Nutrisi
Nutrisi
Nutrisi
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
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
• 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
Prevention
should not delay the treatment
Testing for H1N1 is required but
No testing for H1N1 is required
by the doctor
Category-C
Categories
Chemoprophylaxis References
Oral Oseltamivir and inhaled Zanamivir are approved for che- 1. Taubenberger JK, Morens DM. 1918 influenza: the mother of all
moprophylaxis; however Oseltamivir is the first choice. pandemics. Emerg Infect Dis. 2006;12:15–22.
Prophylaxis should be given till 10 d after the last exposure, 2. Itolikar S, Nadkar MY. H1N1 revisited after six years: then and
now. J Assoc Physicians India. 2015;63:41–3.
for a maximum period of 6 wk. Prophylaxis is not indicated 3. Mukherjee S, Sen S, Nakate PC, Moitra S. Management of swine
for infants <3 mo of age. They should be referred to specialist flu (H1N1) outbreak and its treatment guidelines. Community
for critical evaluation in this regard [5]. Acquir Infect. 2015;48:71–8.
4. Pediatric influenza: Practice essentials, background, pathophysiol-
ogy. Available at: http://emedicine.medscape.com/article/972269
overview#a7. Accessed on 27 Feb 2016.
Infection Control Measures 5. Wrigth PF. Influenza viruses. In: Kliegman R, Stanton B, St. Geme,
Schor N, Behrman R, editors. Nelson Textbook of Pediatrics. 19th
At the level of community/individual [12]. ed. Philadelphia: Saunders Elsevier; 2011. chp: 250.
1. Hand hygiene is the most important measure to reduce the 6. Saha A, Jha N, Dubey NK, Gupta VK, Kalaivani M. Swine-origin
influenza A (H1N1) in Indian children. Ann Trop Paediatr.
risk of infection transmission from person to person.
2010;30:51–5.
Hands should be washed with non-medicated soap and 7. Recommendations for Prevention and Control of Influenza in
water/alcohol based hand rub after contact with respirato- Children, 2014–2015, Policy Statement American Academy
ry secretions or contaminated surfaces. of Pediatrics. Available at: http://pediatrics.aappublications.
2. Cough etiquette must be practiced by all the persons hav- org/content/early/2014/09/17/peds.2014-2413. Accessed 27
Feb 2016.
ing flu like symptoms.
8. Influenza virus infections in humans (February 2014) WHO.
& This includes covering nose and mouth with a clean Available at: http://www.who.int/entity/influenza/human_animal_
interface/influenza_h7n9/H7N9VirusNaming_16Apr13.pdf.
cloth/ tissue paper while coughing. Accessed 20 Feb 2016.
& Use tissue paper to clear respiratory secretions and 9. Parakh A, Kumar A, Kumar V, Dutta AK, Khare S. Pediatric hos-
dispose them in nearest available waste disposal bin. pitalizations associated with 2009 pandemic influenza A (H1N1):
& Clean hands after contact with respiratory secretions an experience from a tertiary care center in north India. Indian J
or contaminated surfaces. Pediatr. 2010;77:981–5.
10. Kumar S, Havens PL, Chusid MJ, Willoughby RE Jr, Simpson P,
& Stay at least one meter away from a person having Henrickson KJ. Clinical and epidemiologic characteristics of chil-
cough or sneeze. dren hospitalized with 2009 pandemic H1N1 influenza A infection.
Pediatr Infect Dis J. 2010;29:591–4.
3. Use of mask is not routinely advised unless there is epi- 11. Guidelines for sample collection and handling of human clinical
samples for laboratory diagnosis of H1N1 influenza. National
demic situation. As a matter of extreme precaution, family
Institute of Communicable Diseases. Available at: http://www.
contacts may be advised to use surgical three layer mask. mohfw.nic.in/WriteReadData/l892s/5718778857Guidelines%20
4. While transporting the patient to a health care facility, for%20Sample%20Collection.pdf. Accessed 7 Apr 2016.
patient and contacts both should wear three layered surgi- 12. Ministry of Health & Family Welfare, Seasonal Influenza A
cal masks. (H1N1). Guidelines on categorization of seasonal influenza A
H1N1 cases during screening for home isolation, testing, treatment
5. The waste generated from influenza cases should be con- and hospitalization (Revised on 11.02.2015). Available at:
sidered as clinical infectious waste. http://nrhmchd.gov.in/Disease_updates/H1N1_risk_guide2015.
pdf. Accessed on 2 Apr 2016.
Compliance with Ethical Standards 13. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder
KR, Karron RA. Prevention and control of influenza with
Conflict of Interest None. vaccines: recommendations of the Advisory Committee on
Immunization Practices, United States, 2015–16 Influenza
Source of Funding None. Season. MMWR. 2015;64:818–25.