What is the treatment for a child with influenza (flu)?

Treatment of Influenza in Children

Oral oseltamivir is the antiviral drug of choice for children with influenza, and should be initiated within 48 hours of symptom onset in children with fever >38.5°C, combined with supportive care including antipyretics for comfort and antibiotics only if bacterial complications develop. 1

Antiviral Therapy

When to Start Oseltamivir:

• Initiate treatment if the child has all three criteria: acute influenza-like illness, fever >38.5°C, and symptoms for ≤2 days 1
• The greatest benefit occurs when started within 24 hours of symptom onset 2
• In severely ill hospitalized children, oseltamivir may be used up to 6 days after symptom onset, though evidence for benefit is limited in this timeframe 1

Dosing by Age and Weight: 1

• Children ≥12 months: Weight-based dosing twice daily for 5 days
  • ≤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

• Infants 9-11 months: 3.5 mg/kg twice daily for 5 days
• Term infants 0-8 months: 3 mg/kg twice daily for 5 days

Expected Benefits:

• Reduces illness duration by approximately 1.5 days 3
• Decreases complications requiring antibiotics by 35% 3

Symptomatic Management

Antipyretic Therapy:

• Use acetaminophen or ibuprofen to improve overall comfort rather than normalize temperature 4
• Never use aspirin in children due to Reye's syndrome risk 5
• Ibuprofen may provide slightly better fever reduction than acetaminophen in children under 2 years 6
• Combined use of both antipyretics provides an additional 4.4 hours without fever over 24 hours compared to single agents, but increases risk of dosing errors 7

Supportive Care:

• Ensure adequate hydration, especially in febrile children 5
• Avoid over-the-counter cough and cold medications in children under 4 years—they lack proven benefit and carry risk of serious harm 5

Antibiotic Therapy

Antibiotics are NOT indicated for uncomplicated influenza 5

When to Add Antibiotics:

• Only prescribe if bacterial complications develop (acute otitis media, bacterial sinusitis, or secondary bacterial pneumonia) 5
• Children requiring hospital admission with influenza complications should receive antibiotics covering S. pneumoniae, S. aureus, and H. influenzae 1, 8

Antibiotic Selection: 1

• Children <12 years: Co-amoxiclav (amoxicillin-clavulanate) is first-line
• Penicillin allergy: Use clarithromycin or cefuroxime
• Children >12 years: Doxycycline is an alternative
• Severely ill with pneumonia: Add a second agent (clarithromycin or cefuroxime) and give intravenously

Hospital Management Criteria

Indications for Hospitalization: 8

• Respiratory distress (increased respiratory rate, grunting, intercostal retractions)
• Oxygen saturation ≤92% on room air
• Severe dehydration or inability to maintain oral intake
• Altered consciousness
• Signs of septicemia

Inpatient Management: 1, 8

• Provide supplemental oxygen to maintain saturation >92% via nasal cannula, head box, or face mask
• Administer IV fluids at 80% basal levels if oral intake inadequate
• Perform investigations in severely ill children: complete blood count, electrolytes, liver enzymes, blood culture
• Pulse oximetry monitoring for all admitted children

Discharge Criteria: 1, 8

• Clearly improving and physiologically stable
• Tolerating oral feeds
• Respiratory rate <40/min (<50/min in infants)
• Oxygen saturation >92% in room air while awake

Critical Red Flags Requiring Immediate Evaluation

Parents should return immediately if the child develops: 5

• Fever persisting >3 days
• Respiratory distress or cyanosis
• Severe dehydration
• Altered consciousness
• Severe earache (suggesting otitis media)

Common Pitfalls to Avoid

• Do not prescribe antibiotics prophylactically for uncomplicated influenza—this promotes resistance without benefit 5
• Do not delay oseltamivir while awaiting laboratory confirmation in high-risk children during flu season 1
• Do not use combination antipyretics routinely—while more effective, the complexity increases risk of accidental overdose; if used, carefully document all dose times 7
• Do not reassure parents that fever itself is dangerous—fever is a beneficial physiologic response, and the goal is comfort, not temperature normalization 4