early in the season increases the
risk of infection for children.
Both trivalent and quadrivalent inactivated influenza vaccines (IIV) are available in the
U.S. for the 2017-’ 18 season.
Although manufacturers anticipate an adequate supply of
quadrivalent vaccine, pediatricians should administer whichever formulation is available in their
communities. Neither inactivated
vaccine formulation is preferred
over the other. The vaccine composition has changed.
• The influenza A (H1N1) virus
in both formulations differs
from that contained in the
2016-’ 17 seasonal vaccines.
•The influenza A (H3N2)
vaccine strain and influenza
B vaccine strains included in
the trivalent and quadrivalent
vaccines are the same as those contained in the
2016-’ 17 seasonal vaccines.
Quadrivalent live attenuated influenza vaccine
(LAIV4) is not recommended for use in any
setting in the U.S. during the 2017-’ 18 influenza season.
This interim recommendation made in 2016 resulted from review of observational data from the
U.S. Influenza Vaccine Effectiveness Network indicating that LAIV4 performed poorly against influenza A (H1N1) pdm09 viruses in recent influenza
seasons. Vaccine effectiveness can vary depending on
match/mismatch of circulating virus with vaccine
strains, vaccine product, and patient age and immune state. No data have been published to warrant
rescinding this recommendation.
Immunization is indicated for all children and
adolescents 6 months of age and older.
Special outreach efforts should be made to vacci-
nate people in the following groups:
• children with conditions that increase the risk of
complications from influenza (e.g., asthma and
other chronic lung diseases, diabetes mellitus,
sickle cell disease, hemodynamically significant
cardiac disease, immunosuppression, renal and
hepatic disorders, or neurologic and neurodevel-
• all household contacts and out-of-home care
providers of children with high-risk conditions
or children younger than 5 years, especially infants younger than 6 months;
• children and adolescents ( 6 months through
18 years of age) receiving an aspirin- or salicy-late-containing medication, which places them
at risk for Reye syndrome following influenza
• American Indian/Alaska Native children;
• all health care personnel;
• all child care providers and staff; and
• all women who are pregnant, are considering
pregnancy, are in the postpartum period or are
breastfeeding during the influenza season.
The number of seasonal influenza vaccine
doses to be administered in the 2017-’ 18
influenza season depends on the child’s age
at the time of the first administered dose and
Influenza vaccines are not licensed for administration to infants younger than 6 months. Children 6
months through 8 years may need two doses given
four weeks apart (see figure). A child who receives
only one of the recommended two doses as a quadrivalent formulation is likely to have less protection
against the additional B virus. Children 9 years and
older need only one dose. Vaccination should not
be delayed to obtain a specific vaccine product. Any
available, age-appropriate trivalent or quadrivalent
inactivated vaccine can be used.
All children with egg allergy of any severity
can receive influenza vaccine without any
additional precautions beyond those recommended for any vaccine.
Special precautions for egg-allergic recipients of
IIV are not warranted, as the rate of anaphylaxis after
IIV administration is no greater in egg-allergic than
non-egg-allergic recipients or from other universally
recommended vaccines. Standard vaccination practice
for all vaccines in children should include the ability
to respond to rare acute hypersensitivity reactions.
All health care personnel should receive an
annual seasonal influenza vaccine.
This is a crucial step in preventing influenza be-
cause health care personnel often care for individuals
at high risk for influenza-related
continue to be important in
influenza control but are not
a substitute for influenza
Pediatricians should prompt-
ly identify children suspected
of having influenza infection
for timely initiation of antivi-
ral treatment, when indicated,
Regardless of influenza immunization status and
whether illness onset has been less than 48 hours,
treatment should be offered as early as possible to:
• any hospitalized child clinically presumed to
have influenza disease or with severe, compli-
cated or progressive illness attributable to in-
• children with influenza infection of any severity
who are at high risk of complications.
Treatment should be considered for:
• any otherwise healthy child clinically presumed
to have influenza disease even if treatment is ini-
tiated after 48 hours of illness onset; and
• children clinically presumed to have influenza
disease and whose siblings or household contacts
are younger than 6 months or have underlying
medical conditions that predispose them to
complications of influenza.
Dr. Bernstein is associate editor of Red Book
Online and an ex-officio member of the AAP
Committee on Infectious
Diseases (COID). Dr.
Munoz is a member of
COID. Angie Lee, B.A., and Shannon Cleary, B.A.,
clinical research assistants at Cohen Children’s Medical
Center, contributed to this article.
Dr. Bernstein Dr. Munoz
Number of seasonal influenza doses for children 6 months
through 8 years of age
The two doses need not have been received during the same season or consecutive seasons.
† Receipt of LAIV4 is still expected to have primed a child’s immune system, despite recent evidence for
poor effectiveness. There currently are no data that suggest otherwise.