9/15/2015 CDC H1N1 Flu| Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children

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Interim Guidance for Clinicians on the Prevention and Treatment of
Swine-Origin Influenza Virus Infection in Young Children

April 28, 2009 7:00 PM ET.

This document provides interim guidance for clinicians who are caring for young children with confirmed or suspected swine-origin influenza A (HIN1) virus infection,

Background

Young children and swine-origin influenza virus (S-OIV)
Little is currently known about how this new S-OIV circulating in people may affect children, However, we know from seasonal influenza and past pandemics that
young children, especially those younger than 5 years of age and children who have high risk medical conditions, are at increased risk of influenza-related complications

Illness

caused by influenza virus infection are difficult to distinguish from illnesses caused by other respiratory pathogens based on symptoms alone. Young children
are less likely to have typical influenza symptoms (e.g., fever and cough) and infants may present to medical care with fever and lethargy, and may not have cough or
other respiratory symptoms or signs.

Influenza-associated deaths among children, while uncommon, do occur with seasonal influenza with an estimated average of approximately 92 influenza-related
pediatric deaths each year in the United States, Some deaths in children have been associated with co-infection with influenza and Staphylococcus aureus, particularly
methicillin resistant S. aureus (MRSA).

Symptoms of severe disease may include:

« Apnea

* Tachypnea

© Dyspnea

© Cyanosis

© Dehydration

« Altered mental status
© Extreme irritability

Treatment and prevention of swine flu

No vaccine is currently available to prevent S-OIV infection and it is thought unlikely that seasonal influenza vaccine will provide protection against this new virus.
While not a substitute for a vaccine, a number of other interventions may be used to decrease the risk of infection and possible complications from S-OIV infeetion in
children.

Influenza antiviral medications for use in children age 1 year and
older

Antiviral treatment with oseltamivir or zanamivir is recommended for children with confirmed or probable S-OIV infection. See

www cde gov/h1n1flu/casedef_swineflu htm (/sweb/20090504072 153/http:/Avww_cde_gov/hInIflu/casedef_swinefluhtm) for case definitions. Empiric antiviral treatment is also
recommended for children with suspected cases of swine influenza A (H1N1) virus infection, especially those with severe illness. Antiviral treatment with zanamivir or
oseltamivir should be initiated as soon as possible after the onset of symptoms. Evidence for benefits from treatment in studies of seasonal influenza is strongest when
treatment is started within 48 hours of illness onset, However, some studies of treatment of seasonal influenza have indicated benefit, including reductions in mortality or
duration of hospitalization even for patients whose treatment was started more than 48 hours afier illness onset. Recommended duration of treatment is five days.
Recommendations for use of antivirals may change as data on antiviral effectiveness, side effects and antiviral susceptibilities become available. Antiviral doses
recommended for treatment of S-OIV infection in children | year of age or older are the same as those recommended for seasonal influenza (Table 1).

Table 1. Recommended doses of zanamivir and oseltamivir antiviral medications for the treatment and prevention of influenza in children 1-18 years-old

Age group (yrs)
1-6 19 10-12 13-18

Antiviral agent

NAT 10 mg (2 inhalations) 10 mg (2 inhalations) 10 mg (2 inhalations)

Treatment, influenza A and B
twice daily twice daily twice daily

Zanamivir*

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9/15/2015 CDC H1N1 Flu| Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children

Chemoprophylaxis, influenza Ages 1-4 Ages 5-9 10 mg (2 inhalations) once 10 mg (2 inhalations) once
AandB N/A 10 mg (2 inhalations) once gaily daily
daily
Treatmentt, influenza A and B DOS Vaties by child's Dose varies by child's Dose varies by child's 75 549 ive daily
weight weight weights
Oseltamivir
Chemoprophylaxis, influenza Dose varies by child's Dose varies by child's Dose varies by child's 75 spi
AandB weights] weight] weight] ¥
Duration of Treatment Recommended duration for antiviral treatment is 5 days.
‘Treatment Chemoprophylaxis Recommended duration is 10 days after the last known exposure.

Children Younger than 1 Year of Age

Children less than one year of age are at higher risk for complications associated with seasonal human influenza virus infections compared to older children, and the risk
of influenza complications is especially high for children less than 6 months of age. The characteristics of human infections with $-OTV are still being studied, and it is
not known whether infants are at higher risk for complications associated with $-OTV infection compared to older children. However, children less than 1 year old are
known to be at increased risk of complications from seasonal influenza infection and during previous pandemics. Limited safety data on the use of oseltamivir (or
zanamivir) is available from children less than one year of age, and oseltamivir is not licensed for use in children less than | year old. Available data comes from use of
oseltamivir for treatment of seasonal influenza. However, these data suggest that severe adverse events are rare, and the Infectious Diseases Society of America recently
noted that *.,. limited retrospective data on the safety and efficacy of oseltamivir in this young age group have not demonstrated age-specific drug-attributable toxicities to
date.”

Because infants typically have higher rates of morbidity and mortality from influenza compared to healthy older children, infants with $-OTV infections may benefit from
treatment using oseltamivir. Oseltamivir use for children less than | year old was recently approved by the FDA under an Emergeney Use Authorization (EUA), and

dosing for these children is age-based. (Table 2)

Table 2. Recommended doses of oseltamivir antiviral medication for the treatment of S-OIV influenza for children less than I year of age.

Age Recommended treatment dose for 5 days
<3 months 12 mg twice daily
3-5 months 20mg twice daily
6-11 months 25 mg twice daily

Use of fever-reducing medications in children

Aspirin or aspirin-containing products (e.g. bismuth subsalicylate — Pepto Bismol) should ot be administered to any confirmed or suspected ill case of swine influenza
A (HIN1) virus infection aged 18 years old and younger due to the risk of Reye syndrome, For relief of fever, other anti-pyretic medications are recommended such as
acetaminophen or non steroidal anti-inflammatory drugs

Antiviral Chemoprophylaxis

For antiviral chemoprophylaxis of S-OLV infection, either oseltamivir or zanamivir are recommended for children 1 year of age or older (Table 1). Oseltamivir can be
used for chemoprophylaxis under the EUA for children less than 1 year-old (Table 3). Under this EUA, chemoprophylaxis is not recommended for infants less than 3
months old unless the situation is judged to be critical. Duration of antiviral chemoprophylaxis postexposure is 10 days after the last known exposure to an ill confirmed
case of swine influenza A (HIN1) virus infection. For pre-exposure protection, chemoprophylaxis should be given during the potential exposure period and continued
for 10 days after the last known exposure to an ill confirmed case of swine influenza A (HIN1) virus infection.

Table 3. Recommended doses of oseltamivir antiviral medication for the prevention of swine influenza for children less than I year of age.

TABLE 3 HERE

Age Recommended prophylaxis dose for 10 days
<3 months Not recommended unless situation judged critical

3-5 months 20mg once daily

6-11 months 25 mg onee daily

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9/15/2015 CDC H1N1 Flu| Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children

Antiviral chemoprophylaxis with either oseltamivir or zanamivir is recommended for the following children:

years-old and

Household close contacts who are at high-risk for complications of influenza (children younger than 5 years old , pregnant women, persons >
those with certain chronic medical conditions) of a confirmed or suspected case

School children or daycare attendees who are at high-risk for complications of influenza (children younger than 5 years old, pregnant women, persons >65
years-old and those with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed, probable, or suspected case

Children who traveled to Mexico who are at high-risk for complications of influenza (children younger than 5 years old pregnant women, persons >65 years-old
and those with certain chronic medical conditions),

Rv

Other measures to prevent swine influenza in children

* Inaddition to antiviral medications, other information on measures that can help prevent the spread of influenza can be found at www.cde gov/swineflu
Céweb/20090504072153/http://www cde gov/swineflu) under the following headings:

« Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been
Detected (/web/20090504072153/http://www.cde,gov/hInIflumasks htm)

« Interim Guidance for Swine influenza A (HIN 1): Taking Care of a Sick Person in Your Home
Cweb/20090504072153/http://www.cde.gow/hInIflu/guidance_homecare htm)

« Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (HIN1) Virus Infection and Close Contacts

C/web/20090504072153/http://www_ cde gow/hIn! fluw/recommendations. htm)

Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (HIN1) Virus Infection in a Healthcare Settin;

Céweb/20090504072153/http://www cde gov/hIn1flu/guidelines infection control htm) Apr 24, 2009

Interim CDC Guidance for Nonpharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (HIN1) Virus
(/web/20090504072 153/http,//www.cde,gov/hInIflu/mitigation htm) Apr 26, 2009, 11:45 PM ET

«Links to non-federal organizations are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their
programs by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages
found at these links.

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Page last reviewed April 28, 2009 11:00 PM ET
Page last updated April 28, 2009 11:00 PM ET.
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