Influenza in Children: Is Treat Early, Treat Often the Best Strategy?

Weijen Chang, MD; Matthew Garber, MD; Ricardo A. Quinonez, MD

Disclosures

February 25, 2015

Editorial Collaboration

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In This Article

Putting It Into Practice

Dr Chang: Does the severity of the current influenza season, coupled with the lower-than-expected efficacy of the seasonal vaccine, warrant increased antiviral usage by hospitalists?

Dr Garber: I don't think it does. But to be fair, this argument is not completely without merit. As I discussed before, it's hard to disprove a negative, but with the large number of patients studied, I think we can rule out a large effect size of the antivirals. While antivirals may have a small effect size to prevent complications in a limited group of patients, there is currently no high-quality evidence supporting this. The clinician must weigh several factors when considering interventions for her patients.

Let's pretend, just for the sake of argument, that a particular antiviral was shown to have absolutely no side effects and was free (maybe it's derived from a pesky weed that homeowners would be happy for us to pluck and ingest). Let's also pretend that this year's influenza season is much worse than the 1918 Spanish flu epidemic (imagine Ebola that spreads like the flu). In this imaginary scenario, prescribing the antiviral makes sense. No side effects and it's free. It may help some people avoid complications, but even if it doesn't, what's the harm? Unfortunately, no such medicine exists. They all have side effects, and current recommended antivirals are quite pricey. We know that oseltamivir has a significant rate of emesis and, though rare, occasionally causes severe neuropsychiatric symptoms, even suicide. So those need to be added into the equation, and the more prescriptions we write, the more potential harm we cause.

While harms resonate with doctors and patients more than costs, we also must consider costs. Because the United States does not have unlimited resources, money spent in one area of healthcare will not be available in another. That is the reasoning behind the statement, "Waste is unethical." We need to be good stewards of our country's healthcare dollars and should not allocate large resources to unproven therapies as there will undoubtedly be patients who will be denied effective therapy as a result.

So there is a balancing act. We must weigh the severity of the disease and the evidence supporting the potential of the therapy to improve important outcomes (such as mortality) against potential harms and costs of the therapy. Right now we do not have strong evidence that antivirals improve important outcomes, but they do have significant side effects and high costs. So at this time I don't think the severity of the season coupled with the poor efficacy of the vaccine warrant increased use of antivirals by hospitalists.

Dr Chang: Would you treat a 12-month-old previously healthy child admitted to the hospital with bronchiolitis, dehydration, and mild increased work of breathing if the testing for influenza was positive?

Dr Quinonez: Obviously if we followed the CDC recommendations, the answer would be yes. But let's think about this, ignoring this recommendation for the sake of argument. Would I start a medication on a child who is already ill that may have some effect on duration of symptoms but also may have significant risk of causing vomiting in a child who is already dehydrated? The risk outweighs the benefit in my mind, particularly if the child has been sick for over 48 hours, in which case the evidence for benefit is even weaker for antivirals. Most kids who present to the hospital with bronchiolitis are usually between day 3 and 5 of illness. So my evidence-based risk assessment, harm vs benefit answer, would be no.

Dr Garber: I agree with Ricardo. We know that bronchiolitis is a self-limited disease with basically zero mortality in this patient population. This particular child was admitted for dehydration, a minor complication of this disease that can be treated with simple interventions (increased nasal suctioning, small frequent feeds, or, if necessary, intravenous or nasogastric fluids). The average length of stay for such a child is quite short.

As an experienced hospitalist, I would say that a previously healthy child with bronchiolitis older than 1-2 months of age admitted solely for dehydration with no oxygen requirement usually goes home the following day, often in less than 24 hours. If the child has been ill more than 48 hours (and a close reading of the evidence suggests that most benefit is seen in patients treated within 24 hours), I see no evidence that oseltamivir will benefit this child, though it might induce emesis, which has a high likelihood of prolonging the hospitalization, increasing the potential for an adverse event from the hospitalization itself.

If the child has been ill fewer than 24 hours, I think a discussion with the family is appropriate. Prescribing oseltamivir may decrease his duration of symptoms by about a day and may prevent an otitis media. Side effects and costs should also be discussed with the family, and a shared decision to prescribe or not prescribe should be made, with anticipatory guidance about stopping the medication if side effects occur.

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