Pediatric Influenza in the Emergency Department: Diagnosis and Management

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

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

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?

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

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Tables and Figures

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Key References

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

• 1. US Centers for Disease Control and Prevention. “Types of Influenza viruses.“ Accessed December 15, 2020. (CDC information)
• 6. Poehling KA, Edwards KM, Weinberg GA, et al. The underrecognized burden of influenza in young children. N Engl J Med. 2006;355(1):31-40. (Epidemiologic study) DOI: 10.1056/NEJMoa054869
• 9. United States Centers for Disease Control and Prevention. “Clinical signs and symptoms of influenza.“ Accessed December 15, 2020. (CDC information)
• 11. Teutsch SM, Zurynski YA, Nunez C, et al. Ten years of national seasonal surveillance for severe complications of influenza in Australian children. Pediatr Infect Dis J. 2020. Volume Online First Issue. (Prospective surveillance study) DOI: 10.1097/INF.0000000000002961
• 17. US Centers for Disease Control and Prevention. “Flu & young children.“ Accessed December 15, 2020. (CDC information)
• 24. US Centers for Disease Control and Prevention. “Interim guidance on infection control measures for 2009 H1N1 influenza in healthcare settings, including protection of healthcare personnel.“ Accessed December 15, 2020. (CDC guidance)
• 30. Kerr J, Macartney K, Britton PN. Influenza-associated myositis: a single-centre, 5-year retrospective study. Eur J Pediatr. 2020. (Retrospective study) DOI: 10.1007/s00431-020-03835-w
• 40. US Centers for Disease Control and Prevention. “Influenza antiviral medications: summary for clinicians.“ Accessed December 15, 2020. (CDC recommendations)
• 42. Prescribing information. Oseltamivir. Accessed December 15, 2020. (Product information)
• 43. Prescribing information. Zanamivir. Accessed December 15, 2020. (Product information)
• 44. rescribing information. Peramivir. Accessed December 15, 2020. (Product information)
• 45. Prescribing information. Baloxavir marboxil. Accessed December 15, 2020. (Product information)
• 50. Lewis EN, Griffin MR, Szilagyi PG, et al. Childhood influenza: number needed to vaccinate to prevent 1 hospitalization or outpatient visit. Pediatrics. 2007;120(3):467-472. (Estimation study based on published disease rates) DOI: 10.1542/peds.2007-0167
• 51. US Centers for Disease Control and Prevention. “Who should and who should not get a flu vaccine.“ Accessed December 15, 2020. (CDC information)
• 52. US Centers for Disease Control and Prevention. “Vaccine effectiveness: how well do the flu vaccines work?“  Accessed December 15, 2020. (CDC information)
• 59. Baumer-Mouradian SH, Kleinschmidt A, Servi A, et al. Vaccinating in the emergency department, a novel approach to improve influenza vaccination rates via a quality improvement initiative. Pediatr Qual Saf. 2020;5(4):e322. (Interventional study; 33,311 children) DOI: /10.1097/pq9.0000000000000322
• 61. US Centers for Disease Control and Prevention. “2019-20 season’s pediatric flu deaths tie high mark set during 2017-18 season.“ Accessed December 15, 2020. (CDC information)
• 68. World Health Organization. “H1N1 in post-pandemic period: director-general’s opening statement at virtual press conference. August 10, 2010.“ Accessed December 15, 2020. (WHO statement)
• 69. World Health Organization. “WHO guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses.“ Accessed December 15, 2020. (Guidelines)
• 77. World Health Organization. “Coronavirus disease (COVID-19): similarities and differences with influenza.“ Accessed December 15, 2020. (WHO guideline)

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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