Recommendations for Prevention and Control of Influenza in Children, 2022–2023

Children consistently have the highest attack rates of influenza in the community during seasonal influenza epidemics. Children, especially those younger than 5 years and those with certain underlying medical conditions, can experience substantial morbidity, including severe or fatal complications, from influenza virus infection.¹  School-aged children bear a large influenza disease burden and are more likely to seek influenza-related medical care compared with healthy adults.^1,2  Children also play a pivotal role in the transmission of influenza virus infection to household and other close contacts.^1,2  Thus, reducing influenza virus transmission among children decreases the burden of childhood influenza and transmission of influenza virus to household contacts and community members of all ages.^1,2  Influenza vaccination is particularly important to reduce the burden of respiratory illnesses and preserve the capacity of the health care infrastructure when other viruses, including severe acute respiratory syndrome-coronavirus, are cocirculating. The American Academy of Pediatrics (AAP) recommends routine influenza vaccination and antiviral agents for the prevention and treatment of influenza in children, respectively. Unfortunately, influenza vaccination coverage lagged during the 2021–2022 season. Through April 9, 2022, only 53.3% of children 6 months through 17 years had been vaccinated, and coverage levels were 8.1 percentage points lower for non-Hispanic Black children compared with non-Hispanic white children.³  Efforts to increase influenza vaccination, including strategies to decrease health disparities, address influenza vaccine hesitancy, and increase influenza vaccine coverage, are urgently needed.

This policy statement summarizes updates and recommendations for the 2022–2023 influenza season. An accompanying technical report provides further detail regarding recent influenza seasons, influenza vaccine effectiveness, detailed discussion of inactivated and live attenuated influenza vaccines, influenza vaccination coverage, timing of vaccination, duration of protection, and vaccine delivery strategies.⁴ 

1. The composition of the influenza vaccines for the 2022–2023 season has been updated (Table 1). The recommended influenza A (H3N2) and influenza B Victoria lineage components of the vaccine are new for this season. The influenza A (H1N1) pmd09 and influenza B Yamagata lineage components are unchanged from the previous season.^5,6 

2. The vaccine formulations available for children are unchanged from last season (Table 2), except the age indication for the cell culture-based inactivated influenza vaccine (IIV) Flucelvax Quadrivalent has been lowered to 6 months and older (previously indicated for 2 years and older), providing one more option for young children.⁷ 

3. Evidence-based strategies for increasing influenza vaccine uptake are highlighted (Table 3).

4. The age indication for the neuraminidase inhibitor peramivir has been lowered to 6 months of age.

5. The age indication for the cap-endonuclease inhibitor baloxavir has been lowered to 5 years for the treatment of acute uncomplicated influenza in otherwise healthy children who have been symptomatic for no more than 48 hours and for chemoprophylaxis of influenza following contact with someone with influenza.⁸ 

Children younger than 5 years, especially those younger than 2 years, and children with certain underlying medical conditions are at increased risk of hospitalization and complications attributable to influenza (Table 4).⁴  Although universal influenza vaccination is recommended for everyone starting at 6 months, emphasis should be placed on ensuring that high-risk and medically vulnerable children and their household contacts and caregivers receive annual influenza vaccine (Table 3). Additionally, increased efforts are needed to eliminate barriers to immunization in all persons experiencing higher rates of adverse outcomes from influenza. In one cross-sectional study spanning 10 influenza seasons, Black, Hispanic, and American Indian/Alaska Native people had higher rates of influenza-associated hospitalizations and ICU admissions, and disparities were highest in children ≤4 years of age.⁹  Influenza-associated, in-hospital deaths were 3- to 4-fold higher in Black, Hispanic, and Asian/Pacific Islander children compared with white children.⁹  This higher fatality rate may be attributable to already existing causes for disparities such as inequities in health care system access or other social determinants of health.

The seasonal influenza vaccines licensed for children and adults for the 2022–2023 season are shown in Table 2. More than one product may be appropriate for a given patient, and there is no preference for one product over another. Thus, influenza vaccination should not be delayed to obtain a specific product.

All 2022–2023 seasonal influenza vaccines are quadrivalent and contain the same influenza strains as recommended by the World Health Organization and the US Food and Drug Administration Vaccines and Related Biological Products Advisory Committee for the Northern Hemisphere (Table 1).^5,6  The influenza A (H3N2) and influenza B Victoria lineage vaccine components for the 2022–2023 season are different from those in the previous season, whereas the influenza A (H1N1) and influenza B Yamagata lineage components are unchanged. Different, but antigenically-related, influenza A strains are included in this season’s egg-based and cell-based or recombinant vaccines. They are matched to the strains expected to circulate in the 2022–2023 season.

1. The AAP recommends influenza vaccination of everyone 6 months and older, including children and adolescents, during the 2022–2023 influenza season.

2. The AAP recommends any licensed influenza vaccine product appropriate for age and health status and does not prefer one product over another, including IIV or live attenuated influenza vaccine (LAIV). Providers may administer whichever product is appropriate and readily available to capture all opportunities for influenza vaccination and achieve the highest possible coverage this season. An IIV or recombinant influenza vaccine (RIV) (if age-eligible) is the appropriate choice for some persons, including those who are immunocompromised.

3. The number of influenza vaccine doses recommended for children remains unchanged in the 2022–2023 influenza season and depends on the child’s age at first dose administration and influenza vaccination history (Fig 1). Children 6 months through 8 years of age who are receiving influenza vaccine for the first time or who received only 1 dose before July 1, 2022, or whose vaccination status is unknown should receive 2 doses of influenza vaccine at least 4 weeks apart. Doses given up to 4 days before the minimum suggested interval should be regarded as acceptable. All other children should receive 1 dose this season.

4. The total number of full doses appropriate for age should be administered. If a child is inadvertently vaccinated with a formulation only approved for older children or adults, the dose should be counted as valid. If a lower dose than recommended is inadvertently administered to a child 36 months or older (eg, 0.25 mL), an additional 0.25-mL dose should be administered to provide a full dose of 0.5 mL as soon as possible. A 0.5 mL dose of any IIV should not be split into 2 separate 0.25-mL doses.

5. When a child requires 2 doses of vaccine in a given season, the doses do not need to be the same brand. A child may receive a combination of IIV and LAIV if appropriate for age and health status.

6. Influenza vaccine should be offered as soon as it becomes available, especially to children who require 2 doses, with the recommended dose(s) ideally received by the end of October. This differs from the Advisory Committee on Immunization Practices recommendation that most adults, particularly those ≥65 years, not be immunized in July and August because of a concern about waning immunity. Influenza vaccination efforts should continue throughout the season.

7. IIV (or RIV if age-appropriate) may be administered simultaneously with or at any time before or after other inactivated or live vaccines. LAIV may be administered simultaneously with other live or inactivated vaccines. If not administered simultaneously, ≥4 weeks should pass between the administration of LAIV and other nonoral live vaccines. A 4-day grace period is permitted.

8. Current guidance indicates that influenza vaccine can be administered simultaneously with or at any time before or after coronavirus disease 2019 vaccine administration. Providers should review the latest information regarding coadministration from the AAP, as well as the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (https://www.cdc.gov/vaccines/covid-19/clinical- considerations/interim- considerations-us.html# recommendations).

9. Pregnant individuals may receive IIV (or RIV if age-appropriate) at any time during pregnancy to protect themselves and their infants. Those who do not receive it during pregnancy should receive influenza vaccine before hospital discharge. Influenza vaccination during breastfeeding is safe for mothers and their infants.

10. Efforts should be made to promote influenza vaccination of all children, especially those in high-risk groups (Table 4) and their contacts, unless contraindicated (Table 5). To promote influenza vaccination in communities affected by health disparities, it is important to include the community members in the development of culturally relevant strategies. Evidence-based strategies for increasing influenza vaccine uptake are presented in Table 3.

11. Increasing access and reducing barriers to immunizations in schools, pharmacies, and other nontraditional settings could improve immunization rates, although immunization in the medical home is optimal for the youngest children. A visit for influenza vaccine is an opportunity to give necessary well care, preventive screening, anticipatory guidance, and other important childhood vaccinations. When immunization takes place in a nontraditional setting, communication with the medical home or recording in an immunization strategy is strongly encouraged.

12. The AAP supports mandatory influenza vaccination of health care personnel as a crucial element in preventing influenza and reducing health care-associated influenza virus infections.

Contraindications and precautions for the use of influenza vaccines are described in Table 5, and further details are provided in the technical report.⁴  Key points include:

1. Product-specific contraindications must be considered when selecting the type of influenza vaccine to administer.¹⁰ 

2. Although a history of severe allergic reaction (eg, anaphylaxis) to any influenza vaccine is generally a contraindication to future receipt of influenza vaccines, children who have had a severe allergic reaction after influenza vaccination should be evaluated by an allergist to help identify the vaccine component responsible for the reaction and to determine whether future vaccine receipt is appropriate. Children who are allergic to gelatin (very rare) should receive IIV (or RIV if age-appropriate) instead of LAIV.

3. Children with egg allergy can receive any influenza vaccine without any additional precautions beyond those recommended for all vaccines.

4. Children with acute moderate or severe illness, including coronavirus disease 2019, may receive influenza vaccine as soon as their acute illness has improved; children with mild illness, including a low-grade fever, can still be vaccinated.

Antiviral medications available for the treatment and prophylaxis of influenza in children are described in Table 6. Key points include:

1. Antiviral medications are important adjunct in the control of influenza but are not a substitute for influenza vaccination. Providers should promptly identify patients suspected of having influenza for timely initiation of antiviral treatment, when indicated and based on shared decision-making between the provider and child’s caregiver, to reduce morbidity and mortality. Potential benefits and harms of antiviral treatment are summarized in the technical report (http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-059275; see section "Rationale for Influenza Treatment in Children").

2. Although best results are observed when the child is treated within 48 hours of symptom onset, antiviral therapy should still be considered beyond 48 hours in certain cases (see below).

3. Antiviral treatment should be offered as early as possible to the following individuals, regardless of influenza vaccination status and duration of symptoms:

   • Any child hospitalized with suspected or confirmed influenza disease;

   • Any child with severe, complicated, or progressive influenza disease, regardless of health care setting (ie, inpatient or outpatient); and

   • Any child with suspected or confirmed influenza disease of any severity if they are at high risk for influenza complications, regardless of health care setting (ie, inpatient or outpatient) (Table 4).

4. Treatment may be considered for the following individuals in the outpatient setting:

   • Any child with suspected or confirmed influenza disease who is not at high risk for influenza complications, if treatment can be initiated within 48 hours of illness onset; and

   • Any child with suspected or confirmed influenza disease whose siblings or household contacts are either younger than 6 months or at high risk for influenza complications (Table 4).

Antiviral chemoprophylaxis is recommended after known or suspected influenza exposure in the following situations:

• Any child at high risk for influenza complications for whom influenza vaccine is contraindicated or has not yet been administered this season;

• Any child at high risk for influenza complications who received influenza vaccine in the past 2 weeks (ie, optimal immunity may not yet be achieved);

• Any child at high risk for influenza complications who has been vaccinated but may not have mounted a sufficient immune response (ie, because of immunosuppression);

• Any child at high risk for influenza complications, as well as family members and close contacts, including health care personnel, when influenza virus strains circulating in the community are not well matched with those of the seasonal influenza vaccine per the Centers for Disease Control and Prevention (https://www.cdc.gov/flu/vaccines-work/effectiveness-studies.htm);

• Family members and close contacts who are unvaccinated and are likely to have ongoing, close exposure to:

  • o unvaccinated children at high risk for influenza complications; or

  • o unvaccinated infants and toddlers who are younger than 24 months;

• Family members and close contacts who are at high risk for influenza complications; and

• Unvaccinated staff and children in a closed institutional setting with children at high risk for influenza complications (eg, extended-care facilities), to control influenza outbreaks.

Sean T. O’Leary, MD, MPH, FAAP, chairperson

James D. Campbell, MD, MS, FAAP, vice chairperson

Monica I. Ardura, DO, MSCS, FAAP

Ritu Banerjee, MD, PhD, FAAP

Kristina A. Bryant, MD, FAAP

Mary T. Caserta, MD, FAAP

Chandy C. John, MD, MS, FAAP

Jeffrey S. Gerber, MD, PhD, FAAP

Athena P. Kourtis, MD, PhD, MPH, FAAP

Angela Myers, MD, MPH, FAAP

Pia Pannaraj, MD, MPH, FAAP

Adam J. Ratner, MD, MPH, FAAP

José R. Romero, MD, FAAP

Samir S. Shah, MD, MSCE, FAAP

Kenneth M. Zangwill, MD, FAAP

Yvonne A. Maldonado, MD, FAAP

Annika M. Hofstetter, MD, PhD, MPH, FAAP

Juan D. Chaparro, MD, MS, FAAP

Jeremy J. Michel, MD, MHS, FAAP

David W. Kimberlin, MD, FAAP, Red Book editor

Elizabeth D. Barnett MD, FAAP, Red Book associate editor

Ruth Lynfield, MD, FAAP, Red Book associate editor

Mark H. Sawyer, MD, FAAP, Red Book associate editor

Henry H. Bernstein, DO, MHCM, FAAP, Red Book online associate editor

Karen M. Farizo, MD, US Food and Drug Administration

Lisa M. Kafer, MD, FAAP, Committee on Practice Ambulatory Medicine

David Kim, MD, HHS Office of Infectious Disease and HIV/AIDS Policy

Eduardo López Medina, MD, MSc, Sociedad Latinoamericana de Infectologia Pediatrica

Denee Moore, MD, FAAFP, American Academy of Family Physicians

Lakshmi Panagiotakopoulos, MD, MPH, Centers for Disease Control and Prevention

Laura Sauvé, MD, MPH, FAAP, FRCPS, Canadian Pediatric Society

Jeffrey R. Starke, MD, FAAP, American Thoracic Society

Jennifer Thompson, MD, American College of Obstetricians and Gynecologists

Kay M. Tomashek, MD, MPH, DTM, National Institutes of Health

Melinda Wharton, MD, MPH, Centers for Disease Control and Prevention

Charles R. Woods, Jr., MD, MS, FAAP, Pediatric Infectious Diseases Society

Jennifer M. Frantz, MPH

The Committee on Infectious Diseases gratefully acknowledges Kristina A. Bryant, MD, FAAP, and Annika M. Hofstetter, MD, PhD, MPH, FAAP, for their leadership in drafting the policy statement and technical report; and Juan D. Chaparro, MD, MS, FAAP, and Jeremy J. Michel, MD, MHS, FAAP, for their significant contributions in providing input on the initial drafts on behalf of the AAP Partnership for Policy Initiative.

AAP

American Academy of Pediatrics

IIV

inactivated influenza vaccine

LAIV

live attenuated influenza vaccine

RIV

recombinant influenza vaccine