The American Academy of Pediatrics reaffirmed its recommendation that young and high-risk children receive COVID-19 vaccines and expanded the list of high-risk children it advises to receive respiratory syncytial virus immunization for a second season.
The recommendations, published Sept. 2, come amid upheaval among federal health officials. About three weeks ago, President Donald Trump directed HHS to assess a reduced immunization schedule for children.
COVID-19 vaccines and the respiratory syncytial virus (RSV) products are expected to remain covered under private insurance and the Vaccines for Children program.
COVID-19 recommendations
For COVID-19, the AAP recommends all children 6 to 23 months without a contraindication receive the 2026-2027 vaccine, regardless of prior doses or infection. It also recommends vaccination for children and adolescents who are moderately or severely immunocompromised, who need two or more doses.
“It still remains highly efficacious in preventing severe disease and hospitalization in children,” said Roberta DeBiasi, MD, who led the AAP Committee on Infectious Diseases COVID-19 subgroup.
For children 2 to 18, the AAP recommends a single dose for those at high risk of severe disease, residents of long-term care or other congregate settings, those never vaccinated, or those with a high-risk household contact. Children outside those groups should be offered a dose if a parent wants the protection.
The FDA has approved updated vaccines — reformulated with the XFG subvariant of the JN.1 lineage — for high-risk children. The AAP’s recommendations give pediatricians evidence-based standards to vaccinate healthy children off-label.
RSV recommendations
On RSV, the AAP added four groups to its list of children 8 to 19 months at high risk for severe disease and recommended for a second season of immunization: those born before 32 weeks’ gestation, regardless of support needs; those with hemodynamically significant congenital heart disease; those with anatomic pulmonary abnormalities or neuromuscular disorders that raise their risk; and those with Down syndrome or other chromosomal differences that raise their risk.
The existing high-risk list already included children with chronic lung disease of prematurity, severe immunocompromise, certain children with cystic fibrosis and American Indian and Alaska Native children. The academy continues to recommend immunization for all infants under 8 months entering their first RSV season who are not protected by vaccination during pregnancy.
RSV causes 58,000 to 80,000 hospitalizations a year in children under 5 and has been the leading cause of infant hospitalization in the U.S., according to the CDC. The newly added population is small but consequential for hospitals, said Sean O’Leary, MD, the AAP’s immunization schedule editor and leader of the RSV subgroup.
“When they do get hospitalized their length of stay tends to be quite a bit longer and hospital costs tend to be quite a bit higher,” Dr. O’Leary said.
The AAP said it is in talks with insurers to secure coverage for the expanded second-season indications. Access barriers persist: some hospitals are not enrolled in the Vaccines for Children program, and some are still negotiating with insurers to fold the products into bundled hospital payments or bill them separately.
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