Changes in Antiviral Prescribing for Children With Influenza in US Emergency Departments.

Importance: Despite national recommendations, antiviral prescribing in emergency departments (EDs) for children at higher risk of severe influenza, such as those younger than 5 years and those with specific underlying conditions, remains low. Objective: To assess whether there were changes in antiviral prescribing for children at higher risk of severe influenza in academic pediatric EDs before the COVID-19 pandemic (2016-2020) vs the late pandemic period (2021-2023). Design, Setting, and Participants: This multicenter, cross-sectional study included influenza-positive children younger than 18 years presenting to the ED at 1 of 7 US pediatric academic hospitals participating in the Centers for Disease Control and Prevention's New Vaccine Surveillance Network. The analysis focused on children at higher risk of severe influenza seen in the ED from December 1, 2016, to June 30, 2023. Exposure: High risk of severe influenza. Main Outcomes and Measures: The primary outcome was antiviral prescribing. Children with influenza who met the criteria for higher risk of severe influenza were included. Antiviral prescribing practices were compared across the prepandemic and late pandemic periods. Mixed-effects logistic regression was used to identify factors associated with prescribing during the late pandemic period. Results: Of 3378 influenza-positive children (median [IQR] age, 3.9 [1.8-7.2] years), 2514 (74.4%; 1363 male [40.3%]) were classified as having higher risk of severe influenza during the prepandemic and late pandemic periods. Antiviral prescriptions decreased from 32.2% (622 of 1931 children) before the pandemic to 15.6% (91 of 583 children) in the late pandemic period, representing a 53% relative decrease. In the late pandemic period, symptom duration less than 2 days (adjusted odds ratio, 4.08; 95% CI, 2.49-6.71) and clinical influenza testing (adjusted odds ratio, 17.20; 95% CI, 4.08-72.37) were significantly associated with antiviral prescribing. Conclusions and Relevance: This multicenter, cross-sectional study of children with influenza in EDs found that, for children at higher risk of severe influenza illness, influenza antiviral prescribing decreased during the COVID-19 pandemic compared with prepandemic levels, despite unchanged treatment guidelines. Interventions are needed to support guideline-concordant prescribing in this population.