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This guideline was initially written in response to the novel influenza H1N1 (swine flu) pandemic based on a number of other guidelines (including the Royal Children's Hospital Melbourne and the Ministry of Health). It has been adapted to be generic for influenza. For local detailed infection control information please see ADHB Policies and Guidelines Library 'Influenza and Influenza-like illness - prevention of in-hospital spread'.
A confirmed case of influenza is defined as a person with laboratory confirmed influenza virus infection by one or more of the following tests:
- PCR on respiratory secretions (nasopharyngeal swab or aspirate)
- viral culture (not usually performed during pandemic)
- four-fold rise in influenza virus specific neutralising antibodies
A probable case of influenza is defined as a person with an influenza-like illness (ILI) who has a strong epidemiological link to a confirmed case or defined cluster.
Close contact is defined as having cared for, lived with, or had direct contact with respiratory secretions or bodily fluids of a probable or confirmed case.
- History of fever, chills, and sweating or clinically documented
fever ≥38 °C,
- cough or sore throat
Other features to consider in children include body aches, fatigue, tiredness and shortness of breath. Diarrhoea is a common symptom in children. Children with influenza can present with neurologic complications such as seizures or encephalopathy.
This is not all inclusive but will help with detection of children most likely to have influenza. Children under 12 months of age may have an even more non-specific illness. Surveillance studies suggest a low rate of influenza as a cause of acute wheezing illnesses in children.
When assessing children with Influenza-like illness consideration needs to be given to the possibility of influenza with a secondary bacterial infection (e.g. pneumococcal or staphylococcal disease) or bacterial infection with non-specific symptoms presenting similarly to influenza such as meningococcal disease. These possibilities would warrant use of appropriate antibiotics.
Co-morbidities, particularly immune suppression, chronic lung disease and morbid obesity, are risk factors for more serious disease.
Contracting influenza while on long term aspirin therapy is a risk factor for Reye's syndrome
Emergency Department Assessment
Patient assessed to be well enough for discharge:
- No viral investigations are needed unless the child is in a residential care facility such as Wilson Home or boarding school. Early in the influenza season viral swabs may be taken to establish aetiology.
- Recommend patients stay at home until symptoms are resolved
- Most patients do not require antiviral therapy. Oseltamivir should only be given as treatment (see below) if patient has risk factors for more serious disease and if the seasonal influenza strains are known to be oseltamivir sensitive. These children should be discussed with the CED specialist on duty.
- Prophylaxis (see below) should only be given to close family members if they have risk factors for serious disease. Symptomatic family members should not stay in the hospital or at Ronald McDonald house.
Unwell patient being admitted to hospital
- Respiratory isolation on ward - droplet precautions
- Appropriate sample taken (nasopharyngeal viral swab or aspirate) to confirm diagnosis and for cohorting purposes - airborne precautions for procedure
- Oseltamivir started if fulfils case definition (confirmed or probable) AND are either moderately/severely unwell or have co-morbidities AND the circulating strains are known to be oseltamivir-sensitive
NB: Most children who are started on oseltamivir will also require initiation of antibiotics (see Starship pneumonia guideline). Bacterial superinfection can be a significant contribution to morbidity: - awareness and early initiation of antibiotics are required to minimise this.
NB: Can be used in hospital but special authority required for community dispensing
See separate Auckland Hospital guidelines for outpatient oseltamivir prescribing.
Please note that seasonal influenza may be oseltamivir-resistant and it should not be used in such cases. The resistance pattern of circulating strains will be known early in each season or epidemic.
Oseltamivir is licensed for treatment and prophylaxis of children over one year of age. It has not been widely studied in children under 12 months of age, but can be considered for hospitalised patient with risk factors. Clinical judgement should be used weighing risks of disease against unknown risks of oseltamivir.
There is even less information about use of oseltamivir in infants under 3 months of age. Discuss with Paediatric Infectious Disease specialist on call if considering this.
Oseltamivir may reduce duration of illness, severity of illness
and duration of viral shedding - especially if treatment begins
within 48-72 hours of symptoms starting.
Cases where oseltamivir use is appropriate include:
- Severe, complicated or progressive respiratory illness
- CHF (severe/poorly controlled)
- Chronic Respiratory Disease (severe)
- Asthma (severe + steroids)
- Renal haemodialysis or CAPD
- Any other condition putting patient at high risk e.g. poorly controlled diabetes, morbid obesity, metabolic disease, severe liver or neurological disease
- Chronic care facility resident
Oseltamivir (Tamiflu) Dosing
For patients who cannot swallow capsules, Tamiflu® oral suspension is the preferred formulation. The suspension is available as 6mg/ml. Doses in this guideline for children < 1 year are based on 2 to 3mg/kg per dose and have been adjusted to account for the strength of the suspension.
The bottle comes with a dispenser marked for 30, 45 & 60 mg which should not be used for doses less than 30mg. Provide patients with an oral syringe instead (e.g. 3 ml or 5 ml) to measure doses and give instructions in mL.
If the oral suspension is not available, dissolve contents of capsule (75mg) in 5 ml water (15mg/ml) using graduated syringe; mix well and withdraw required dose. May be mixed with sweetened liquids/ food to mask the bitter taste of the medication.
Children < 1 year
- Preterm, <38 weeks postmenstrual age: 1mg/kg/dose PO twice daily
- Preterm, 38 - 40 weeks postmenstrual age: 1.5mg/kg/dose PO twice daily (from 2016 Nelson's Paediatric Antimicrobial Therapy, 22nd Ed)
|Patient weight||Treatment Dosing|
|≤ 3 kg||6mg twice daily for 5 days|
|>3 to 4 kg||9mg twice daily for 5 days|
|>4 to 6 kg||12mg twice daily for 5 days|
|>6 to 9 kg||18mg twice daily for 5 days|
|>9 to 12 kg||24mg twice daily for 5 days|
|>12 to 14 kg||30mg twice daily for 5 days|
Children > 1 year
|Patient weight||Treatment Dosing|
|< 15 kg||30 mg twice daily for 5 days|
|15 to 23 kg||45 mg twice daily for 5 days|
|23 to 40 kg||60 mg twice daily for 5 days|
Adolescents and children > 40kg
|Patient weight||Treatment Dosing|
|>40 kg||75 mg twice daily for 5 days|
- For post-exposure prophylaxis use the same dose but ONCE daily for 10 days
- Refer to product datasheet for further prescribing information.
- Adjust dosing for renal failure and dialysis. Discuss with Paediatric Renal team or Paediatric Pharmacist.
- Give doses with food to minimise GI upset. If vomiting occurs within 30 minutes of administration a repeat dose should be given.
Zanamavir is another neuraminidase inhibitor, delivered as an inhaled powder by rotadisk. It is active against influenza A and B, sometimes even for strains resistant to Oseltamivir. It is licensed for children >5years. Treatment dose is 2 x 5mg inhalations twice daily for 5 days; prophylaxis dose is 2x 5mg inhalations once daily for 10 days.
Infection Control Issues
See also ADHB document 'Influenza and Influenza-like illness - prevention of in-hospital spread' under the policies and guidelines library
Careful hand hygiene and social distancing remain the most effective way to reduce the spread of infection
There is no consensus on duration of isolation in hospital. The decision will be influenced by the presence of underlying disease (e.g. chronic respiratory disease or immunosuppression), patient age and the use of antiviral medication.
- 5 years with no co-morbidities, immunosuppression or underlying significant respiratory disease (excluding asthma): Take out of isolation after 5 days of oseltamivir or if no antiviral taken after 7 days of illness with resolution of symptoms
- < 5 years with no co-morbidities, immunosuppression or underlying significant respiratory disease (excluding asthma): Take out of isolation after 5 days of oseltamivir or if no antiviral taken after 10 days of illness with resolution of symptoms. Younger children are believed to excrete virus for longer periods.
- If immunosuppressed or significant respiratory disease eg bronchiectasis remain in isolation for length of hospital stay. Can be discussed with Paediatric Infectious Disease specialist on call.
See ADHB policies and guidelines library for 'Influenza and Influenza-like illness - prevention of in-hospital spread'.
Information for Families
See Kidshealth factsheet on flu (influenza) (http://www.kidshealth.org.nz/flu-influenza)
Medsafe Data sheet (Tamiflu®) [Datasheet online] Roche Products. http://www.medsafe.govt.nz/profs/Datasheet/dsform.asp
Royal Children's Hospital Melbourne, Oseltamivir doses in children Version 5, 23 June 2009
Did you find this information helpful?
- Date last published: 20 February 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Infectious Diseases
- Author(s): Elizabeth Wilson, Lesley Voss
- Owner: Elizabeth Wilson
- Editor: Greg Williams
- Review frequency: 2 years
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