Source: Campbell AP, Tokars JI, Reynolds S, et al. Influenza antiviral treatment and length of stay. Pediatrics. 2021;148(4):e2021050417; doi:10.1542/peds.2021-050417Investigators from multiple institutions conducted a retrospective study to assess the effect of treatment with neuraminidase inhibitors (NAIs) on length of hospital stay (LOS) in children with influenza. Study data were abstracted from the Influenza Hospitalization Surveillance Network (FluServ-NET), a population-based surveillance network with data from 10 counties in different states and 5 entire states. Information on patients in the surveillance system, including demographics, patient characteristics, treatment with NAIs, symptom onset, and details on hospitalization were collected. Study participants were children <18 years old with laboratory-identified influenza who were divided into 2 cohorts for analysis. Cohort 1 included children with ≥1 medical condition and not admitted or transferred to an ICU who were hospitalized during the 2012–2013 influenza season. Cohort 2 were children with or without an underlying medical condition who were admitted to an ICU during 3 consecutive influenza seasons (2010–2011, 2011–2012, and 2012–2013). Exclusion criteria included missing information on receipt of NAIs, LOS <1 day, and symptom onset on or after ≥3 days prior to admission. Receipt of NAIs was classified as never, ≤2 days after onset of symptoms (early), or ≥3 days after symptoms (late). The primary study outcome was LOS, and the association of treatment with NAIs on LOS was evaluated using Cox regression after controlling for confounders.During the 2012–2013 influenza season, data on 1,924 children hospitalized with influenza were collected in FluServ-NET; 1,039 (54%) had ≥1 underlying medical condition. After applying exclusions, cohort 1 consisted of 309 children, of whom 199 (64.4%) received early NAI ≤2 days after treatment, 37 (12.0%) were treated ≥3 days after symptom onset, and 73 (23.6%) had no treatment with NAIs. After controlling for confounders, a shorter LOS was statistically associated with early NAI treatment (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.05, 1.80), but not late treatment (HR, 1.02; 95% CI, 0.67, 1.54). There were 299 children admitted to an ICU, included in cohort 2 analyses, with a median LOS of 5 days. NAIs were started ≤2 days after symptom onset in 168 (56%), ≥3 days after onset of symptoms in 45 (15%), and never in 86 (29%). In this cohort, early NAI treatment also was associated with shorter LOS (HR, 1.46; 95% CI, 1.11, 1.92), and late NAI treatment was not (HR, 1.20; 95% CI, 0.85, 1.69).The authors conclude that early treatment with NAIs in children with influenza was associated with shorter hospitalizations.Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Treatment with NAIs has been shown to reduce hospitalization among high-risk adults and children with influenza.1 NAIs also have been shown to reduce mortality among hospitalized adults when given ≤2 days after symptom onset but have not been associated with a reduction in mortality among children <16 years.2 Because of these studies and others, treatment with NAIs has been recommended for patients of all ages with influenza since 2009.3 However, since most studies of NAIs were performed on outpatients and adults, the experience among hospitalized children is limited.4 The current investigators close that gap.The investigators employed a large data set, controlled for confounding variables, and were careful to reject participants for whom NAI use was not known. Further, they studied children who would benefit the most from NAIs: those with ≥1 chronic illness and those admitted to the ICU. The most common chronic medical conditions included chronic lung and cardiac diseases such as asthma, neurologic diseases, prematurity, immunocompromise, and chronic metabolic or blood disorders. Interestingly, 48% of the chronic illness cohort and 37% of the ICU cohort were vaccinated for influenza. Vaccination status was not associated with LOS.The results of the current study affirm the Centers for Disease Control and Prevention (CDC) position to start early empiric treatment with NAIs on all patients suspected of influenza.3 Interestingly, the CDC also recommends NAIs in all hospitalized patients with influenza regardless of time of onset due to potential reduction in viral shedding and LOS.5Among children with influenza admitted to the ICU or with ≥1 chronic conditions, treatment with NAIs within ≤2 days of symptom onset is associated with a shorter LOS compared to those treated ≥3 days after symptom onset or not at all. (See AAP Grand Rounds. 2021;46[4]:39).6