Treatment of COVID-19 and Influenza in Pediatric Patients
Yes, pediatric patients are treated for both COVID-19 and influenza with antiviral medications, with treatment decisions based primarily on age, underlying medical conditions, and illness severity—though the evidence base and specific recommendations differ substantially between the two infections.
Influenza Treatment in Children
Who Gets Treated
The American Academy of Pediatrics strongly recommends antiviral treatment for all children under 2 years of age with suspected or confirmed influenza, regardless of vaccination status, illness severity, or time since symptom onset, because this age group faces exceptionally high risk for complications, hospitalization, and death. 1
Additional high-priority groups for treatment include: 2, 1, 3
- All hospitalized children with suspected influenza
- Children with severe, complicated, or progressive illness
- Children of any age with underlying medical conditions (asthma, neurologic disorders, cardiovascular disease, diabetes, obesity, immunocompromise)
- Children whose household contacts are <6 months old or have high-risk conditions
Treatment may be considered for any otherwise healthy child with suspected influenza, especially if initiated within 48 hours of symptom onset. 1, 3
Timing Is Critical
Do not delay treatment while awaiting confirmatory test results—initiate immediately based on clinical suspicion. 1 The greatest benefit occurs when started within 48 hours of symptom onset, reducing illness duration by approximately 36 hours (26% reduction) and decreasing otitis media risk by 34%. 1 However, even beyond 48 hours, treatment remains beneficial for high-risk children, particularly those hospitalized or severely ill. 2, 1
Recommended Antiviral: Oseltamivir
Oseltamivir (oral) is the antiviral of choice for pediatric influenza, FDA-approved for children as young as 2 weeks of age. 2, 1
Weight-based dosing for children ≥12 months: 1
| Weight | Dose |
|---|---|
| ≤15 kg | 30 mg twice daily × 5 days |
| >15-23 kg | 45 mg twice daily × 5 days |
| >23-40 kg | 60 mg twice daily × 5 days |
| >40 kg | 75 mg twice daily × 5 days |
Age-based dosing for infants <12 months: 1
- 9-11 months: 3.5 mg/kg per dose twice daily × 5 days
- 0-8 months: 3 mg/kg per dose twice daily × 5 days
Use the commercially manufactured oral suspension (6 mg/mL concentration); if unavailable, pharmacies can compound from capsules. 1 Administer with food to reduce gastrointestinal side effects. 1
Alternative Antivirals
- Zanamivir (inhaled): Acceptable alternative for children ≥7 years without chronic respiratory disease, though more difficult to administer 1
- Peramivir (IV): Approved for children ≥2 years with acute uncomplicated influenza, symptomatic ≤2 days 1
- Amantadine/rimantadine: Do NOT use due to widespread resistance 1
Safety Profile
Vomiting occurs in approximately 5-15% of children taking oseltamivir but is generally mild and transient. 1 Despite historical concerns, controlled trials and ongoing surveillance have failed to establish a link between oseltamivir and neuropsychiatric events. 1
Secondary Bacterial Infections
Secondary bacterial pneumonia and otitis media are common complications in children with influenza. 2
Antibiotic indications: 2
- Clinical deterioration after initial improvement
- Persistent high fever beyond 3-4 days
- New respiratory findings suggesting bacterial pneumonia
- Confirmed bacterial co-infection
Antibiotic choices: 2
- Children <12 years: Co-amoxiclav (first-line)
- Penicillin allergy: Clarithromycin or cefuroxime
- Children >12 years: Doxycycline is an alternative
- Severe pneumonia: Add second agent for gram-positive coverage (clarithromycin or cefuroxime), give IV
COVID-19 Treatment in Children
Treatment Landscape: Limited Evidence
The evidence base for COVID-19 antiviral treatment in children is substantially weaker than for influenza, with most guidelines based on adult data and indirect evidence. 2
Who Gets Treated
Children at higher risk for severe COVID-19 include: 4
- Age <2 years (especially infants)
- Underlying conditions: Chronic lung disease, neurologic disorders, cardiovascular disease, diabetes, obesity, immunocompromise, feeding tube dependence
- Prematurity and airway abnormalities (in children <2 years)
Approximately 30% of hospitalized children develop severe COVID-19 (ICU admission, mechanical ventilation, or death), with 0.5% mortality. 4 Severe COVID-19 rates are highest among infants, Hispanic children, and non-Hispanic Black children. 4
Antiviral Options: Conflicting Recommendations
Remdesivir: 2
- NIH guideline: Recommends for hospitalized children ≥12 years with risk factors who have emergent/increasing oxygen needs
- NHMRC guideline: Against routine use in children outside trials
- AEP guideline: No recommendation
The evidence consists entirely of adult RCTs, with no pediatric-specific data. 2
Tocilizumab (for hyperinflammation, not direct antiviral): 2
- NHMRC: Consider for children requiring supplemental oxygen with systemic inflammation
- AEP: Do not use
- NIH: No recommendation
Again, recommendations are based solely on adult data. 2
Multisystem Inflammatory Syndrome in Children (MIS-C)
IVIG + methylprednisolone is recommended for MIS-C by most guidelines (AEP, NHMRC, ACR, SSICM/PIGS), though NIH makes no recommendation due to limited evidence. 2 The evidence base consists of cohort studies comparing IVIG with/without corticosteroids (not assessing IVIG effect directly) and indirect evidence from Kawasaki disease. 2
Critical Limitation
Most COVID-19 treatment guidelines for children rely on adult trial data, with minimal pediatric-specific evidence and conflicting recommendations across guideline bodies. 2 Clinical judgment regarding underlying risk factors and illness severity should guide treatment decisions more than specific antiviral protocols.
Key Differences: Influenza vs COVID-19 Treatment
| Feature | Influenza | COVID-19 |
|---|---|---|
| Evidence quality | Strong pediatric RCT data | Primarily adult data, limited pediatric evidence |
| Treatment consensus | Clear, consistent guidelines | Conflicting recommendations across guidelines |
| Primary antiviral | Oseltamivir (well-established) | Remdesivir (controversial in children) |
| Age-specific dosing | FDA-approved from 2 weeks | Limited pediatric approval/data |
| Treatment threshold | All children <2 years + high-risk | Primarily hospitalized/severe cases |
Common Pitfalls to Avoid
- Do not delay influenza treatment awaiting test results in high-risk children—negative rapid tests have poor sensitivity and should not rule out treatment 1
- Do not withhold oseltamivir from infants <1 year due to age alone—FDA approval extends to 2 weeks of age 1
- Do not assume vaccination eliminates need for treatment—antiviral therapy is recommended regardless of vaccination status in high-risk groups 1, 3
- Do not routinely prescribe antibiotics for influenza without evidence of bacterial co-infection 2
- Do not rely on COVID-19 treatment guidelines as definitive for children—most are extrapolated from adult data with significant inter-guideline variability 2
Clinical Comparison: Influenza vs COVID-19 Severity
Despite demographic differences (influenza patients younger, less likely to have underlying conditions), children hospitalized with influenza vs COVID-19 have similar rates of life-threatening complications: mechanical ventilation (30% both), vasopressor support (20% both), ECMO (3% both), and mortality (2.2% vs 2.9%). 5 This underscores the importance of prevention and early treatment for both infections.