Declining Antiviral Prescribing for High-Risk Children with Influenza in US Pediatric Emergency Departments During the COVID-19 Era

Highlight

1. Antiviral prescribing in pediatric emergency departments (EDs) for children at higher risk of severe influenza significantly decreased during the COVID-19 pandemic compared to prepandemic levels.
2. Despite unchanged treatment guidelines recommending antiviral use for high-risk children, prescribing dropped from 32.2% before the pandemic to 15.6% in the late pandemic period.
3. Clinical influenza testing and early symptom duration (<2 days) were associated with higher likelihood of antiviral prescription.
4. These findings highlight an urgent need for targeted interventions to enhance guideline-concordant antiviral use in pediatric EDs.

Study Background

Influenza remains a significant cause of morbidity in children, particularly those younger than 5 years or with underlying medical conditions that predispose to severe disease. Antiviral therapy, primarily with neuraminidase inhibitors such as oseltamivir, is recommended for children at higher risk of influenza complications to reduce severity and hospitalization rates. Emergency departments (EDs) often serve as entry points for acute pediatric influenza management, underscoring the importance of appropriate antiviral prescribing in this setting.

Despite longstanding national guidelines endorsing early antiviral use in high-risk pediatric populations, prior data revealed suboptimal prescribing rates in EDs. The emergence of the COVID-19 pandemic in 2020 added complexity to respiratory illness evaluation and management, potentially influencing clinical decision-making around influenza treatment.

Study Design

This multicenter, cross-sectional study analyzed influenza-positive children younger than 18 years who presented to emergency departments of seven US pediatric academic hospitals participating in the Centers for Disease Control and Prevention’s New Vaccine Surveillance Network. The study period spanned from December 1, 2016, through June 30, 2023, allowing comparison between the prepandemic (2016-2020) and late pandemic (2021-2023) periods.

Children classified as higher risk for severe influenza—based on age younger than 5 or the presence of specific underlying conditions—were the focus. The primary outcome was the proportion of antiviral prescriptions given during the ED visit. Mixed-effects logistic regression analysis was used to explore factors associated with antiviral prescribing in the late pandemic interval.

Key Findings

A total of 3,378 influenza-positive children were included, with a median age of 3.9 years (interquartile range, 1.8-7.2 years). Of these, 2,514 (74.4%) met criteria for higher risk of severe influenza illness.

Antiviral prescribing decreased markedly from 32.2% (622 of 1,931 children) in the prepandemic period to 15.6% (91 of 583 children) in the late pandemic period, representing a 53% relative reduction. This decline occurred despite no changes in clinical guidelines recommending antiviral treatment for this population.

Factors independently associated with antiviral prescribing during the late pandemic included symptom duration less than two days (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.49-6.71) and undergoing clinical influenza testing in the ED (aOR, 17.20; 95% CI, 4.08-72.37). Notably, younger age or specific high-risk conditions did not remain significantly associated in the adjusted model, indicating testing and early presentation influenced prescribing decisions more robustly than baseline risk status.

The findings suggest a shift in clinician practice patterns potentially related to altered perceptions of influenza risk, greater diagnostic uncertainty, or resource constraints during the pandemic.

Expert Commentary

This study raises critical concerns about decreased adherence to antiviral prescribing guidelines for children most vulnerable to severe influenza outcomes. Although the COVID-19 pandemic shifted healthcare priorities and clinical workflows, maintaining evidence-based treatment for influenza remains essential, especially as other respiratory viruses resurge following pandemic mitigation measure relaxation.

The strong association between antiviral prescribing and influenza testing highlights the crucial role of rapid diagnostic confirmation in guiding treatment decisions. Barriers such as limited testing availability, quick turnaround times, or competing clinical demands during the pandemic may have contributed to reduced antiviral use.

Study limitations include potential unmeasured confounders affecting prescribing, lack of detailed information on clinician rationale, and the focus on academic pediatric EDs, which may limit generalizability to other settings. Nonetheless, the multicenter design strengthens the validity of observed trends across diverse geographic regions.

Conclusion

Despite clear guidelines advocating antiviral treatment for children at high risk of severe influenza, this study reveals a significant decrease in prescribing in pediatric EDs during the COVID-19 pandemic. Prompt clinical influenza testing and early symptom duration remain important drivers of antiviral use.
Targeted interventions—such as clinician education, optimized diagnostic workflows, and stewardship programs—are urgently needed to restore and enhance guideline-concordant antiviral prescribing to mitigate severe influenza outcomes in vulnerable pediatric populations.

Future research should explore underlying causes for reduced antiviral use and evaluate strategies to integrate influenza management protocols effectively within the evolving landscape of respiratory infections post-pandemic.

Funding and Clinical Trials

This study was conducted within the CDC’s New Vaccine Surveillance Network. Specific funding sources were not detailed in the report. Clinical trial registration was not applicable given the observational study design.

References

Stopczynski T, Hamdan O, Amarin JZ, et al. Changes in Antiviral Prescribing for Children With Influenza in US Emergency Departments. JAMA Netw Open. 2025;8(10):e2538729. doi:10.1001/jamanetworkopen.2025.38729

Centers for Disease Control and Prevention. Influenza Antiviral Medications: Summary for Clinicians. Accessed 2025. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm