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Indian J Pediatr (February 2017) 84(2):139–143

DOI 10.1007/s12098-016-2232-x

REVIEW ARTICLE

Influenza in Children
Virendra Kumar 1

Received: 4 July 2016 / Accepted: 7 September 2016 / Published online: 19 September 2016
# Dr. K C Chaudhuri Foundation 2016

Abstract In children, influenza is one among the commonest Keywords Influenza . H1N1 . Oseltamivir . Influenza
causes of acute respiratory illness and loss of school days. vaccine
Influenza A, B, and C are 3 types of viruses responsible for
illness. Type A virus has many subtypes based on antigens but
Type B and Type C viruses have no known subtypes. Introduction
Currently, influenza A/H1N1, A/H3N2, and influenza type
B viruses are circulating in humans. Transmission of influenza Acute respiratory illnesses are the most common prob-
occurs through droplets from infected person or through direct lems of childhood and influenza viruses are among the
contact with person or fomites. Clinically, influenza is charac- common viruses responsible for them. Influenza infec-
terized by acute onset fever, chills, running nose, cough, sore tion rate is higher in preschool children. It is generally
throat, headache and myalgia. Mostly, febrile illness lasts for considered as a mild disease, however, it may contribute
3–4 d with resolution of disease in 7–10 d. Confirmation of to significant mortality, especially in children with un-
influenza can be done either by virus culture, RT-PCR or derlying chronic medical conditions. Influenza viruses
specific neutralizing antibodies in blood. Basic principles of are known to cause seasonal outbreaks, epidemics and
management include prompt institution of infection control pandemics. The first pandemic of influenza H1N1 virus
measures, early identification of children at higher risk, sup- was reported in 1918, infecting 500 million people
portive care and antiviral drugs. Vaccine and chemoprophy- across the world and killed 50–100 million people, 3–
laxis are two commonly used methods for prevention of in- 5 % of the world’s population [1]. The last pandemic
fluenza. Currently, inactivated influenza vaccine (IIV) and live with influenza virus (swine-origin H1N1 strain) was re-
attenuated influenza vaccine (LAIV) are available for use with ported in 2009 and accounted for the loss of about
good efficacy. Cough etiquette, use of face masks and hand 17,000 people across the globe [2]. In India also, pan-
hygiene are the most important measures to reduce the risk of demic H1N1 strains are circulating and more than 2500
infection transmission from person to person. deaths have been reported till date [3].

Learning objectives: After reading this article readers should be able to Etiology
• understand pathogenesis and epidemiology of influenza
• identify the common features and complications of influenza Influenza viruses are RNA viruses belonging to the
• manage influenza in children
Orthomyxoviridae family. There are three types of influ-
• decide when children should be referred to the specialist
enza viruses (Type A, B and C). Segmented viral ge-
* Virendra Kumar
nome is encased in a lipid containing surface envelope
drvkumar1@gmail.com having Hemagglutinin (H) and Neuraminidase (N), two
major surface antigens. Subtype of influenza virus is
1
Department of Pediatrics, Kalawati Saran Children’s Hospital, Lady determined by these H and N antigens. Type A virus
Hardinge Medical College, New Delhi 110001, India has many subtypes with a different combination of 17
140 Indian J Pediatr (February 2017) 84(2):139–143

H and 10 N antigens (e.g., H1N1, H3N2, H5N1). Type Influenza Virus Infections in Humans
B and Type C viruses have no known subtypes [4].
Type A viruses are capable of infecting multiple spe- Seasonal Influenza
cies (Human, Avian, Swine, Equine). They are antigen-
ically unstable, and known to undergo mutations within Seasonal disease caused by circulating influenza viruses oc-
the viral genome (antigenic shift) causing sporadic curs in humans every year. All three types (A, B, and C) of
cases, seasonal outbreaks and epidemics. Whereas re- influenza viruses can cause seasonal disease.
assortment of genetic material among the subtypes re-
sults in a new virus strain (antigenic shift) for which the Pandemic Influenza
population has no immunity. This new strain may be-
come easily transmissible from person to person, posing Type A influenza virus is mainly responsible for pandemics.
a potential risk of epidemics or pandemics in humans. As a result of major antigenic change in circulating influenza
Type B viruses infect humans only and have no viruses, a new strain may emerge for which population has no
known animal reservoir. They have less frequent anti- immunity. This may result in rapid spread of influenza from
genic variations in genome, limiting themselves to cases person to person and the pandemic. In 2009, a strain of influ-
of seasonal influenza or rarely, epidemics. Type C vi- enza A (H1N1) emerged and caused pandemic. This pandem-
ruses infect humans and pigs and cause mild upper re- ic A (H1N1) virus is now established as a seasonal influenza
spiratory disease only. They are antigenically stable and virus in humans.
do not cause epidemics [4].
Zoonotic or Variant Influenza

When animal influenza viruses infect their natural animal


Epidemiology host, they are named for that host, such as avian influenza,
swine influenza, or equine influenza. Rarely, humans can also
Currently three strains of influenza virus are mainly get infected with these animal influenza viruses, resulting in
circulating in humans, two of type A (H1N1 and mild to severe respiratory illness [8].
H3N2) and one of type B. Each year’s strain is new
to infants, as they lack their own protective antibodies.
Antibodies transferred from the mother protect only for Clinical Features
first few months of life. The attack rate of primary
influenza infection is highest in young children and they Like any other viral respiratory illness, clinically, influenza is
shed virus for longer than adults [5]. characterized by acute onset fever, chills, running nose,
Though sporadic cases are reported round the year, cough, sore throat, headache and myalgia. Diarrhea, vomiting
outbreaks in temperate zones occur in winter and in and abdominal pain may be seen. In uncomplicated cases, the
tropic and sub tropics in rainy season. Report of disease mostly presents as mild upper respiratory illness and
Influenza Surveillance Network in India shows an in- the febrile illness lasts for 3–4 d with resolution of disease in
crease in influenza cases in the month of June to 7–10 d. Dry cough however, may last longer in some cases [6,
September, coinciding with the monsoon in India [2, 9, 10]. The infants and young children may look very sick and
6]. Overcrowding helps in rapid transmission of infec- toxic and present with illness resembling sepsis, pneumonia,
tion, mostly affecting urban and sub urban areas. Higher croup or bronchiolitis. Though overall prognosis for recovery
attack rate is also observed in army barracks, schools, from influenza is good, deaths are reported even in children
colleges and public transport system. without risk factors. Probability of death is higher in first 3 d
Disease transmission occurs through droplets from of illness [9].
infected person or through direct contact with the per-
son or fomites. Incubation period of influenza is short;
1–2 d only. Peak viral shedding occurs on first day of Complications
illness but communicable period may last up to 7–10 d
in young children. Children on immunosuppressive Acute otitis media, sinusitis, pneumonia and bronchitis are
drugs or immunodeficiency state shed virus for longer common complications of influenza. Secondary bacterial in-
period. Antibodies appear in first week and reach max- vasion of damaged respiratory epithelium with Streptococcus
imum level in two weeks. Cross immunity between dif- pneumoniae or Staphylococcus is mainly responsible for these
ferent strains does not occur and immunity drops down complications. Children with underlying bronchopulmonary
to pre infection level by about 12 mo period [5, 7]. dysplasia, asthma, cystic fibrosis, heart disease and
Indian J Pediatr (February 2017) 84(2):139–143 141

neuromuscular diseases are at higher risk for severe disease Treatment


and complications [5].
The basic principles of management are

Diagnosis – Prompt institution of infection control policy to minimize


healthcare or household spread of disease.
Diagnosis of influenza is usually made on the basis of clinical – Early initiation of antiviral drugs if indicated and other
features of flu like symptoms without localization, especially supportive care to prevent severe disease and
if linked epidemiologically to influenza cases. Routine inves- complications.
tigations may show nonspecific hematological and radiologi- – Early identification of children at higher risk for disease
cal changes, including leucopenia or infiltrates/atelectasis in prevention and surveillance.
some cases. Laboratory confirmation is not required in all
cases. However, it should be done in all children with severe Categorization of Influenza A H1N1 cases during screen-
disease requiring hospitalization or in children who are at a ing for home isolation, testing treatment, and hospitalization is
higher risk for complications [11]. shown Table 1 [3, 7].
Confirmation of influenza can be done by: All clinical or confirmed cases of influenza requiring hos-
pitalization should be managed in isolation room. If it is not
(1) Virus culture possible, these cases can be managed in well ventilated isola-
(2) Real time polymerase chain reaction (RT-PCR) tion ward with a bed to bed distance of at least one meter and
(3) Four-fold rise in virus specific neutralizing antibodies. provision of separate material and supplies and waste
disposal.
Respiratory specimen for virus culture and RT-PCR may be Treatment options primarily depend on the disease severity.
obtained from nasopharyngeal/throat swab or tracheal aspi- Children with mild disease can be managed at home with
rates in intubated patients, preferably within 4–5 d of illness. supportive care including rest, adequate fluid intake, paracet-
Among all these tests, Real-time polymerase chain reaction amol for fever and myalgia. Aspirin should always be avoided
(RT-PCR) test remains the mainstay of diagnosis. The sample due to risk of Reye’s syndrome. Hospitalization and antiviral
collection and transportation should be done as per the guide- drugs are not indicated in mild disease.
lines [11]. Children with risk factor or moderate to severe disease or
requiring hospitalization are managed with maintenance of
hydration, oxygenation, antipyretics, and antiviral drugs.
Case Definition Secondary bacterial infection should be suspected if deterio-
ration in general condition, prolonged fever or recurrence of
Suspected Case fever is observed. In such cases, appropriate antibiotics should
be used as per the hospital policy. The author prefers using a
Acute febrile respiratory illness with onset within 7 d of close combination of Ceftriaxone (50 mg/kg/dose, twice a day) and
contact with a confirmed case of influenza or within 7 d of Vancomycin (15 mg/kg/dose, three times a day). Most of the
travel to an area where confirmed case has been reported, or children with uncomplicated influenza feel better by second or
resides in an area where there are one or more confirmed third day of illness [5].
influenza cases [12]. Antiviral drugs used for the treatment of influenza are
Oseltamivir, Zanamivir, Amantadine and Rimantadine.
Probable Case However, Oseltamivir is the one which is widely available
and easy to administer. It can be used for treatment and pro-
Any suspected case of influenza with a positive test for influ- phylaxis both. Though Oseltamivir is generally well tolerated
enza viral infection or a person with clinically compatible in children, nausea, vomiting, abdominal pain, epistaxis and
illness who died of an unexplained respiratory illness and rash may be observed.
epidemiologically linked to a probable or confirmed case [12].

Confirmed Case
When to Refer to Specialist/Higher Centre
Any person with acute respiratory illness with confirmed in-
fluenza infection from WHO certified laboratory, with either Most of the children can be managed at home or primary
RT-PCR or culture or four fold rise in virus specific antibodies health center, however, children with following conditions
[12]. should be considered for early referral.
142 Indian J Pediatr (February 2017) 84(2):139–143

• Consider broad spectrum antibiotics


– Children with mild disease having risk factors for se-

• Avoid mixing up with public and


high risk members in the family
• May require home isolation and
vere disease or complications.

• Requires home isolation and


• Broad spectrum antibiotics


Children with high fever and sore throat interfering

• Immediate hospitalization
• No need for Oseltamivir;
• Symptomatic treatment;
with feeding.

• Supportive treatment
– Children with persistent vomiting.
– Children not able to feed.

Oseltamivir

Oseltamivir

• Oseltamivir
Children on long term corticosteroid therapy.
Treatment

– Children with severe respiratory distress (cyanosis,


RR > 60/min, severe chest indrawing, SpO2 < 92 %).
– Children with circulatory failure (cold hands, weak and
fast pulse, capillary refill time > 3 s).
– Children with CNS symptoms (drowsiness, seizures).

Prevention
should not delay the treatment
Testing for H1N1 is required but
No testing for H1N1 is required

No testing for H1N1 is required

No testing for H1N1 is required

Vaccine and chemoprophylaxis are two commonly


Reassessed at 24 h to 48 h

used methods for prevention of influenza, in addition


to reduction of exposure to influenza cases. Currently,
Categorization of influenza A H1N1 cases during screening for home isolation, testing, treatment, and hospitalization

inactivated influenza vaccine (IIV) and live attenuated


Investigations

by the doctor

influenza vaccine (LAIV) are available for use with


good efficacy. LAIV is for intranasal administration
while IIV is given by intramuscular route. American
Academy of Pediatrics recommends annual seasonal
influenza immunization for all children above 6 mo
of age. Children with following conditions should re-
ceive the vaccine on priority:

– Children who are at higher risk for severe disease or


shortness of breath, difficulty in breathing, worsening
has one or more of the following: somnolence, high/
In addition to the above signs/ symptoms, if the patient

complications of influenza, such as asthma and other


persistent fever, inability to feed well, convulsions,
disease, kidney disease, blood disorders, diabetes,
neurological disorders, cancer, HIV/AIDS and on

chronic respiratory diseases, diabetes, immunosuppres-


Children with mild illness but with predisposing
risk factors; lung diseases, heart disease, liver

sion, significant heart disease or progressive neurolog-


ical diseases.
with or without body ache, headache,

– Household contact and out of home care provider of


In addition to Category-A: high grade

children less than 6 mo of age.


of underlying chronic conditions
Mild fever plus cough / sore throat

– Pregnant and lactating mothers.


fever and severe sore throat
diarrhea and vomiting

Children between 6 mo to 8 y of age who have


immunosuppression

received influenza vaccine in the preceding season


should be given one dose, otherwise give two doses
Clinical features

of IIV at 4 wk interval (age 6–36 mo – 0.25 ml, IM;


> 3 y – 0.5 ml, IM). Children 9 y and above should
be given only one dose of IIV (0.5 ml, IM) annually.
It takes about two weeks after vaccination to develop
protective levels of antibodies against influenza.
LAIV is given by intranasal route and recommended
for use in children more than 2 y of age. Children
between 2 and 4 y who have asthma or had wheezing
in last one year, LAIV should be avoided. It is contra-
Category-B (ii)
Category-B (i)

indicated in children receiving aspirin, antiviral medica-


Category-A

Category-C
Categories

tions, egg allergy, pregnancy and immunecompromised


Table 1

state. Other live vaccines should also be avoided within


4 wk of LAIV [13].
Indian J Pediatr (February 2017) 84(2):139–143 143

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