Thursday, December 10, 2009

Influenza in infants - oseltamivir and a daycare

Well, it seems as throughout the progression of the flu season, the number of cases have been decreasing, however, the flu has taken its toll in terms of mortality, so we should be very careful and not dismiss the safety measures wisely implemented. Follow the CDC H1N1 Flu updates here.

I wish I would be able to convince many parents who adamantly refuses the influenza H1N1 vaccine given the extreme misinformation provided by the media "based" on "non-evidence-based" resources. It is frustrating as a physician it is my main interest to enhance and ensure the well being of the human-kind. But for the most part, the majority of parents have been very well compliant with the recommendations. It should be recognized the fact that immunizations are perhaps, the best discovery of the last century, and hopefully the truth will overcome the fear toward immunizations.

Today, I had a 6 months old little boy admitted with URI symptoms, with very prominent clear rinorrhea, nasal congestion, cough and concerns for bronchiolitis. As soon as he had his nose cleared with bulb syringe suctioning, his symptoms improved dramatically and did not require oxygen. As part of the admission we obtained a Respiratory Viral Panel (an example of what it detects is here). The baby had positive Influenza A, and by definition, on this season, you consider it as H1N1. His family got the influenza vaccine; his parents are extremely pleasant, but the fact is that the baby started going to daycare last week.

Fortunately for him his chest roentgenogram is normal and is not requiring oxygen, however, the question brought to the table was: it is safe to start him on antivirals?

The data on safety and dosing of oseltamivir in infants is very limited, and if used, a careful monitoring for adverse events should be pursued. FDA recommends against routine prophylactic use in infants younger that 3 months of age. Recently (October 30, 2009), the FDA released a statement about Emergency use of Tamiflu in Infants less than 1 year of age.

The recommended treatment dose for infants younger than 12 months of age is 3 mg/kg/dose twice a day. However, as it will likely happen, if weight is unknown, a dose based on age can be used: birth to 2 mo, 12 mg (1 mL) BID; 3-5 mo, 20 mg (1.6 mL) BID; 6-11 mo, 25 mg (2 mL) BID.

The recommended prophylactic dose for infants 3 mo to 1 year old is 3 mg/kg/dose once daily. For infants younger than 3 months it is not recommended.

Of note, the FDA makes it very clear that the weight-based dosing recommendations are not intended for premature infants, as given their immature renal function, they can have slower clearance and offer the potential for toxicity.

So, we started him on oseltamivir, and we had as well an immediate concern for the parents. So we gave them a prescription for prophylactic oseltamivir use. Hopefully they won't develop the symptoms. They are immunized and hopefully in the case that the flu shows up, it will be as mild as it can be.

What about the other kids in the daycare? should they receive prophylaxis? what is my role as a hospitalist? - we essentially let the parents inform the daycare about the case and the other children's parents can discuss with their pediatricians; most likely they'll get prophylaxis.

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