Pediatric Influenza Medication

Updated: Oct 30, 2018
  • Author: Itzhak Brook, MD, MSc; Chief Editor: Russell W Steele, MD  more...
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Medication

Medication Summary

Baloxavir marboxil is an oral antiviral which inhibits cap-dependent endonuclease, an enzyme specific to influenza, resulting in inhibition of viral replication. It is indicated for the treatment of influenza in adolescents and adults and adolescents aged 12 years or older. It has shown activity against influenza A and B as well as strains resistant to neuraminidase inhibitors and is dosed in a convenient single PO weight-based dose. Oseltamivir and zanamivir are antiviral neuraminidase inhibitors that are used for chemoprophylaxis and treatment of influenza A and B infection. Oseltamivir is an oral antiviral that is approved for children aged 2 weeks or older for treatment and aged 1 year or older for prophylaxis. Zanamivir is an oral powder that is inhaled. It is approved for children aged 7 years or older for treatment and aged 5 years or older for prophylaxis. It is not recommended for use in children with underlying conditions who may be unable to adequately inhale the drug (eg, asthma, muscular dystrophy). Peramivir is a neuraminidase inhibitor that is administered IV as a single dose in children aged 2 years or older for treatment. Amantadine and rimantadine are older antiviral agents that are no longer recommended by the CDC because of resistance.

Vaccines against seasonal influenza are reformulated annually in order to contain the most recently circulating strains. For the trivalent formulation influenza vaccines, two strains of influenza A and one of influenza B are included. The quadrivalent vaccines contain an additional influenza B strain. The vaccine viruses recommended by the World Health Organization and the CDC for the 2018-2019 Northern Hemisphere influenza season differs from the previous season. [79]

The trivalent 2018-2019 Northern Hemisphere vaccine season, contains the following components:

  • A/Michigan/45/2015 (H1N1)pdm09-like virus (no change from last season)

  • A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus (new for 2018-2019)

  • B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) (new for 2018-2019)

The quadrivalent influenza vaccines contain the following additional B strain in addition to the 3 viral strains listed above:

  • B/Phuket/3073/2013-like virus (B/Yamagata lineage) (no change from last year)

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Antiviral agents

Class Summary

Use of influenza-specific antiviral drugs for chemoprophylaxis or treatment of influenza is an important adjunct to vaccination, particularly for controlling outbreaks in closed populations.

Baloxavir marboxil, a cap-dependent endonuclease inhibitor, is the most recent antiviral approved in the U.S. for treatment of influenza. It has shown activity against influenza A and B as well as strains resistant to neuraminidase inhibitors and is dosed as a single PO weight-based dose.

Zanamivir and oseltamivir are members of a class of drugs termed neuraminidase inhibitors and are active against both influenza virus type A and type B. They are approved for both prophylaxis and treatment of influenza. When used for treatment, these agents should be started as soon as possible after the onset of symptoms, but no later than 2 days after onset.

Oseltamivir (Tamiflu) resistance emerged in the United States during the 2008-2009 influenza season, and the CDC issued revised interim recommendations for antiviral treatment and prophylaxis of influenza. Similarly, during the 2009-2010 novel influenza A H1N1 pandemic, preliminary data from a limited number of states indicated a high prevalence of virus strains resistant to oseltamivir. Because of this, zanamivir was recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure was suspected.

A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.

The neuraminidase inhibitor peramivir, is approved for children aged 2 years or older for treatment of acute uncomplicated influenza. It is administered as a single IV dose infused over 15-30 minutes.

Amantadine and rimantadine are effective against type A influenza virus only. They are approved by the US Food and Drug Administration (FDA) for prophylaxis of influenza type A in patients older than 1 year. Amantadine is also FDA-approved for treatment in children.

Since the 2005-2006 influenza season, amantadine and rimantadine are no longer recommended by the Centers for Disease Control and Prevention (CDC) because circulating strains of influenza virus have proved resistant.

Baloxavir marboxil (Xofluza)

Baloxavir marboxil is a prodrug that is metabolized to baloxavir. It inhibits cap-dependent endonuclease, an enzyme specific to influenza, resulting in inhibition of viral replication. It is indicated as a single, oral, weight-based dose for treatment of acute uncomplicated influenza in adults and adolescents aged 12 years or older who have been symptomatic for less than 48 hours.

Oseltamivir (Tamiflu)

Oseltamivir is an inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Oseltamivir is effective against influenza virus types A and B.

Oseltamivir is approved for use in children older than 1 year, for prevention of influenza following exposure. It is approved for treatment of influenza A or B in children aged 2 weeks or older who have been symptomatic for no more than 2 days. It is available as capsules and as an oral suspension. During the 2009-2010 novel influenza A (H1N1) pandemic, the CDC issued an emergency use authorization for oseltamivir prophylaxis in patients younger than 1 year.

As resistance to oseltamivir may occur, physicians should maintain awareness of current CDC recommendations for antiviral treatment and prophylaxis of influenza. In addition, local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice. A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone.

Zanamivir (Relenza)

Zanamivir is an inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Zanamivir is effective against both influenza types A and B.

Zanamivir is approved for the treatment of uncomplicated acute influenza A or B in persons aged 7 years and older who have been symptomatic for no more than 2 days, and for prophylaxis of influenza in adults and pediatric patients aged 5 years and older. This agent is inhaled through a Diskhaler PO inhalation device. Circular foil disks containing 5-mg blisters of drug are inserted into a supplied inhalation device.

Peramivir (Rapivab)

Inhibitor of influenza virus neuraminidase, an enzyme that releases viral particles from the plasma membrane of infected cells. Indicated for treatment of acute uncomplicated influenza in patients aged 2 years or older who have been symptomatic for <2 days.

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Vaccines

Class Summary

These agents elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Current seasonal influenza vaccines provide no protection against human infection with highly pathogenic avian influenza type A viruses, including H5N1. However, reducing seasonal influenza risk through influenza vaccination of persons who might be exposed to nonhuman influenza viruses (eg, H5N1 viruses) might reduce the theoretical risk for recombination of an avian influenza type A virus and human influenza type A virus by preventing seasonal influenza virus infection within a human host. The CDC has recommended that persons who are charged with responding to avian influenza outbreaks among poultry receive seasonal influenza vaccination.

Influenza virus vaccine trivalent (Fluzone, Afluria, Fluarix, Fluvirin)

Influenza vaccine is indicated for active immunization to prevent infection from influenza A and B viruses. The vaccine induces antibodies specific to virus strains contained in the vaccine. The US Public Health Service determines influenza vaccine contents annually. Typically, 3 live attenuated virus strains, which antigenically represent the influenza strains likely to circulate the next flu season, are included in the formulation each year. Fluzone is approved for children as young as 6 months, Fluarix for children aged 3 years or older, Fluvirin for children aged 4 years or older, and Afluria for children aged 5 years or older.

Influenza virus vaccine quadrivalent (Afluria Quadrivalent, Fluarix Quadrivalent, Fluzone Quadrivalent, FluLaval Quadrivalent)

Quadrivalent vaccines contain two strains of influenza A and two of influenza B. The vaccine induces antibodies specific to virus strains contained in vaccine. Each year, the US Public Health Service determines which viral strains will be included in the seasonal influenza vaccine that will antigenically represent the viral strains most likely to circulate in the next flu season. It is administered as an IM injection. Afluria, Fluzone, FluLaval, and Fluarix Quadrivalent vaccines are approved for children aged 6 months or older. Flucelvax Quadrivalent is approved for children aged 4 y or older.

Influenza virus vaccine quadrivalent, intranasal (FluMist Quadrivalent)

The Advisory Committee on Immunization Practices (ACIP) recommends return of intranasal flu vaccine in the U.S. for 2018-2019 season. The recommendation was based on positive results from a U.S. study in children between the ages of 2 to <4 years evaluating the shedding and antibody responses of the H1N1 strain in the live attenuated influenza vaccine (LAIV).

Influenza virus vaccine (H5N1)

The H5N1 inactivated virus vaccine induces antibodies against viral hemagglutinin, thereby blocking viral attachment to human respiratory tract epithelial cells. The vaccine is estimated to reduce the risk of contracting avian influenza by 45%. This vaccine is indicated for active immunization of adults at increased risk of exposure to the H5N1 influenza virus subtype.

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