Updated AAP flu policy offers more options this year
Flor M.Munoz, M.D., M.Sc., FAAP
AAP prevention and treatment recommendations for the 2019-’20 influenza season include
seven main updates and continue to urge annual vaccination for everyone 6 months and
The policy statement Recommendations for Prevention and Control of Influenza in Children, 2019-2020, from the Committee on Infectious Diseases, is available at https://doi.org/10.1542/peds.2019-2478 and will be published in the October issue of Pediatrics. Following are highlights of the updates:
Both inactivated influenza vaccine (IIV) and live attenuated influenza vaccine (LAIV)
are options for children. Those 6 months and older can receive any licensed available
vaccine that is appropriate for their age and health status, with no preference.
The A(H1N1)pdm09 and A(H3N2) components of the 2019-’20 influenza vaccines are new
this season, while the B strains are unchanged from last season.
All pediatric influenza vaccines available this season are quadrivalent vaccines.
The age indication for some of them has been expanded. There are four egg-based quadrivalent
IIVs licensed by the Food and Drug Administration (FDA) for children 6 months and
older; one cell-based quadrivalent IIV for children 4 years and older; and one quadrivalent
LAIV for children 2 years and older who are otherwise healthy.
The FDA has approved new formulations of licensed inactivated flu vaccines with a
volume of 0.5 mL per dose for children 6 through 36 months of age. Children 6 through
35 monthsof age may receive either the 0.25 mL or 0.5 mL dose of IIV, and children 36 months
of age and older continue to receive a 0.5 mL dose. (Both formulations for children
6 through 35 months are licensed for the age indication described. Neither the AAP
nor the CDC have a preference, as there are no studies showing superiority of one
formulation over the other. Any available vaccine licensed for that age group can
Children 6 months through 8 years of age who are receiving flu vaccine for the first
time — or who received only one dose before July 1, 2019 — should receive two doses
of influenza vaccine.
Influenza vaccines should be offered as soon as they are available. Children needing
one or two doses of vaccine ideally should be vaccinated by the end of October.
A new antiviral medication has been licensed for treatment of influenza in children
(see policy). Treatment and prophylaxis recommendations are unchanged
Q: Why no preference for this year’s influenza vaccine for children?
A: The AAP recommends use of any licensed influenza vaccine appropriate for age and health status in children, including
IIV and LAIV as appropriate. This guidance is based on review of available data on
vaccine effectiveness (VE) of LAIV and IIV. The AAP will continue to review VE data
as they become available and update recommendations if necessary.
The AAP does not prefer any influenza vaccine product for children who have no contraindication
to influenza vaccination and for whom more than one licensed product appropriate for
age and health status is available. Pediatricians should administer whichever formulation
is available in their communities to achieve the highest possible vaccination coverage
(for supply constraints, see resources).
Q: Are there special recommendations for children in high-risk groups, including those
with egg allergy?
A: Efforts should be made to ensure children in high-risk groups (see Table 1 in the
policy) and their contacts are vaccinated, unless medically contraindicated. Providers
should consider product-specific contraindications when selecting the type of vaccine
An allergist should evaluate children who had a severe allergic reaction (e.g., anaphylaxis)
after a previous dose of any influenza vaccine to determine whether it is appropriate
to receive the vaccine in the future. Children with egg allergy can receive influenza
vaccine without additional precautions beyond those recommended for all vaccines.
Q: When can pregnant women receive an influenza vaccination?
A: Pregnant women may receive IIV at any time during pregnancy to protect themselves
and their infants, who benefit from the transplacental transfer of antibodies. Postpartum
women not vaccinated during pregnancy are encouraged to receive influenza vaccine
before hospital discharge. Influenza vaccination during breastfeeding is safe for
mothers and their infants.
Q: Are there additional recommendations for medical staff?
A: The AAP supports mandatory vaccination of health care personnel.
Q: Which patients should receive antivirals and when?
A: Pediatricians should promptly identify patients suspected of having influenza infection
for timely initiation of antiviral treatment when indicated. Although best results
are observed within 48 hours of symptom onset, antiviral therapy should be considered
beyond that time frame in children with severe or progressive disease or a high risk
of complications, and in all patients hospitalized for influenza.
Offer antiviral treatment as early as possible to the following individuals, regardless of influenza vaccination status:
Any hospitalized child with suspected or confirmed influenza disease, regardless of
Any child (inpatient or outpatient) with severe, complicated or progressive illness
attributable to influenza, regardless of symptom duration.
Influenza infection of any severity in children at high risk of complications of influenza,
regardless of symptom duration (see Table 1 in the policy).
Consider offeringantiviral treatment to these individuals:
Any previously healthy, symptomatic outpatient not at high risk for flu complications
with confirmed or suspected influenza — on the basis of clinical judgment — if treatment
can be initiated within 48 hours of illness onset.
Children with suspected or confirmed influenza disease whose siblings or household
contacts are younger than 6 months or belong to a high-risk group that predisposes
them to complications of influenza.
See the policy for recommendations on antiviral chemoprophylaxis.
Q: What did we learn from the 2018-’19 influenza season?
A: It was moderately severe and the longest-lasting U.S. influenza season in the past
decade, at 21 consecutive weeks. Influenza A (H1N1) viruses predominated from October
to mid-February and drifted strains of influenza A (H3N2) viruses from February to
There were 116 laboratory-confirmed pediatric deaths (median age 6 years). Among the
104 children with known medical history, nearly half of the deaths occurred in previously
healthy patients. Most had not been vaccinated against influenza.
Dr. Munoz, a lead author of the policy statement, is a member of the AAP Committee
on Infectious Diseases.