Treatment of Viral Illnesses in Children
Most viral illnesses in children are self-limited and require only supportive care, but influenza is a critical exception where early antiviral treatment with oseltamivir significantly reduces morbidity and mortality in high-risk children and those with severe disease. 1, 2
Influenza-Specific Treatment
When to Treat with Antivirals
Oseltamivir treatment should be started immediately (without waiting for test results) for: 1, 2
- Any child hospitalized with suspected influenza 1, 2
- Children with severe, complicated, or progressive illness 1, 2
- All children under 2 years of age (high-risk group) 2
- Children with chronic medical conditions (asthma, diabetes, immunosuppression, neurologic disorders, cardiac/pulmonary disease) 3
- Children whose siblings are under 6 months or have high-risk conditions 2
Treatment may be considered for: 1, 2
- Any otherwise healthy child when symptom reduction is desired, especially if within 48 hours of onset 1, 2
Timing is Critical
- Initiate treatment within 48 hours of symptom onset for maximum benefit (reduces illness duration by 36 hours and otitis media risk by 34%) 1, 4
- Treatment after 48 hours still provides benefit in children with moderate-to-severe or progressive disease 3, 2
- Do not delay treatment while awaiting confirmatory testing 1, 2
Oseltamivir Dosing (5-day course)
For infants 0-8 months: 3 mg/kg per dose twice daily 1, 4
For infants 9-11 months: 3.5 mg/kg per dose twice daily 1, 4
For children ≥12 months (weight-based): 1, 4
- ≤15 kg: 30 mg twice daily
15-23 kg: 45 mg twice daily
23-40 kg: 60 mg twice daily
40 kg: 75 mg twice daily
Important Caveats
- Rapid antigen tests have low sensitivity and should not be used to rule out influenza - negative results should not delay treatment 3, 1
- Vomiting occurs in approximately 5-15% of treated children (vs 9% placebo) but is generally manageable 1, 2
- Oseltamivir is FDA-approved from 2 weeks of age and supported by AAP from birth 2, 4
- Diarrhea may occur in infants under 1 year 1
General Supportive Care for Viral Illnesses
Respiratory Support
For children with respiratory symptoms requiring hospitalization: 3
- Perform pulse oximetry on all children assessed for admission 3
- Administer oxygen via nasal cannulae, head box, or face mask if oxygen saturation ≤92% to maintain saturation >92% 3
- High-flow oxygen or non-invasive ventilation for acute hypoxemic respiratory failure 5
Hydration and Nutrition
- Provide supplementary fluids enterally when possible 3
- Intravenous fluids at 80% basal levels for severe pneumonia 3
- Continue breastfeeding in infants with viral infections 5
Discharge Criteria
Children can be safely discharged when: 3
- Clearly improving clinically
- Physiologically stable
- Tolerating oral feeds
- Respiratory rate <40/min (<50/min in infants)
- Awake oxygen saturation >92% in room air
Bacterial Superinfection Considerations
When to Add Antibiotics
During influenza pandemics or severe influenza illness, add antibiotics for: 3
- Children at risk of complications or requiring hospitalization 3
- Coverage needed for S. pneumoniae, Staph. aureus, and H. influenzae 3
Antibiotic choice: 3
- Under 12 years: Co-amoxiclav (first-line) 3
- Penicillin allergy: Clarithromycin or cefuroxime 3
- Over 12 years: Doxycycline as alternative 3
- Severe pneumonia: Add second agent (clarithromycin or cefuroxime) and give IV 3
Important Pitfall
- Concurrent serious bacterial infections are rare in RSV and most viral illnesses - avoid routine antibiotic use 6
- Blood cultures should be obtained before starting antibiotics in children with influenza-related pneumonia 3
Respiratory Syncytial Virus (RSV)
Treatment is entirely supportive - no antivirals indicated 6
- Maintain hydration and oxygenation 6
- Bronchodilator trial appropriate for wheezing, but discontinue if no prompt response 6
- Neither antibiotics nor corticosteroids are helpful 6
- Hospitalize children <60 days or with severe symptoms 6
Other Common Viral Illnesses
Most childhood viral infections (rhinovirus, adenovirus, enterovirus) are self-limited: 7
- Symptomatic treatment with antipyretics for fever 3, 5
- Adequate hydration 3
- Observation for complications 7
Prevention Strategies
- Influenza vaccination remains the primary prevention strategy - not a substitute for treatment 3
- Frequent handwashing and contact isolation prevent RSV spread 6
- Palivizumab prophylaxis for high-risk infants <2 years during RSV season (premature <35 weeks, chronic lung/cardiac disease) 6
Red Flags Requiring Immediate Attention
Seek emergency care for: 1
- Difficulty breathing, fast breathing, or chest retractions
- Fever persisting beyond 3-4 days or returning after improvement
- Seizures, altered mental status, or extreme irritability
- Inability to maintain hydration