Influenza antiviral use declined among hospitalized children during the COVID-19 pandemic

Influenza antivirals are recommended for children hospitalized with influenza because they can reduce complications and improve outcomes.¹ However, new data suggest that antiviral use declined during the COVID-19 pandemic, even as influenza severity rebounded. A multicenter surveillance study published in Pediatrics examined patterns of influenza antiviral use among hospitalized children before and during the COVID-19 pandemic and identified clinical and system-level factors associated with prescribing.²

The study, conducted through the New Vaccine Surveillance Network (NVSN), analyzed data from children younger than 18 years hospitalized with acute respiratory illness and laboratory-confirmed influenza at 7 US pediatric hospitals between December 1, 2016, and June 30, 2023. Investigators compared antiviral use during the pre-pandemic period (2016–2020) with the late pandemic period (2021–2023), excluding the early pandemic period because of minimal influenza circulation.²

Study design and population

Researchers included children hospitalized within 10 days of symptom onset who tested positive for influenza by clinical or research testing. Clinical testing was provider-directed, whereas research testing results were not available to clinicians. Antiviral use was defined as receipt of oseltamivir, peramivir, baloxavir, or zanamivir during hospitalization.

Among 31,312 hospitalized children tested for influenza, 1,560 (5.0%) had laboratory-confirmed influenza. Of these cases, 1,188 occurred during the prepandemic period and 372 during the late pandemic period. The median age of hospitalized children increased slightly from 3.7 years prepandemic to 4.5 years during the late pandemic. Fewer children hospitalized during the late pandemic had at least 1 underlying medical condition or had received the current season influenza vaccine.

Trends in antiviral use

During the pre-pandemic period, influenza antiviral use among hospitalized children ranged from 48.3% to 56.8% across influenza seasons. In contrast, antiviral use declined during the late pandemic period, reaching 38.1% in the 2021–2022 season and 46.1% in the 2022–2023 season.

Overall, antiviral use during the late pandemic was significantly lower than during the prepandemic period. The authors reported that “the estimated antiviral use was 23% lower in the late pandemic (incidence proportion ratio, 0.77; 95% CI, 0.68–0.87) compared with the prepandemic period.” Even during the 2022–2023 influenza season, which was classified as high severity, antiviral use remained significantly below prepandemic levels.

Notably, declines were also observed among infants younger than 6 months, a population ineligible for influenza vaccination. In this group, 64.0% received antivirals during the pre-pandemic period compared with 41.9% during the late pandemic.

Factors associated with antiviral prescribing

The study identified several factors associated with higher odds of antiviral use during the late pandemic period. These included the presence of at least 1 underlying medical condition, receipt of the current season influenza vaccine, clinical testing for influenza, and intensive care unit admission at presentation. In contrast, symptom duration of 2 or more days at presentation was associated with lower odds of antiviral receipt.

The authors also observed substantial site-to-site variation in antiviral use, even after adjustment for patient and clinical factors. Differences between the highest- and lowest-utilizing hospitals exceeded fivefold, suggesting institutional practices may influence antiviral prescribing.

Clinical influenza testing appeared to play a key role. Among children who underwent clinical testing and had positive results, antiviral use was substantially higher than among those who were not clinically tested. However, despite increased clinical testing during the late pandemic period, overall antiviral use declined.

Interpretation and implications

All children hospitalized with influenza meet criteria for antiviral treatment under current recommendations from the Centers for Disease Control and Prevention and professional societies. The authors emphasized that “influenza antiviral use in children hospitalized with influenza remained suboptimal following the COVID-19 pandemic.”

Potential explanations for declining antiviral use include changes in health care utilization, shifts in provider decision-making, concerns about medication availability, and broader effects of the pandemic on trust in medical interventions. The authors noted that despite guideline consistency before and after the pandemic, prescribing patterns changed in ways that were not fully explained by patient characteristics alone.

Conclusions

The investigators concluded, “This study shows a concerning decline in the use of influenza antivirals among hospitalized children with laboratory-confirmed influenza during the late COVID-19 pandemic compared with prepandemic levels.” They further stated that “our study highlights the need to improve antiviral use in children hospitalized with influenza.”

These findings underscore the importance of reinforcing guideline-concordant care and monitoring antiviral prescribing trends as influenza continues to circulate with variable severity in pediatric populations.

References

1. Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. Updated December 8, 2023. Accessed January 22, 2026. https://www.cdc.gov/flu/hcp/antivirals/summary-clinicians.html
2. Hamdan O, Amarin JZ, Antoon JW, et al. Influenza Antiviral Use in Hospitalized Children Before and During the COVID-19 Pandemic. Pediatrics. Published online January 14, 2026. doi:https://doi.org/10.1542/peds.2025-071898