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id.influenza-peds.v1PRODUCTION
id.influenza-peds.v1

Pediatric Influenza

infectious_diseaseacutepediatricneonatal
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Pediatric influenza spectrum: uncomplicated febrile ILI / influenza pneumonia (primary viral) / bacterial superinfection (S. aureus including MRSA + S. pneumoniae + S. pyogenes — biphasic illness pattern) / influenza-associated neurologic disease (IAND) / acute necrotizing encephalopathy (ANE) / myocarditis / MIS-C-like post-viral hyperinflammatory / otitis media overlay; age stratification (neonate / infant / toddler / preschool / school-age / adolescent); strain (H1N1 / H3N2 / B-Victoria / A-unsubtyped); host risk (< 5 yr, asthma, immunocompromised, CHD, neuromuscular, sickle cell, chronic metabolic, on long-term aspirin — Reye); severity tier; distinguished from adult id.influenza.core.v1 by pediatric dosing + Reye contraindication + peds-specific complications (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)

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Pediatric influenza phenotype framed (uncomplicated / pneumonia / bacterial superinfection / ANE-IAND / myocarditis / MIS-C-like / otitis overlay) and host-risk + age + severity stratified

Patient inputs (17)

Age determines antiviral choice + dosing (oseltamivir all ages including < 1 mo; baloxavir ≥ 5 yr healthy / ≥ 12 yr high-risk; peramivir IV ≥ 6 mo; zanamivir ≥ 7 yr inhaled — avoid asthma), high-risk-host stratification (< 2 yr is independent high-risk per AAP Red Book 2025-26; < 5 yr is generally high-risk per CDC peds 2025-26), and ANE / IAND / myocarditis / MIS-C-like differential weight

Weight is required for oseltamivir age + weight-banded dosing (≤ 15 kg 30 mg / > 15-23 kg 45 mg / > 23-40 kg 60 mg / > 40 kg 75 mg BID); peramivir 12 mg/kg IV (max 600 mg) for ≥ 6 mo to < 13 yr; all per CDC peds 2025-26

Children on long-term aspirin (juvenile RA, Kawasaki disease) have Reye syndrome risk independent of influenza acquisition; aspirin must be assessed for discontinuation during acute influenza per AAP Red Book 2025-26

Asthma is independent peds high-risk for influenza complications; zanamivir contraindicated (bronchospasm risk per FDA label); continue inhaled corticosteroid + add SABA PRN; consider systemic corticosteroid per asthma exacerbation protocol if exacerbated by flu (AAP Red Book 2025-26; CDC peds 2025-26)

Immunocompromised children may have prolonged viral shedding; extend oseltamivir to 10 d; consider ID consult + resistance genotyping if no improvement; baloxavir not recommended due to limited efficacy data (IDSA 2018 PMID 30566567; AAP Red Book 2025-26)

Antiviral benefit greatest ≤ 48 h of symptom onset for healthy children; high-risk children + hospitalized + complications-progressing benefit even > 48 h (IDSA 2018 PMID 30566567; AAP Red Book 2025-26)

Rapid molecular flu PCR (Xpert Xpress Flu, ID NOW) preferred over RIDT due to superior sensitivity (95-99% vs 50-70%); multiplex flu/COVID/RSV PCR appropriate during respiratory season (IDSA 2018 PMID 30566567; CDC peds 2025-26)

SpO2 < 94% RA in peds influenza → hospitalization; SpO2 < 92% RA + retractions → admit (some centers admit ≥ 92% with WOB); PEWS escalation per institutional protocol (AAP Red Book 2025-26; IDSA 2018 PMID 30566567)

Age-specific tachypnea: RR ≥ 60 < 5 yr, RR ≥ 40 5-12 yr, RR ≥ 30 ≥ 12 yr — escalate WOB assessment + consider HFNC + admit (AAP Red Book 2025-26; PEWS standards)

Altered mental status / seizures / focal neurological deficits in peds influenza → ANE / IAND concern; ICU + neurology + EEG + MRI + empiric IV acyclovir pending HSV PCR + continue oseltamivir; mortality 30-50% severe ANE (Mizuguchi Brain Dev 1997 PMID 11057302; AAP Red Book 2025-26)

Pediatric high-risk conditions: age < 5 yr (especially < 2 yr), asthma, immunocompromised, CHD, neuromuscular / developmental, sickle cell, chronic metabolic, on long-term aspirin (juvenile RA — Reye risk independent of influenza), American Indian / Alaska Native heritage — empiric antiviral regardless of symptom-onset window (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)

CXR if hypoxia, dyspnea, retractions, persistent fever, or suspected pneumonia — bilateral infiltrates suggest primary viral pneumonia vs focal consolidation suggesting bacterial superinfection (S. aureus including MRSA, S. pneumoniae, S. pyogenes); guides empiric antibiotic decision (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; IDSA/PIDS Peds CAP 2011)

Procalcitonin > 0.25 ng/mL in pediatric influenza + new fever spike / focal consolidation → bacterial superinfection — add empiric amoxicillin/clavulanate (outpatient overlap) OR ceftriaxone ± vancomycin (inpatient/PICU; anti-MRSA if necrotizing pneumonia features) (IDSA/ATS CAP 2019; IDSA 2018 PMID 30566567)

Vaccination status: prior influenza vaccination does NOT exclude diagnosis but may attenuate disease severity; document for outbreak surveillance + post-illness reconciliation (ACIP 2025-26)

CBC with differential — leukopenia, lymphopenia, thrombocytopenia common in severe peds influenza; leukocytosis with neutrophil predominance disproportionate to influenza lymphopenia suggests bacterial superinfection (AAP Red Book 2025-26; IDSA 2018 PMID 30566567)

BMP for hydration assessment + renal function (oseltamivir dose adjustment if CrCl < 30 — rare in peds but verified for adolescents and CKD); hepatic function for hepatic dosing considerations (CDC peds 2025-26)

Chest pain, palpitations, new arrhythmia, syncope in pediatric confirmed/suspected influenza → myocarditis concern; ECG + troponin + echo + cardiology consult + telemetry + continue oseltamivir (Steininger Clin Infect Dis 2003; AAP Red Book 2025-26)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningpediatric_respiratory_failure_in_influenza — AAP Red Book 2025-26
    Pediatric respiratory failure in influenza — SpO2 < 92% RA + retractions + age-specific tachypnea (RR ≥ 60 < 5 yr / ≥ 40 5-12 yr / ≥ 30 ≥ 12 yr) → admit + HFNC 1-2 L/kg/min per PARIS PMID 29562151 + CPAP/BiPAP/intubation for failure + ARDSnet if PaO2/FiO2 ≤ 200 + prone positioning if PaO2/FiO2 < 150 per PROSEVA Guérin NEJM 2013 (AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpediatric_ane_iand_in_influenza — Mizuguchi 1997 PMID 11057302
    Pediatric influenza-associated neurologic disease (IAND) / acute necrotizing encephalopathy (ANE) — altered mental status + seizures + focal neurological deficits in confirmed/suspected pediatric influenza + symmetric thalamic / brainstem / cerebellar lesions on MRI (Mizuguchi pattern) → ICU + neurology + EEG + MRI + LP + CSF (rule out HSV — empiric IV acyclovir pending PCR per Tunkel IDSA encephalitis 2008) + continue oseltamivir; mortality 30-50% in severe ANE; long-term sequelae common in survivors (Mizuguchi Brain Dev 1997 PMID 11057302; AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_myocarditis_in_influenza — Steininger 2003
    Pediatric influenza-associated myocarditis — chest pain + new ECG changes (ST changes, conduction abnormalities) + elevated troponin in confirmed/suspected influenza ± new HF features (EF drop on echo, regional wall motion abnormalities, new pulmonary edema, hemodynamic compromise) → echocardiography + cardiology consult + telemetry + standard HF therapy (guideline-directed but cautious diuresis) + continue oseltamivir + consider cardiac MRI (Steininger Clin Infect Dis 2003; AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_bacterial_superinfection_in_influenza — Bhat 2005 PMID 16354892
    Pediatric influenza bacterial superinfection — biphasic illness pattern (initial improvement → recurrent fever + new productive cough + new focal consolidation on CXR + leukocytosis disproportionate to influenza lymphopenia OR procalcitonin > 0.25 ng/mL) — add empiric amoxicillin/clavulanate (outpatient overlap — 80-90 mg/kg/d amoxicillin component PO BID) OR ceftriaxone IV ± vancomycin (inpatient/PICU; anti-MRSA if necrotizing pneumonia features); S. aureus including MRSA + S. pneumoniae + S. pyogenes most common; cross-route to peds.cap.v1 (Bhat NEJM 2005 PMID 16354892; IDSA 2018 PMID 30566567; IDSA/PIDS Peds CAP 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepeds_mis_c_like_post_influenza — Sun MMWR 2021
    Pediatric MIS-C-like post-viral hyperinflammatory syndrome — 2-6 wk post-influenza + multi-organ involvement (cardiac — myocarditis, cardiogenic shock; mucocutaneous — Kawasaki-disease-like; GI — abdominal pain, vomiting, diarrhea) + elevated inflammatory markers (CRP, ferritin, ESR, D-dimer) — ICU + cardiology + rheum + ID consult; management extrapolated from MIS-C protocols (IVIG + glucocorticoids + biologics if refractory); less common than post-COVID MIS-C but reported (Sun MMWR 2021; AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepeds_high_risk_outpatient_without_antiviral — AAP Red Book 2025-26
    High-risk pediatric outpatient with ILI not yet on antiviral therapy: age < 5 yr (especially < 2 yr — independent high-risk) / asthma / immunocompromised / CHD / neuromuscular / sickle cell / chronic metabolic / on long-term aspirin (juvenile RA — Reye risk independent of influenza) / American Indian / Alaska Native heritage — start oseltamivir age/weight-banded immediately even if symptom onset > 48 h (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepeds_age_lt_2yr_independent_high_risk — AAP Red Book 2025-26
    Pediatric age < 2 yr with influenza is an INDEPENDENT HIGH-RISK condition per AAP Red Book 2025-26 + CDC peds 2025-26 — start oseltamivir age/weight-banded empirically regardless of symptom-onset window; lower admission threshold for any progressive symptoms; surveillance for ANE / IAND / myocarditis / bacterial superinfection; cross-reference peds.bronchiolitis.v1 for differential in younger infants with wheeze; cross-reference peds.febrile-infant.core.v1 if < 60 d febrile (AAP Red Book 2025-26; CDC peds 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepeds_immunocompromised_prolonged_shedding — IDSA 2018 PMID 30566567
    Immunocompromised pediatric patient with influenza — risk of prolonged viral shedding, antiviral resistance emergence (H275Y NA mutation oseltamivir resistance; PA I38T baloxavir resistance), progressive viral pneumonia (IDSA 2018 PMID 30566567; AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepeds_aspirin_contraindication_for_reye_syndrome — AAP Red Book 2025-26
    Pediatric viral illness (including influenza) — aspirin CONTRAINDICATED per Reye syndrome (acute encephalopathy + hepatic dysfunction); use acetaminophen + ibuprofen instead (≥ 6 mo + no dehydration for ibuprofen); children on chronic aspirin therapy (juvenile RA, Kawasaki disease) should have aspirin HELD during acute influenza with pediatric rheumatology / cardiology oversight (AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepeds_dehydration_and_otitis_media_overlay — AAP Red Book 2025-26
    Pediatric influenza with dehydration (poor PO + reduced wet diapers + tachypnea limiting PO) — IV NS maintenance or NG feeds per Oakley 2013; concurrent otitis media (~ 30-40% in young children with influenza) — amoxicillin per AAP otitis media 2013 guideline; if amoxicillin fails or persistent → amoxicillin/clavulanate (AAP Red Book 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Pediatric influenza antiviral treatment — oseltamivir age + weight-banded all ages (first-line) + baloxavir ≥ 5 yr healthy / ≥ 12 yr high-risk + peramivir IV ≥ 6 mo + zanamivir ≥ 7 yr inhaled (AVOID asthma) (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)
axis: peds_influenza_antiviral_treatment
Selected axis "Pediatric influenza antiviral treatment — oseltamivir age + weight-banded all ages (first-line) + baloxavir ≥ 5 yr healthy / ≥ 12 yr high-risk + peramivir IV ≥ 6 mo + zanamivir ≥ 7 yr inhaled (AVOID asthma) (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)" by default fallback (first axis)
  • oseltamivir
    first line
    neuraminidase_inhibitor
    Term neonate 0-1 mo + 1-12 mo: 3 mg/kg/dose PO BID × 5 d; ≥ 1 yr weight-banded: ≤ 15 kg 30 mg BID, > 15-23 kg 45 mg BID, > 23-40 kg 60 mg BID, > 40 kg 75 mg BID × 5 d; extend to 10 d if ICU or immunocompromised • PO • BID × 5 d (× 10 d if ICU/immunocompromised)
    triggers: peds_ili_any_severity_high_risk, peds_ili_le_48h_low_risk, peds_hospitalized_empiric, peds_age_lt_2yr_empiric_regardless_of_window
    First-line peds antiviral for all ages including infants < 1 mo per AAP Red Book 2025-26 + CDC peds 2025-26; Dobson IPD meta PMID 25640810 peds subgroup demonstrates ~ 1-day symptom-duration reduction + reduced complications + reduced hospitalization in high-risk; start empirically without waiting for test results in high-risk + hospitalized + < 2 yr (independent high-risk)
    rxcui 260101
  • baloxavir marboxil
    first line
    cap_dependent_endonuclease_inhibitor
    Single dose 40 mg PO if < 80 kg or 80 mg PO if ≥ 80 kg • PO • single dose
    triggers: peds_uncomplicated_le_48h_age_ge_5yr_healthy, peds_high_risk_outpatient_age_ge_12yr
    Single-dose convenience for ≥ 5 yr healthy (FDA 2022 peds expansion) and ≥ 12 yr high-risk per CDC peds 2025-26; CAPSTONE-1 PMID 30184455 adolescent ≥ 12 yr subgroup demonstrated non-inferiority to oseltamivir + superior viral load reduction; AVOID with polyvalent cation-containing products (Ca/Mg/Fe antacids reduce absorption); not recommended in pregnancy or severely immunocompromised
    rxcui 2099995
  • peramivir
    second line
    neuraminidase_inhibitor
    ≥ 6 mo to < 13 yr: 12 mg/kg IV (max 600 mg) single dose; ≥ 13 yr: 600 mg IV single dose • IV • single dose
    triggers: peds_unable_to_tolerate_oral_or_enteral, peds_critically_ill_iv_access_only
    IV alternative when oral/enteral not feasible per CDC peds 2025-26; ≥ 6 mo FDA-approved; single dose non-inferior to 5-d oseltamivir for uncomplicated influenza
    rxcui 619693
  • zanamivir
    second line
    neuraminidase_inhibitor
    ≥ 7 yr: 10 mg (2 inhalations × 5 mg) inhaled BID × 5 d • inhaled • BID × 5 d
    triggers: peds_age_ge_7yr_no_asthma_no_chronic_lung_disease
    Inhaled alternative ≥ 7 yr per CDC peds 2025-26; AVOID in asthma + chronic lung disease per bronchospasm risk (FDA label); rarely used in current peds practice given oseltamivir + baloxavir availability
    rxcui 69722

outpatient playbook — drug actions (4)

  1. 1. oseltamivir age/weight-banded × 5 d
    rxcui 260101
    Term neonate 0-1 mo + 1-12 mo 3 mg/kg/dose; ≥ 1 yr weight-banded ≤ 15 kg 30 mg / > 15-23 kg 45 mg / > 23-40 kg 60 mg / > 40 kg 75 mg BID • PO • BID
    trigger: High-risk peds + ILI regardless of symptom-onset window OR age < 2 yr regardless OR healthy ≥ 5 yr + ILI ≤ 48 h shared-decision (AAP Red Book 2025-26)
    First-line peds antiviral all ages; ~ 1-d symptom reduction + reduced complications + reduced hospitalization in high-risk (Dobson Lancet 2015 PMID 25640810 peds subgroup; AAP Red Book 2025-26)
  2. 2. baloxavir 40-80 mg single dose ≥ 5 yr healthy or ≥ 12 yr high-risk
    rxcui 2099995
    40 mg (< 80 kg) or 80 mg (≥ 80 kg) PO • PO • single dose
    trigger: Uncomplicated peds influenza ≤ 48 h symptom onset + age ≥ 5 yr healthy OR ≥ 12 yr high-risk; alternative to oseltamivir per shared-decision
    Single-dose convenience; CAPSTONE-1 PMID 30184455 adolescent subgroup non-inferior to oseltamivir + superior viral load reduction; FDA peds expansion ≥ 5 yr 2022 per CDC peds 2025-26
  3. 3. acetaminophen 10-15 mg/kg/dose q4-6h PRN (max 75 mg/kg/d)
    rxcui 161
    10-15 mg/kg/dose • PO • q4-6h PRN
    trigger: Fever, myalgia, headache (AAP Red Book 2025-26)
    Symptomatic relief; preferred over NSAIDs in young infants and in dehydration; preferred in pregnancy adolescents (AAP Red Book 2025-26)
  4. 4. ibuprofen 5-10 mg/kg/dose q6-8h PRN (max 40 mg/kg/d) — ≥ 6 mo + no dehydration
    rxcui 5640
    5-10 mg/kg/dose • PO • q6-8h PRN
    trigger: Fever, myalgia, headache in age ≥ 6 mo + no dehydration (AAP Red Book 2025-26)
    NSAID antipyretic + analgesic; AVOID < 6 mo and in dehydration (AKI risk); AVOID pregnancy 3rd trimester (AAP Red Book 2025-26)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pediatric influenza-like illness: acute onset fever + cough + sore throat + myalgia during influenza season (AAP Red Book 2025-26; CDC peds 2025-26; IDSA 2018 PMID 30566567); Household OR school / daycare outbreak exposure to confirmed influenza case — high-risk peds contact for PEP + active surveillance (CDC peds 2025-26; AAP Red Book 2025-26); Positive rapid molecular flu / multiplex flu-COVID-RSV PCR — pediatric (AAP Red Book 2025-26; CDC peds 2025-26).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric Influenza** (id.influenza-peds.v1).
Phenotype framing: Pediatric influenza vs RSV bronchiolitis (< 2 yr — wheeze + retractions + crackles + URI prodrome — cross-route to peds.bronchiolitis.v1 — multiplex PCR distinguishes; can co-exist) vs SARS-CoV-2 (co-test recommended; cross-route to id.covid19.core.v1) vs peds CAP (bacterial — focal consolidation + procalcitonin; cross-route to peds.cap.v1) vs adenovirus (conjunctivitis + pharyngitis + cervical lymphadenopathy) vs croup (barking cough + inspiratory stridor — laryngotracheobronchitis; usually parainfluenza) vs pertussis (paroxysmal cough + post-tussive emesis + apnea infants < 6 mo — cross-route to id.pertussis.v1) vs strep pharyngitis (rapid strep + exudate + cervical lymphadenopathy + absent cough — Centor criteria) vs other viral URI (rhino, hMPV, parainfluenza) vs early sepsis (toxic appearance + perfusion abnormalities — cross-route to id.sepsis.peds.v1); multiplex respiratory PCR (flu + COVID + RSV + adeno + parainfluenza + hMPV + rhino) discriminates among viral etiologies (AAP Red Book 2025-26; CDC peds 2025-26; IDSA 2018 PMID 30566567)
Scope: Pediatric influenza spectrum: uncomplicated febrile ILI / influenza pneumonia (primary viral) / bacterial superinfection (S. aureus including MRSA + S. pneumoniae + S. pyogenes — biphasic illness pattern) / influenza-associated neurologic disease (IAND) / acute necrotizing encephalopathy (ANE) / myocarditis / MIS-C-like post-viral hyperinflammatory / otitis media overlay; age stratification (neonate / infant / toddler / preschool / school-age / adolescent); strain (H1N1 / H3N2 / B-Victoria / A-unsubtyped); host risk (< 5 yr, asthma, immunocompromised, CHD, neuromuscular, sickle cell, chronic metabolic, on long-term aspirin — Reye); severity tier; distinguished from adult id.influenza.core.v1 by pediatric dosing + Reye contraindication + peds-specific complications (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric influenza antiviral treatment — oseltamivir age + weight-banded all ages (first-line) + baloxavir ≥ 5 yr healthy / ≥ 12 yr high-risk + peramivir IV ≥ 6 mo + zanamivir ≥ 7 yr inhaled (AVOID asthma) (AAP Red Book 2025-26; IDSA 2018 PMID 30566567; CDC peds 2025-26)**.
1. oseltamivir Term neonate 0-1 mo + 1-12 mo: 3 mg/kg/dose PO BID × 5 d; ≥ 1 yr weight-banded: ≤ 15 kg 30 mg BID, > 15-23 kg 45 mg BID, > 23-40 kg 60 mg BID, > 40 kg 75 mg BID × 5 d; extend to 10 d if ICU or immunocompromised PO BID × 5 d (× 10 d if ICU/immunocompromised) (neuraminidase_inhibitor, first line) — First-line peds antiviral for all ages including infants < 1 mo per AAP Red Book 2025-26 + CDC peds 2025-26; Dobson IPD meta PMID 25640810 peds subgroup demonstrates ~ 1-day symptom-duration reduction + reduced complications + reduced hospitalization in high-risk; start empirically without waiting for test results in high-risk + hospitalized + < 2 yr (independent high-risk)
2. baloxavir marboxil Single dose 40 mg PO if < 80 kg or 80 mg PO if ≥ 80 kg PO single dose (cap_dependent_endonuclease_inhibitor, first line) — Single-dose convenience for ≥ 5 yr healthy (FDA 2022 peds expansion) and ≥ 12 yr high-risk per CDC peds 2025-26; CAPSTONE-1 PMID 30184455 adolescent ≥ 12 yr subgroup demonstrated non-inferiority to oseltamivir + superior viral load reduction; AVOID with polyvalent cation-containing products (Ca/Mg/Fe antacids reduce absorption); not recommended in pregnancy or severely immunocompromised
3. peramivir ≥ 6 mo to < 13 yr: 12 mg/kg IV (max 600 mg) single dose; ≥ 13 yr: 600 mg IV single dose IV single dose (neuraminidase_inhibitor, second line) — IV alternative when oral/enteral not feasible per CDC peds 2025-26; ≥ 6 mo FDA-approved; single dose non-inferior to 5-d oseltamivir for uncomplicated influenza
4. zanamivir ≥ 7 yr: 10 mg (2 inhalations × 5 mg) inhaled BID × 5 d inhaled BID × 5 d (neuraminidase_inhibitor, second line) — Inhaled alternative ≥ 7 yr per CDC peds 2025-26; AVOID in asthma + chronic lung disease per bronchospasm risk (FDA label); rarely used in current peds practice given oseltamivir + baloxavir availability

Setting playbook (outpatient) — Diagnose pediatric influenza, risk-stratify by age + comorbidity, initiate oseltamivir age/weight-banded within 48 h for eligible (or any time for high-risk + < 2 yr), provide return precautions + family education (AAP Red Book 2025-26; CDC peds 2025-26)
5. oseltamivir age/weight-banded × 5 d Term neonate 0-1 mo + 1-12 mo 3 mg/kg/dose; ≥ 1 yr weight-banded ≤ 15 kg 30 mg / > 15-23 kg 45 mg / > 23-40 kg 60 mg / > 40 kg 75 mg BID PO BID — High-risk peds + ILI regardless of symptom-onset window OR age < 2 yr regardless OR healthy ≥ 5 yr + ILI ≤ 48 h shared-decision (AAP Red Book 2025-26) (First-line peds antiviral all ages; ~ 1-d symptom reduction + reduced complications + reduced hospitalization in high-risk (Dobson Lancet 2015 PMID 25640810 peds subgroup; AAP Red Book 2025-26))
6. baloxavir 40-80 mg single dose ≥ 5 yr healthy or ≥ 12 yr high-risk 40 mg (< 80 kg) or 80 mg (≥ 80 kg) PO PO single dose — Uncomplicated peds influenza ≤ 48 h symptom onset + age ≥ 5 yr healthy OR ≥ 12 yr high-risk; alternative to oseltamivir per shared-decision (Single-dose convenience; CAPSTONE-1 PMID 30184455 adolescent subgroup non-inferior to oseltamivir + superior viral load reduction; FDA peds expansion ≥ 5 yr 2022 per CDC peds 2025-26)
7. acetaminophen 10-15 mg/kg/dose q4-6h PRN (max 75 mg/kg/d) 10-15 mg/kg/dose PO q4-6h PRN — Fever, myalgia, headache (AAP Red Book 2025-26) (Symptomatic relief; preferred over NSAIDs in young infants and in dehydration; preferred in pregnancy adolescents (AAP Red Book 2025-26))
8. ibuprofen 5-10 mg/kg/dose q6-8h PRN (max 40 mg/kg/d) — ≥ 6 mo + no dehydration 5-10 mg/kg/dose PO q6-8h PRN — Fever, myalgia, headache in age ≥ 6 mo + no dehydration (AAP Red Book 2025-26) (NSAID antipyretic + analgesic; AVOID < 6 mo and in dehydration (AKI risk); AVOID pregnancy 3rd trimester (AAP Red Book 2025-26))

Non-pharmacologic actions:
- NO ASPIRIN per Reye syndrome — hold chronic aspirin (JRA, Kawasaki) during acute influenza per AAP Red Book 2025-26
- Rapid molecular flu PCR (Xpert Xpress Flu, ID NOW) — preferred over RIDT (IDSA 2018 PMID 30566567)
- COVID-19 co-testing during respiratory illness season (CDC peds 2025-26)
- Isolation until afebrile ≥ 24 h without antipyretics (CDC peds 2025-26)
- Hand hygiene + respiratory etiquette education (CDC peds 2025-26)
- Return precautions: worsening dyspnea, retractions, age-specific tachypnea, persistent fever > 3 d, inability to hydrate, biphasic-fever pattern (bacterial superinfection), altered mental status (encephalopathy / ANE), chest pain (myocarditis), new rash + multi-organ symptoms 2-6 wk post-illness (MIS-C-like) (AAP Red Book 2025-26)
- Post-exposure prophylaxis for high-risk household + school contacts: oseltamivir age/weight-banded daily × 7 d (CDC peds 2025-26)
- Annual influenza vaccination reconciliation if unvaccinated — LAIV ≥ 2 yr healthy non-pregnant non-immunocompromised non-asthma OR IIV otherwise; all ≥ 6 mo per ACIP 2025-26
- Aspirin reconciliation post-illness — resume chronic aspirin (JRA, Kawasaki) only after illness resolution + pediatric rheumatology / cardiology oversight (AAP Red Book 2025-26)
- School return when afebrile ≥ 24 h without antipyretics (CDC peds 2025-26)

AVOID / contraindication checks:
- Oseltamivir_age_weight_banded_dosing_required_per_cdc_peds_2025_26 (CDC peds 2025 26)
- Oseltamivir_dose_reduce_if_crcl_lt_30_adolescents_only (IDSA 2018 PMID 30566567)
- Baloxavir_only_ge_5yr_healthy_or_ge_12yr_high_risk_per_cdc_peds_2025_26 (CDC peds 2025 26)
- Baloxavir_avoid_polyvalent_cations (CAPSTONE 1 Hayden NEJM 2018 PMID 30184455)
- Baloxavir_not_recommended_in_pregnant_adolescents_or_severely_immunocompromised (IDSA 2018 PMID 30566567; CDC peds 2025 26)
- Peramivir_only_ge_6mo (CDC peds 2025 26)
- Zanamivir_avoid_in_asthma_or_chronic_lung_disease_bronchospasm_risk (FDA label; AAP Red Book 2025 26)
- Do_not_use_double_dose_oseltamivir_no_benefit (IDSA 2018 PMID 30566567)
- Start_empirically_in_high_risk_or_hospitalized_or_age_lt_2yr_do_not_wait_for_test_result (AAP Red Book 2025 26; IDSA 2018 PMID 30566567)

Monitoring

Regimen monitoring:
- clinical improvement expected within 48 72h of antiviral start (IDSA 2018 PMID 30566567)
- if no improvement by day 3 5 reassess diagnosis and resistance (IDSA 2018 PMID 30566567; AAP Red Book 2025-26)
- extend oseltamivir to 10d if picu or immunocompromised (IDSA 2018 PMID 30566567)
- monitor for bacterial superinfection biphasic illness pattern (AAP Red Book 2025-26)
- pews score serial for admit or picu (AAP Red Book 2025-26; institutional PEWS protocol)

Setting (outpatient) monitoring:
- Symptom resolution expected 5-7 d (AAP Red Book 2025-26)
- Return if worsening after initial improvement — bacterial superinfection (AAP Red Book 2025-26)
- Phone follow-up in 48-72 h for high-risk + < 2 yr (AAP Red Book 2025-26)

Follow-up plan: Post-influenza pediatric follow-up: annual influenza vaccination if unvaccinated this season + next season per ACIP 2025-26 (LAIV ≥ 2 yr healthy non-pregnant non-immunocompromised non-asthma; IIV otherwise; all ≥ 6 mo); household + school contact PEP for high-risk contacts (oseltamivir age/weight-banded × 7 d for high-risk within 48 h of exposure); school return when afebrile ≥ 24 h without antipyretics per CDC public health guidance; cardiology follow-up if myocarditis (echo at 3 + 6 mo; activity restriction per ACC/AHA peds myocarditis statement); neurology + neuropsych follow-up if ANE / IAND (serial imaging + functional assessment; mortality 30-50% in severe ANE per Mizuguchi 1997 PMID 11057302; long-term sequelae common); ID follow-up if immunocompromised; rheum + cardiology if MIS-C-like; public health reporting if institutional outbreak; aspirin reconciliation if held for Reye risk (AAP Red Book 2025-26; CDC peds 2025-26; ACIP 2025-26)
- Close-out criterion: Pediatric follow-up + vaccination + sub-specialty referrals + return precautions delivered

Monitoring phase: Outpatient: symptom resolution 5-7 days expected; biphasic illness pattern → return for bacterial superinfection eval; persistent fever > 3 d → reassess; return precautions on respiratory deterioration, dehydration, altered MS, chest pain. Inpatient: daily PEWS reassessment, respiratory status, SpO2, complication surveillance (neuro exam, cardiac auscultation, abdominal exam for hepatic involvement); clinical improvement expected day 3-5 on oseltamivir; if no improvement reassess for resistance + alternative diagnosis. PICU: continuous cardiopulmonary monitoring, daily neurological exam, serial troponin if myocarditis, ventilator management per ARDSnet, daily viral shedding assessment in immunocompromised. Aspirin reconciliation post-illness — resume if held for Reye risk only after illness resolution + clinician oversight per pediatric rheumatology / cardiology (AAP Red Book 2025-26)

Disposition

Current setting: outpatient — Diagnose pediatric influenza, risk-stratify by age + comorbidity, initiate oseltamivir age/weight-banded within 48 h for eligible (or any time for high-risk + < 2 yr), provide return precautions + family education (AAP Red Book 2025-26; CDC peds 2025-26)

Disposition criteria:
- Discharge home: ≥ 5 yr healthy + SpO2 ≥ 94% + tolerating PO + reliable family + return precautions (AAP Red Book 2025-26)
- Admit: high-risk host with progressive symptoms despite antiviral; pneumonia overlay; dehydration; age < 6 mo with significant illness; failed outpatient management (AAP Red Book 2025-26)

Escalation triggers (move to higher acuity):
- SpO2 < 92% RA + retractions → admit (AAP Red Book 2025-26)
- Age-specific tachypnea + WOB → admit (AAP Red Book 2025-26)
- Persistent fever > 3 d → reassess for bacterial superinfection (AAP Red Book 2025-26)
- Dehydration with inability to maintain PO → IV fluids + admit (AAP Red Book 2025-26)
- Altered mental status / seizures → emergent evaluation + admit + neurology (Mizuguchi Brain Dev 1997 PMID 11057302)
- Chest pain + arrhythmia → cardiology + ECG + troponin (Steininger Clin Infect Dis 2003)
- Age < 6 mo with significant febrile illness → admit + febrile-infant pathway (AAP Red Book 2025-26)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pediatric respiratory failure in influenza — SpO2 < 92% RA + retractions + age-specific tachypnea (RR ≥ 60 < 5 yr / ≥ 40 5-12 yr / ≥ 30 ≥ 12 yr) → admit + HFNC 1-2 L/kg/min per PARIS PMID 29562151 + CPAP/BiPAP/intubation for failure + ARDSnet if PaO2/FiO2 ≤ 200 + prone positioning if PaO2/FiO2 < 150 per PROSEVA Guérin NEJM 2013 (AAP Red Book 2025-26)
- [LIFE_THREATENING] Pediatric influenza-associated neurologic disease (IAND) / acute necrotizing encephalopathy (ANE) — altered mental status + seizures + focal neurological deficits in confirmed/suspected pediatric influenza + symmetric thalamic / brainstem / cerebellar lesions on MRI (Mizuguchi pattern) → ICU + neurology + EEG + MRI + LP + CSF (rule out HSV — empiric IV acyclovir pending PCR per Tunkel IDSA encephalitis 2008) + continue oseltamivir; mortality 30-50% in severe ANE; long-term sequelae common in survivors (Mizuguchi Brain Dev 1997 PMID 11057302; AAP Red Book 2025-26)
- [SEVERE] Pediatric influenza-associated myocarditis — chest pain + new ECG changes (ST changes, conduction abnormalities) + elevated troponin in confirmed/suspected influenza ± new HF features (EF drop on echo, regional wall motion abnormalities, new pulmonary edema, hemodynamic compromise) → echocardiography + cardiology consult + telemetry + standard HF therapy (guideline-directed but cautious diuresis) + continue oseltamivir + consider cardiac MRI (Steininger Clin Infect Dis 2003; AAP Red Book 2025-26)

Citations

- AAP Red Book 2025-26 — Influenza chapter (pediatric) + IDSA 2018 Clinical Practice Guidelines for Seasonal Influenza (Uyeki Clin Infect Dis 2019) + CDC Pediatric Antiviral Guidance 2025-26 Season [PMID:30566567](https://pubmed.ncbi.nlm.nih.gov/30566567/)
- Cited evidence (PMID 30184455) [PMID:30184455](https://pubmed.ncbi.nlm.nih.gov/30184455/)
- Cited evidence (PMID 25640810) [PMID:25640810](https://pubmed.ncbi.nlm.nih.gov/25640810/)
- Cited evidence (PMID 11057302) [PMID:11057302](https://pubmed.ncbi.nlm.nih.gov/11057302/)
- Cited evidence (PMID 16354892) [PMID:16354892](https://pubmed.ncbi.nlm.nih.gov/16354892/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AAP Red Book 2025-26 — Influenza chapter (pediatric) + IDSA 2018 Clinical Practice Guidelines for Seasonal Influenza (Uyeki Clin Infect Dis 2019) + CDC Pediatric Antiviral Guidance 2025-26 Season — PMID:30566567
  • Cited evidence (PMID 30184455) — PMID:30184455
  • Cited evidence (PMID 25640810) — PMID:25640810
  • Cited evidence (PMID 11057302) — PMID:11057302
  • Cited evidence (PMID 16354892) — PMID:16354892