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AAP: Give children IIV flu shot; use LAIV as last resort :

May 21, 2018

Editor’s note: An updated story on AAP flu vaccine recommendations is available at

The Academy recommends pediatricians give children inactivated influenza vaccine in the upcoming season and use live attenuated vaccine only as a last resort.

“Influenza is unpredictable from year to year, so we really want to immunize as many kids as we can against the flu with what we think will be the most effective product. That’s why we’re recommending the flu shot this coming season,” said Henry H. Bernstein, D.O., M.H.C.M., FAAP, Red Book Online associate editor and ex officio member of the AAP Committee on Infectious Diseases (COID).

Everyone 6 months and older should be vaccinated against influenza, which was implicated in the deaths of 168 children so far during the most recent season. Quadrivalent live attenuated influenza vaccine (LAIV4, FluMist), which is given by intranasal spray to healthy patients ages 2 through 49 years, was a popular option for those reluctant to get a shot. While it performed relatively well against influenza B strains, there was modest effectiveness against A/H3N2 strains and no overall effectiveness against A/H1N1 strains. LAIV4 has not been recommended by the AAP and CDC for the past two influenza seasons.

However, FluMist manufacturer MedImmune has changed to a new H1N1 strain (A/Slovenia) that it suggests will produce better antibody responses than the previous H1N1 strain (A/Bolivia). In February, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices reviewed MedImmune data as well as a meta-analysis on vaccine effectiveness and voted to reintroduce LAIV4 as an option for the 2018-’19 season. However, the data on whether or not it will be effective are not definitive.

“There is potential that if we happen to have an H1N1 predominant year and the vaccine turns out to not perform as maybe some are anticipating … then we would potentially be putting some children at risk of getting H1N1 disease and not being protected at all,” said COID member Flor M. Munoz, M.D., FAAP.

Because of these unknowns, the Academy recommends children receive inactivated influenza vaccine (IIV), administered intramuscularly. While IIV effectiveness varies each season, Dr. Munoz said it consistently has been better than LAIV in recent years. If a family refuses the IIV for their child, he or she may be offered LAIV.

“If some people decline the flu shot for their child, it’s better they accept the intranasal product and hopefully get some rather than no protection at all,” Dr. Bernstein said.

Dr. Munoz encouraged pediatricians to stay up to date on how vaccines are performing in the upcoming influenza season. They should discuss the recommendation for IIV and potential risks of LAIV4 with families.

More information will be available in the July issue of AAP News and in the AAP influenza policy released in early September.

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