Management of Pediatric Influenza in the Emergency Department

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Pediatric Influenza in the Emergency Department: Diagnosis and Management (Infectious Disease CME)

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Table of Contents
 

About This Issue

Influenza is one of the most common pediatric infectious diseases, occurring in up to 20% of children annually worldwide. While most children with influenza infections will recover in a few days, some will develop complications that may be life-threatening and result in death. This issue reviews the clinical presentation of influenza in children, offers guidance for infection control measures, and provides recommendations for the evaluation and management of suspected influenza and its complications in pediatric patients. You will learn:

The different types of influenza that infect humans

Common complications of influenza, as well as rare but more serious complications

Which children are at higher risk for complications of influenza

The likelihood of a child with influenza also having a serious bacterial infection

Recommendations for infection control measures within the emergency department

Classic symptoms of influenza and other less common symptoms

Which tests are available for diagnosing influenza

Current recommendations for chemoprophylaxis and treatment of influenza, including which antiviral medications are approved for which age groups

Current vaccination recommendations

How clinical practice guidelines can help guide the disposition of children with influenza

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Classification of Influenza
  6. Epidemiology and the Burden of Illness
    1. Viral Transmission
    2. Complications
      1. Severe Complications
      2. Pneumonia
      3. Staphylococcus aureus Infection
      4. Death
    3. Serious Bacterial Infections
  7. Infection Control Measures
  8. Emergency Department Evaluation
  9. Diagnostic Studies
    1. Available Tests
    2. Accuracy of Rapid Antigen Tests
    3. Impact of Rapid Testing
    4. Comparison of Rapid Testing to Other Modalities
  10. Treatment
    1. Chemoprophylaxis for Influenza
    2. Treatment With Antiviral Medications
  11. Vaccination Against Influenza
  12. Special Considerations
    1. Young Infants With Influenza
    2. Overuse of Antibiotics
    3. Admitting Children With Influenza
    4. Influenza A (H1N1) Pandemic
    5. COVID-19 Pandemic
    6. Overcrowded Emergency Departments
  13. Summary
  14. Risk Management Pitfalls for Influenza in Children
  15. Case Conclusions
  16. Clinical Pathway for Management of Pediatric Patients With Influenza-Like Illness in the Emergency Department
  17. Tables and Figures
    1. Table 1. Patients at Higher Risk for Complications of Influenza
    2. Table 2. Influenza Virus Testing Methods
    3. Table 3. Antiviral Medications Approved by the FDA for Influenza Treatment for Pediatric Patients
    4. Table 4. Age Indication for Influenza Vaccines
    5. Figure 1. Schematic Diagram of an Influenza Virion
  18. References

Abstract

Influenza in children is a significant cause of morbidity and mortality. Presenting symptoms of influenza vary greatly among children; clinical presentation should be assessed for severity of illness and potential complications. Available clinical and laboratory findings should be used to guide treatment for young children with fever. Clinicians should be aware of up-to-date recommendations to diagnose and treat children with influenza and to ensure public health engagement to prevent and manage influenza outbreaks and epidemics. This issue reviews common complications of influenza infection, offers guidance for infection control measures, and provides evidence-based recommendations for the management of pediatric patients with influenza in the emergency department.

Case Presentations

CASE 1
An 18-month-old girl with a runny nose and fever lasting 1 day is brought to the ED by her parents…
  • The girl is up-to-date on her scheduled vaccinations, but has not received an influenza vaccine yet for the season. Her parents also report that she has had frequent coughing episodes, some resulting in vomiting.
  • The girl’s vital signs are: rectal temperature, 39.2°C (102.6°F); heart rate, 130 beats/min; respiratory rate, 36 breaths/min; and oxygen saturation, 100% on room air. On examination, the girl is not in apparent distress, she does not seem to be dehydrated, and her mucous membranes are moist. She has minimal nasal congestion. The patient’s tympanic membranes are clear and not bulging. Some coarse crackles are heard, more in the right lung base, although the examination is limited due to crying. There is no respiratory distress when the patient is calm. Her abdomen is soft and neither tender nor distended. Her capillary refill time is 2 seconds.
  • Is influenza testing appropriate? If so, what type of test should be conducted and how reliable would the result be? Is this patient at increased risk for a more severe disease course? Given the pulmonary findings, could this patient have bacterial or viral pneumonia? Should a chest radiograph be ordered? Is evaluation of the patient’s blood and/or urine necessary?
CASE 2
A 26-day-old boy is brought in by his parents for concern for influenza…
  • The entire family has been having influenza-like symptoms. The mother had a positive rapid influenza test 1 day earlier; her COVID-19 test was negative. The parents report that the infant has not been sneezing and does not have much cough, but that he has a runny nose. The baby has been breastfeeding, albeit slightly less than usual. The baby looks well and has the following vital signs: temperature, 38.5°C (101.3°F); heart rate, 145 beats/min; respiratory rate, 44 breaths/min; blood pressure, 95/58 mm Hg; and oxygen saturation, 98% on room air.
  • You recall that neonates with fever have to go through a full sepsis workup (blood sample, urine test, and a lumbar puncture for CSF testing). Does the concern for influenza mitigate need for further testing?
  • Since the mother is a confirmed contact with a positive rapid influenza test, can the diagnosis of influenza be assumed? If the patient has influenza, how likely are other serious bacterial infections? Can the fever evaluation be modified or avoided altogether?

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Clinical Pathway for Management of Pediatric Patients With Influenza-Like Illness in the Emergency Department

Clinical Pathway for Management of Pediatric Patients With Influenza-Like Illness in the Emergency Department

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Tables and Figures

Table 1. Patients at Higher Risk for Complications of Influenza

Table 2. Influenza Virus Testing Methods
Table 3. Antiviral Medications Approved by the FDA for Influenza Treatment for Pediatric Patients
Table 4. Age Indication for Influenza Vaccines
Figure 1. Schematic Diagram of an Influenza Virion

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Key References

Following are the most informative references cited in this paper, as determined by the author.

Subscribe to get the full list of 80 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: influenza, pediatric influenza, flu, influenza virus, influenza A, influenza B, H1N1, epidemic, pandemic, complications of influenza, acute otitis media, pneumonia, bronchiolitis, myocarditis, encephalitis, myositis, sepsis, serious bacterial infection, infection control measures, rapid influenza test, rapid antigen test, RT-PCR, viral culture, chemoprophylaxis, antiviral medications, antiviral therapy, oseltamivir, peramivir, zanamivir, baloxavir marboxil, influenza-like illness, vaccination, influenza vaccine, COVID-19, co-infection

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Publication Information
Authors

Ran D. Goldman, MD, FRCPC

Peer Reviewed By

Coburn H. Allen, MD, FAAP, FACEP, FPIDS; Sarah C. Cavallaro, MD; David M. Walker, MD, FAAP, FACEP

Publication Date

January 2, 2021

CME Expiration Date

January 3, 2024

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits.

Pub Med ID: 33320486

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CME Information

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