Current Recommendations for Childhood Respiratory Vaccines
November 1, 2025 5 minutes read
By Philip R. Fischer, MD, DTM&H
Synopsis: Amidst prevalent vaccine hesitancy, changing governmental advisory groups, and altered recommendations, COVID immunization still is recommended for all children aged 6 through 23 months and for older children with medical risk factors.
Source: American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for COVID-19 vaccines in infants, children, and adolescents: Policy Statement. Pediatrics. 2025; doi: 10.1542/peds.2025-073924. [Online ahead of print].
Current data show that COVID-19 continues to be a significant cause of childhood hospitalization and death. COVID vaccines are proven to be both safe and effective when used to reduce the risks of seriously bad outcomes associated with SARS-CoV-2 infection (including long COVID and multisystem inflammatory syndrome in children).
With the goal of preventing severe COVID-related disease and based on solid evidence, updated recommendations from the American Academy of Pediatrics focus on children and adolescents who are at risk of severe COVID.
Children aged 6 through 23 months of age without medical contraindications should receive (or, if partially vaccinated, complete) an initial vaccine series. Then, they should receive a single dose of the 2025-2026 vaccine, at least eight weeks after completing the initial vaccine series.
Children 6 months through 18 years of age who are significantly (moderately or severely) immunocompromised should receive at least two doses of the 2025-2026 vaccine (or more if they had not completed a full initial series of COVID vaccinations).
Children aged 2 through 18 years of age who live in a group residential setting, such as a long-term care facility, and children aged 2 through 18 years of age who have a significant chronic medical condition (including asthma, sickle cell disease, cerebral palsy, and diabetes) should receive a single dose of a COVID vaccine, as should all children and adolescents aged 2 through 18 years of age who have never previously received a COVID vaccine.
In addition, COVID vaccination is advised for children who have household contacts at high risk of severe COVID.
Application of these recommendations is not altered by whether the child previously had a COVID infection. Any of the vaccines approved by the Food and Drug Administration is acceptable, as long as it is the newest version of the vaccine as manufactured in view of the 2025-2026 respiratory virus season.
Commentary
The Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) regularly provides updated evidence-based vaccine recommendations for children. Coincidentally, evidence-based respiratory vaccine recommendations for the upcoming winter season in North America were released just a few weeks before a U.S. government group chose not to recommend routine COVID vaccination for children. The evidence-based recommendations of the American Academy of Pediatrics have not changed based on differing conclusions by the newly formulated Advisory Committee on Immunization Practices (ACIP).
Many clinicians and scientists were rightly disappointed by the ACIP’s decision not to positively recommend routine COVID vaccination for children. Many lay people interpreted the new ACIP recommendation as suggesting that children not be vaccinated for COVID protection. However, what the ACIP statement actually said was just that they were not recommending vaccination; the ACIP did not say it was recommending that children not be vaccinated.1
The newly re-formed ACIP recommended that there be shared decision-making between families and healthcare professionals.1 In fact, the recommendation for shared decision-making is consistent with long-term practice for all medical decision-making. Now, armed with the new AAP recommendations, parents can see that their decision, as always, should be based on scientific information and the consensus of actual medical professional subject matter experts.
The ACIP recommendation also suggested consideration of the risks of severe COVID in some individuals; again, this is consistent with AAP advice. Clinicians can make it clear to families that while the ACIP did not recommend either for or against COVID vaccination, the ACIP statement actually is consistent with expert opinion that vaccination be considered and received.
Whether this perspective is helpful in convincing vaccine-hesitant families to vaccinate their children remains to be seen.
The AAP also recently released recommendations for the prevention of pediatric disease due to influenza and respiratory syncytial virus (RSV) infections.2-4 As for COVID vaccination, application of the updated influenza and RSV guidelines can reduce illness and death related to these common winter infections.
Prevention and Treatment of Influenza in Children
During the 2024-2025 respiratory virus season, there were 280 reported childhood deaths in the United States due to influenza; 89% of those children had not been fully vaccinated.5 This represented the second most such deaths since reporting was standardized in 2004 (second only to the 2009-2010 year of H1N1).5
Based on updated evidence (with 268 cited references), the AAP also released its new influenza guidelines.2,3 For the 2025-2026 season, as clearly stated, “The AAP recommends annual influenza vaccination of all children without medical contraindications starting at 6 months of age.”3 The AAP goes on to say that, “antiviral treatment of influenza is recommended for children with suspected or confirmed influenza who are hospitalized or have severe or progressive disease or have underlying conditions that increase their risk of complications of influenza.”3
In the United States, all influenza vaccines currently in use are trivalent; the composition of the vaccines has been updated for the current season.3 Everyone who is at least 6 months of age during the 2025-2026 influenza season should be vaccinated.3
Prevention of RSV Disease in Children
Similarly, the AAP released pre-publication guidelines for the prevention of RSV disease.4 Children younger than 8 months of age entering or during their first RSV season whose mothers were not known to be vaccinated with an RSV vaccine during the pregnancy (and at least two weeks prior to delivery) should be vaccinated.4 For children born during the October through March RSV season, the vaccine should be given within the first week of life.4 Immunization with either nirsevimab and clesrovimab is appropriate.4
Children aged 8 through 19 months entering their second RSV season who are at high risk of serious RSV disease (those with chronic lung disease of prematurity who required treatment for their lung disease during the six months prior to the beginning of the current RSV season, those who are severely immunocompromised, those with cystic fibrosis who had past severe lung disease or who have persisting chest X-ray abnormalities, those whose weight-for-length is below the 10th percentile, and those of Alaskan and Native American heritage) should receive RSV immunizaton.4 Clesrovimab is not yet approved for use in children entering their second RSV season.4
Philip R. Fischer, MD, DTM&H, is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
References
1. U.S. Department of Health and Human Services. ACIP recommends COVID-19 immunization based on individual decision-making. Sept. 19, 2025. www.hhs.gov/press-room/acip-recommends-covid19-vaccination-individual-decision-making.html
2. American Academy of Pediatrics, Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2025-2026: Technical Report. Pediatrics. 2025;156(5):e2025073622.
3. American Academy of Pediatrics, Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2025-2026: Policy Statement. Pediatrics. 2025;156(5):e2025073620.
4. American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for the prevention of RSV disease in infants and children: Policy Statement. Pediatrics. 2025; Aug. 19. doi: 10.1542/peds.2025-073923. [Online ahead of print].
5. Reinhart K, Huang S, Kniss K, et al. Influenza-associated pediatric deaths — United States, 2024-25 influenza season. MMWR Morb Mortal Wkly Rep. 2025;74(36):565-569.
Amidst prevalent vaccine hesitancy, changing governmental advisory groups, and altered recommendations, COVID immunization still is recommended for all children aged 6 through 23 months and for older children with medical risk factors.
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