensed comparator trivalent vaccines.
  • During the 2010–2011 and 2011–2012 influenza seasons, increased reports of febrile seizures in the United States were noted by the Vaccine Adverse Event Reporting System and were associated with IIV3 manufactured by Sanofi Pasteur (Fluzone), mainly in children in the 12- through 23-month age group (the peak age for febrile seizures). The most common vaccine administered concomitantly with IIV3 when a febrile seizure was reported was the 13-valent pneumococcal conjugate vaccine (PCV13). This disproportionate reporting of febrile seizures did not persist through the most recent 2012–2013 influenza season.
  • The most commonly reported reactions in children receiving the quadrivalent live-attenuated influenza vaccine (LAIV4) were runny nose/nasal congestion, headache, decreased activity/lethargy, and sore throat.
  • The most common solicited adverse reactions with trivalent cell culture-based inactivated influenza vaccine (ccIIV3) included injection site pain, erythema at the injection site, headache, fatigue, myalgia, and malaise.
  • The most frequently reported adverse events with trivalent recombinant influenza vaccine (RIV3) were pain, headache, myalgia, and fatigue.
  • As a precautionary measure, people recently vaccinated with LAIV should restrict contact with severely immunocompromised patients (e.g., hematopoietic stem cell transplant recipients during periods that require a protected environment) for 7 days after immunization, although there have been no reports of LAIV transmission from a vaccinated person to an immunocompromised person.
  • There are toxicities associated with antiviral agents, and indiscriminate use might limit availability.

Influenza Vaccines and Egg Allergy

  • Almost all IIV and LAIV are produced in eggs and contain measurable amounts of egg protein, expressed as the concentration of ovalbumin per dose. However, recent data have shown that IIV administered in a single, age-appropriate dose is well tolerated by virtually all recipients who have egg allergy. More conservative approaches, such as skin testing or a 2-step graded challenge, are no longer recommended. No data exist on the safety of administering LAIV to egg-allergic recipients.
  • As a precaution, pediatricians should continue to determine whether the presumed egg allergy is based on a mild (i.e., hives alone) or severe (i.e., anaphylaxis involving cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine) reaction. Pediatricians should consult with an allergist for children with a history of severe reaction. Most vaccine administration to individuals with egg allergy can happen without the need for referral. Data indicate that approximately 1% of children have immunoglobulin E-mediated sensitivity to egg, and of those, a rare minority has a severe allergy. Standard immunization practice should include the ability to respond to acute hypersensitivity reactions. Therefore, influenza vaccine should be given to people with egg allergy with the following preconditions (see Figure 3 in the original guideline document): (1) appropriate resuscitative equipment must be readily available, and (2) the vaccine recipient should be observed in the office for 30 minutes after immunization, the standard observation time for receiving immunotherapy.

Contraindications

Contraindications

Children Who Should Not Be Vaccinated with Inactivated Influenza Vaccine (IIV)

  • Infants younger than 6 months
  • Children who have a moderate-to-severe febrile illness on the basis of clinical judgment of the clinician

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 an amount of nasal congestion that would notably impede vaccine delivery
  • Children with chronic underlying medical conditions, including metabolic disease, diabetes mellitus, asthma, other chronic disorders of the pulmonary or cardiovascular systems, renal dysfunction, or hemoglobinopathies
  • Children 2 through 4 years of age with a history of recurrent wheezing or a medically attended wheezing episode in the previous 12 months because of the potential for increased wheezing after immunization. In this age range, many children have a history of wheezing with respiratory tract illnesses and are eventually diagnosed with asthma. Therefore, when offering LAIV to children 24 through 59 months of age, the pediatrician should screen them by asking the parent/guardian the question, "In the previous 12 months, has a health care professional ever told you that your child had wheezing?" If a parent answers yes to this question, LAIV is not recommended for the child. IIV would be recommended for the child to whom LAIV is not given.
  • Children who have received other live-virus vaccines within the past 4 weeks; however, other live-virus vaccines can be given on the same day as LAIV
  • 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 woman 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
  • Children taking an influenza antiviral medication should not receive LAIV until 48 hours after stopping the influenza antiviral therapy. If a child recently received LAIV but has an influenza illness for which antiviral agents are appropriate, the antiviral agents should be given. Reimmunization may be indicated because of the potential effects of antiviral medications on LAIV replication and immunogenicity.

Qualifying Statements

Qualifying Statements

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Implementation of the Guideline

Description of Implementation Strategy

Vaccine Implementation

  • These updated recommendations for prevention and control of influenza in children will have considerable operational and fiscal effects 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 External Web Site Policy.
  • In addition, the AAP's Partnership for Policy Implementation has developed a series of definitions using accepted health information technology standards to assist in the implementation of this guideline in computer systems and quality measurement efforts. This document is available at www2.aap.org/informatics/PPI.html External Web Site Policy.
Implementation Tools
Clinical Algorithm
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2013-2014. Pediatrics. 2013 Oct;132(4):e1089-104. [3 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2007 Apr (revised 2013 Oct)
Guideline Developer(s)
American Academy of Pediatrics - Medical Specialty Society
Source(s) of Funding

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

Guideline Committee

Committee on Infectious Diseases

Composition of Group That Authored the Guideline

Committee Members 2013–2014: Michael T. Brady, MD (Chairperson), Red Book Associate Editor; Carrie L. Byington, MD; H. Dele Davies, MD; Kathryn M. Edwards, MD; Mary Anne Jackson, MD, Red Book Associate Editor; Yvonne A. Maldonado, MD; Dennis L. Murray, MD; Walter A. Orenstein, MD; Mobeen Rathore, MD; Mark Sawyer, MD; Gordon E. Schutze, MD; Rodney E. Willoughby, MD; Theoklis E. Zaoutis, MD

Former Committee Members: John Bradley, MD; Mary P. Glode, MD; Harry L. Keyserling, 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, Food and Drug Administration; Joan Robinson, MD, Canadian Pediatric Society; Marco Aurelio Palazzi Safadi, MD, Sociedad Latinoamericana de Infectologia Pediatrica; Jane Seward, MBBS, MPH, Centers for Disease Control and Prevention; Jeffrey R. Starke, MD, American Thoracic Society; Geoffrey Simon, MD, Committee on Practice Ambulatory Medicine; Tina Q. Tan, MD, Pediatric Infectious Diseases Society

Ex Officio: Henry H. Bernstein, DO, Red Book Online Associate Editor; David W. Kimberlin, MD, Red Book Editor; Sarah S. Long, MD, Red Book Associate Editor; H. Cody Meissner, MD, Visual Red Book Associate Editor

Contributors: Stuart T. Weinberg, MD, Partnership for Policy Implementation; Jenna A. Katz, BA, Research Assistant, Cohen Children's Medical Center of NY; Rebecca J. Schneyer, BA, Research Assistant, Cohen Children's Medical Center of NY; John M. Kelso, MD

Staff: Jennifer Frantz, MPH

Financial Disclosures/Conflicts of Interest

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.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2011-2012. Pediatrics. 2011 Oct;128(4):813-25.

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.

Guideline Availability

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

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

Availability of Companion Documents

The following is available:

  • Influenza implementation guidance. For pediatricians, physicians, nurse practitioners, physician assistants, nurses, medical assistants, and office managers. Elk Grove Village (IL): American Academy of Pediatrics; 2013. 27 p. Electronic copies: Available in Portable Document Format from the American Academy of Pediatrics Web site External Web Site Policy.
Patient Resources

None available

NGC Status

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 was updated by ECRI Institute on November 12, 2013.

Copyright Statement

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.

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