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Complications from influenzalike illnesses occur in one-third of children

Publish date: August 4, 2014
By
Tara Haelle

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Clinical judgment is still essential in treating influenzalike illness

In an attempt to identify those at risk for serious complications of influenza, investigators analyzed outcomes for 241 children who presented to the emergency department, met the CDC definition of influenzalike illness (ILI) – fever and sore throat or cough – and had moderate to severe illness based on a medical decision to obtain a venipuncture and multiplex polymerase chain reaction (PCR) respiratory viral testing at the time of the visit. While influenza was confirmed in 25% (80% with influenza A), many other viral respiratory pathogens also were identified, confirming that ILI is not specific for influenza in children. More than one virus was detected in 12%. A chronic medical condition was noted in about one-half, most commonly neurologic and neuromuscular diseases or asthma, and complications including pneumonia and respiratory failure occurred in 30% of those with influenza and 35% with non-influenza viral infection.

Consistent with American Academy of Pediatrics and the Centers for Disease Control and Prevention guidelines, the authors recommend empiric oseltamivir for a child with influenzalike illness who has a condition that places them at risk for influenza complications, particularly if the suspected agent is the pandemic H1N1 virus. However, the data highlight the difficulty in identifying all children who may benefit from oseltamivir therapy, especially given that the majority of children with ILI don’t have influenza, oseltamivir therapy is best initiated within 48 hours of onset of symptoms, the most readily available test (rapid influenza testing) generally lacks sensitivity to identify those with influenza, and PCR testing is expensive and not available in many hospital emergency rooms.

Approximately half of the study patients had a history of influenza vaccine, and it is unclear whether this represented one or two doses in the younger patients. The results underscore the importance of influenza vaccine, and this year the AAP has issued a preference for the nasal live attenuated vaccine for any child aged 2-8 years who doesn’t have an underlying contraindication – emphasizing that vaccination should not be delayed in order to obtain a specific product for either dose.

Dr. Mary Anne Jackson is director of the division of infectious diseases and associate chair of community and regional pediatric collaboration at Children’s Mercy Hospital & Clinics, and professor of pediatrics at University of Missouri–Kansas City. She has no disclosures.


 

FROM PEDIATRICS

References

One in three (35.3%) children developed complications with influenzalike illnesses, and children with neurologic or neuromuscular conditions were at highest risk for complications, according to a recent study.

The most commonly developed complication was pneumonia (26.1% of the participants), but the overall rate of complications did not vary among those who had influenza, compared with those with a different virus, Dr. Rakesh D. Mistry of the University of Colorado in Aurora, and his colleagues reported online (Pediatrics 2014 Aug. 4 [doi:10.1542/peds.2014-0505]). The next most common complications were respiratory failure (7.1%) and seizures (5.8%).

The researchers prospectively assessed 241 children aged 0-19 years who presented to a children’s hospital emergency department with influenzalike illness – fever plus a cough or sore throat without another cause – from early winter 2008 to late spring 2010. The study included only children with moderate to severe symptoms (defined by physicians’ decision to do venipuncture and respiratory viral testing) who did not already have severe complications. Severe complications included seizures, encephalopathy, pneumonia, bacteremia, bacterial tracheitis, respiratory failure, myocarditis, or death.

Overall, 24.9% of the children had influenza, 28.2% had no virus detected, 14.5% had rhinovirus, 11.6% had respiratory syncytial virus, and the remainder had human metapneumovirus, adenovirus or parainfluenza viruses. Among children with influenza, the risk of developing pneumonia was 7.6 times higher with the H1N1 strain than with other strains.

Asthma was the most common chronic medical condition among the 53.5% of children who had one. Although children with neurologic or neuromuscular conditions were four times more likely to develop complications, no other high-risk conditions were linked to complications, and 41.2% of children developing complications had no underlying conditions.

The authors wrote that their findings regarding children with underlying conditions "support the need for increased preventive measures in this subgroup of children, including influenza vaccination and early institution of antiviral treatment."

The study was supported in part by the Commonwealth of Pennsylvania Department of Health. The authors reported no disclosures.

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