Pediatric Rounds
Fall 2003

1. Common pediatric issue: Acute abdominal pain in children
2. Addressing bullying: An opportunity for injury prevention
3. Innovative program launched to help overweight children
4. Pediatric obesity specialist to lead NEW Kids Program 
5. Awards
6. New CSG members
7. FluMist vaccine facts

1. Common pediatric issue: Acute abdominal pain in children

According to the National Center for Health Statistics, acute abdominal pain is the most common reason for emergency department visits for patients of all ages. It also is one of the most frequent complaints in children visiting outpatient clinics.

Evaluation of children with acute abdominal pain is complex and challenging, largely because of enormous differential diagnoses. Diagnoses vary significantly with age range, from newborn to adulthood. In very young or uncooperative children, it often is difficult to obtain a complete history and physical examination. The key to successful evaluation lies in understanding the likely etiology within specific age groups. (See Table 1).

Table 1: Common causes of acute abdominal pain in children

	Infancy (under 2 years)	Preschool (2-5 years)	School age (6-12 years)	Adolescent(over 12 years)
Intra-abdominal	Appendicitis Colic Constipation GE Hernia Hirschsprung's Intussusception Pyloric stenosis Trauma Volvulus	Appendicitis Constipation GE Hernia Intussusception Non-specific AP Trauma	Appendicitis Constipation GE IBD Non-specific AP Testicular torsion Trauma	Appendicitis Constipation Dysmenorrhea GE IBD Non-specific AP Pregnancy (ectopic) Testicular torsion Trauma Tubo-ovarian Dz
Non-abdominal	HUS Metabolic Dz Pneumonia Sepsis Toxic ingestion	DKA HUS Pneumonia Sepsis Strep pharyngitis Toxic ingestion	DKA Collagen vascular HUS Pneumonia Sepsis Strep pharyngitis Toxic ingestion	DKA Collagen vascular HUS Drug abuse Pneumonia Sepsis Strep pharyngitis Toxic ingestion

Items in bold are life threatening conditions

History and physical examination
It is essential to obtain a comprehensive history of pain, vomiting, bowel movement, urinary symptoms and sexual activity. (See Table 2). The presence of fever should be noted and information regarding medical and surgical history and medication use also should be obtained.

If a child is in severe pain or is uncooperative it can be especially difficult to complete an examination. The goal is to perform a quick assessment of overall stability with a focus on a thorough abdominal examination. Helpful examination techniques include keeping the child comfortable in parent's arms or lap and using distraction methods. While flexing the child's hip note subtle facial expressions from discomfort or pain. In some cases, parenteral analgesics may be needed to adequately assess the abdomen and to provide comfort to the child.

Physical examination includes general appearance and attitude in bed, vital signs an other obvious extra-abdominal findings.

Abdominal pain may manifest in infants and younger children in the following ways:

• Irritability.
• Tachypnea, grunting or retraction.
• Tachycardia.
• Preferred hip flexion.
• Abnormal gait or sitting position.

Components of an abnormal examination include:

• Visual inspection for distention.
• Bowel sounds.
• Tenderness to light and deep palpation (note voluntary or involuntary guarding).
• Tenderness to percussion.

Other helpful findings and terms include:

• The rebound tenderness test no longer is recommended as it may cause unexpected and unnecessary pain to patients. Gentle percussion will provide more accurate information - it can be regulated and tenderness can be localized easily.
• Rovsing sign: referred tenderness during palpitation.
• Iliopsoas sign: painful extension at the hip.
• Obturator sign: painful internal rotation of the hip.
• GU, pelvic and/or rectal examinations may be warranted.

After the initial evaluation, immediate intervention should be provided to children with a potentially life-threatening condition or they should be transferred in a timely manner to a tertiary facility for definitive care.

Table 2: Components of history in children with abdominal pain

Pain	Vomiting	Bowel movement	Urinary	Sexual*
Onset Location Severity Quality Character Radiation Pattern	Color Volume Frequency Character Duration Severity Relationship to pain Nausea Appetite	History of constipation Frequency Consistency Color Relationship to pain	Dysuria Urgency Frequency Color	Character of menses LMP Discharge Blood Sexual activity Protection History of STD

*When applicable

Diagnostic studies
In addition to comprehensive history, methodical and skillful examination usually can identify many of the etiologies without the need for diagnostic studies. "Although helpful at times, over reliance on laboratory tests and radiologic evaluations very often will mislead the clinician, especially if the history and physical examination are less then diligent and complete."

• CBCs are of limited use in the diagnosis of acute abdominal pain in children and routine ordering strongly is discouraged. Elevated WBC has been used extensively in suspicion of appendicitis, however normal WBC is seen in 10 percent of patients with appendicitis and elevated levels in 60 percent of those without.
• Up to 25 percent of patients with appendicitis can have greater than five WBC in urinalysis. Therefore, routine urinalysis on patients with acute abdominal pain can mislead clinicians and delay definitive diagnosis.
• The abdominal radiograph, helpful in selected patients without a clear diagnosis, assesses the bowel gas pattern, amount of stool, fecolith - if present - and any contraindications for GI contrast studies.
• The role of ultrasound to evaluate children with abdominal pain is limited by availability and by the experience of the technician and radiologist. Other limitations include the lack of global assessment of the entire abdomen and the need for full bladder. However, in selected cases, the ultrasound is helpful in evaluation of the gallbladder, pancreas, tuboovarian and renal pathologies.
• Recently, the use of CT has been extensively studied in the diagnosis of appendicitis, with reports of diagnostic accuracy in the range of 93 to 96 percent. However, the decision to order a CT should be made in equivocal cases in conjunction with surgical evaluation. The advantages of abdominal CT include the ability to detect mass lesions and solid organ abnormalities within the entire abdomen. It is readily available and used commonly for patients with blunt abdominal trauma.  

A judicious use of diagnostic methods, after thorough clinical evaluation, will minimize delays in definitive interventions, false sense of security or urgency, and unnecessary exposure and cost. Clinical examination by an experiences clinician is the best diagnostic tool available.

Disposition
Evaluating children with abdominal pain in an office setting can be challenging. Evaluating children with abdominal pain in an office setting can be challenging. Availability of personnel, equipment and medications, diagnostic modalities, pediatric radiologists, and inability to monitor the patient over time frequently are encountered limitations. When a patient requires more than simple evaluation and treatment, it is recommended that the patient be referred to a tertiary pediatric emergency department for continued evaluation and intervention.

When referring patients to the Children's Hospital's Emergency Department/Trauma Center, it is essential that you communicate directly with a staff member. Call (414) 266-2626 and a professional will help facilitate the transfer and formulate a care plan. Provide a brief history and physical, likely diagnosis, interventions made and test results. If there is a preferred method of transport, we can assist in arranging for it and expediting patient care upon arrival at Children's Hospital. For patients with severe abdominal pain in need of urgent intervention, or a child who is unstable, contact Children's Hospital Transport at (414) 266-0366.

Summary

• Clinical evaluation is the key to diagnosis.
• Limtiations exist with many diagnostic studies.
• Determination of life-threatening conditions is essential.
• Timely transfer of child, if indicated, is important for severe abdominal problems.

Source: Michael K. Kim, MD, is on staff in the Emergency Department/Trauma Center  at Childrnen's Hospital of Wisconsin. He is an assistant professor of Pediatrics (Emergency Medicine) at the Medical College of Wisconsin and a member of Children's Specialty Group.

For more information:
Emergency Department/Trauma Center:
(414) 266-2626

Children's Hospital Transport:
(414) 266-2460 or toll free outside of Milwaukee at (800) 266-0366.

2. Addressing bullying: An opportunity for injury prevention

Bullying is a significant problem for many school-aged children. When school starts each fall, many children and their parents worry about how children will cope with their peers. Both physical and emotional problems ensue when bullying begins. In recent school shootings, it has been suggested that bullying and the resulting isolation may have been precipitating factors for the violence. Physicians who care for children have an important role to prevent, identify and treat bullying behaviors.

Definition
Bullying is defined as:

• An intentional act of aggression with the objective of causing physical, psychological or emotional distress to another.  
• A relationship existing with a disproportionate distribution of power, with the stronger individual or group abusing the weaker one.
• The behavior pattern is repeated over time. The abuse includes, but is not limited to, behaviors such as hitting, kicking, name-calling, rumors, negative Internet messages and exclusion.

There are three ways to participate in bullying:

1. Direct bullying involves an active confrontation between the bully and the victim.
2. Indirect bullying occurs by shunning or ignoring the victim.
3. Passive bullying happens when other children provide support to a bully.

Profiles
Once associated only with boys, a greater number of girls now are affected by bullying.

Bullies participate in aggressive and antisocial behavior. The tendency to dominate over others is a prevalent attitude. Bullies may feel rewarded by sensing social influence, a feeling of being "in control," and occasionally stealing material goods. Contrary to the popular stereotype that bullies are insecure, bullies have average or lower than average levels of anxiety and insecurity. Physically, bullies usually are stronger than most of their peers, but particularly stronger than their victims.

Victims generally react passively and anxiously to situations. They often view the current situation as hopeless and will try avoiding the places the bully may be. Children with physical disabilities, developmental delay or conversely, outstanding academic skills, all are at increased risk for being bullied. Homosexuals also are targeted.

Prevalence
Bullying is common in elementary school children in the United States as well as throughout the world. Nansel et al. examined surveys completed the World Health Organization's Health Behaviour survey in 1998. Twenty-nine percent of the sample reported moderate or frequent involvement in bullying: 13 percent as a bully, 10 percent as a victim of bullying and 6 percent as both. Olweus found in Norwegian children that younger children were more apt to be bullied than older children with rates of 17 percent at age 7 to 4 percent at age 15. Boys are more likely to be involved in bullying than girls, 14 percent versus 9 percent. Boys are more likely to be involved in physical victimization - some resulting in beatings with serious head injuries, multiple contusions and fractures. Whereas girls are more likely to utilize rumor, isolation and name-calling in their bullying attacks. Most bullying episodes occur at school or on the way to and from school.

Effects of bullying
Victims of bullying suffer physical, emotional, developmental and educational losses. They may feel they deserve to be teased. These victims have greater difficulty making friends at school because other children may be fearful they also will become victims of bullying by association. Avoiding school to avoid bullying is a common problem for the bullied child. Many bullied children ask to stay indoors at recess, a time when many bullying attacks occur.

Bullies also may suffer consequences. Aggressive behavior during childhood may lead to other physically aggressive acts, violence and delinquency. They may also face - much like their victims - social isolation, peer rejection and suicidal ideation. Bullies also are at risk for criminal convictions and alcoholism in adulthood. For these reasons, metal health services are an important consideration for bullies.

Physician's role
The child's physician should:

• Identify the problem.
• Counsel children, parents and school personnel on methods of intervention and prevention.
• Screen for and treat, or refer the child to mental health specialists, when symptoms of this or any mental illness is present.
• Support schools and communities in violence prevention activities.

Identification
When children come in for a visit, ask "How are things going at school?" This question can serve to open conversations. If the response indicates something is wrong, be prepared to ask more specific question. (See below).

Screening questions for children:

• Why don't you like school?
• Do other children tease you at school?
• At recess do you usually play by yourself?
• How long has this been going on?
• Have you told the teacher?

Parents also may provide information to suggest that a child is involved in a bullying relationship.

Screening questions for parents:

• Is your child being called o the principal's office frequently for fighting?
• Is your child often in the school nurse's office?
• Does your child have many friends?
• Is it normal for children to harass each other?

Physical complaints associated with bullying victims:
Children who have been victims of bullies report a number of complaints. These include:

• Headaches.
• Abdominal pain.
• Sleep difficulties.
• Enuresis.

Studies have shown that some behaviors and lifestyle conditions may increase the risk of a child becoming a bully. Behaviors of preschool-age children that may increase the risk of becoming bullies include:

• Irregular and unpredictable eating and sleeping habits.
• Strong negative moods.
• Slow adaptation to new situations.

Lifestyle conditions that may promote bullying are:

• No defined limits on aggression.
• Lack of a supportive home environment.
• Parents who model partner violence in their intimate relationships.
• Parents who use corporal punishment with their children.

Physicians need to include counseling during well-child visits for families of preschool children at risk for bullying.

Counseling parents
Parents of the victim should teach the child how to use nonviolent methods when encountering bullying. Children should be taught to stand up straight, speak firmly, make eye contact with the bully and walk away. Role-play with the child to establish a plan for the child to follow. Extracurricular activities such as sports, martial arts, art classes and music lessons can be a way to boost the child's self-confidence and make new friends.

Parents of the bully or victim should be counseled to initiate and attend a conflict resolution meeting with the parents of the other child involved. Many teachers and school counselors will assist in mediation during such meetings. Parents should seek mental health counseling for their children who have been in a bullying relationship.

Prevention is the most effective tool to reduce bullying behavior in children. Parents can help reduce bullying behaviors in their children by:

• Modeling aggression control.
• Teaching children that violence is a behavior that is not tolerated.
• Explaining the adverse effects of bullying.
• Teaching a child how to control feelings of anger and aggression.

Counseling school personnel
Many schools in Wisconsin have developed "conflict resolution" committees to address fighting that occurs during school. However, for individual students, school personnel may not know that a child is being bullied. School most likely is the place that bullying occurs, and it also is the place where prevention efforts can be most effective. Important efforts include:

• Creating awareness and involvement of all students, staff, parents and other who spend time helping or supervising the children.
• Dedicating a "peace at school" day to set a non-violent tone.
• Defining what constitutes an act of bullying.
• Setting forth guidelines that explain what steps a victim may take and the consequences of bullying.
• Scheduling updates for the children to provide input on the effectiveness of the program.
• Involving parents when bullying is discovered.
• Increasing the number of adult supervisors in activities such as recess.

These methods are effectiveness to decrease the incidence; however, teachers also should be trained to deal with a bullying incident when it occurs. It is important for teachers to know when a bully is caught during an incident they likely will change the focus of their aggression from the victim to the person intervening. Teachers should remove the victim and themselves from the incident. The consequences for bullying should not include punishment, but rather compensation to the victim. Some ideas for compensation would include:

• A public or private apology.
• A special favor for the victim.
• Replacing any items taken or damaged by the bully.

If the problem persists or increases in severity or frequency, the teacher may suggest involving healthcare professionals.

Screening for mental health issues
When bullying is a consideration in a child, the physician needs to screen for any other mental illness and prescribe appropriate treatment. Physicians should check for depression, suicidal ideation and anxiety disorder. In many instances, early referral to a psychiatrist or psychologist is indicated. Anger management and conflict resolution may be helpful to both the child and parents.

Advocacy
Physicians must advocate for bullying prevention in the community, particularly through schools, churches and youth-serving, community-based organizations. Our chief responsibility is to ensure the health of our patients. We should strive to prevent young patients from being subjected to violence or undue aggression. Our role is to promote their physical, emotional and educational development.

Source: Marlene Melzer-Lange, MD, is program director of Project Ujima and is on staff in the Emergency Department/Trauma Center at Children's Hospital of Wisconsin. She is a professor of Pediatrics (Emergency Medicine) at the Medical College of Wisconsin and a member of Children's Specialty Group.

Project Ujima:
Started in 1995, Project Ujima is a community project committed to helping stop the cycle of violent crimes by reducing the number of repeat victims of violence. Project Ujima includes the collaborative efforts of: Children's Hospital of Wisconsin, the Medical College of Wisconsin, the Kujichagulia Lutheran Center and the University of Wisconsin-Milwaukee Department of Psychology.

For more information:
Marlene Melzer-Lange, MD:
(414) 266-2647

Project Ujima:
(414) 266-6115

3. Innovative program launched to help overweight children

In conjunction with ongoing care from the primary care physician, the NEW (Nutrition, Exercise and Weight Management) Kids Program at Children's Hospital of Wisconsin offers a team approach to the increasing problem of overweight children. The NEW Kids Program is a multidisciplinary holistic approach that includes the coordinated effort of nurse practitioners, psychologists, dietitians, exercise physiologists and physicians. Children's Hospital has partnered with the YMCA of Metropolitan Milwaukee to attack this nationwide epidemic

Physicians and other health professionals at Children's Hospital, led by Jospeh Skelton, MD, developed this new program over the course of nearly a year. Skelton was chief resident at the time and now is a fellow in Pediatric Gastroenterology in the Gastroenterology Center at Children's Hospital. Experts in gastroenterology, diabetes, nutrition, psychology, pulmonary medicine and other disciplines provided their insights in creating the NEW Kids Program. Only a handful of similar programs for children currently exist throughout the country.

Program provides two avenues for treatment
The NEW Kids Program at Children's Hospital offers a multidisciplinary team to care for and design individual treatment plans for children who have complications of being overweight. In addition, family-centered exercise therapy is provided at local YMCAs.

New Kids at the Y is a community-based program that takes place at three branches of the YMCA of Metropolitan Milwaukee. Designed by a team of experts at Children's Hospital and the YMCA, this program provides families with in-depth nutrition, behavior and exercise education in a comfortable, family-friendly atmosphere. Primary care physicians will medically manage the child, providing support to the family and monitoring progress.

Due to the level of services needed to address this problem, both programs will see children by physician referral only. Children who do not meet the program criteria, or for whom incomplete information is given, cannot be seen. In addition, families must be motivated and want to make a change.

Evaluation and management of overweight children is challenging. To ensure that each child is referred to the proper caregivers, evaluation and treatment guidelines were created. If the tools are used properly, children with possible comorbidities will be identified and sent to the NEW Kids Program. In the Milwaukee area, those without an identifiable complication of overweight, but who still are motivated, can be followed by the primary care physician and participate in the NEW Kids at the Y with support from the NEW Kids Program team at Children's Hospital.

Who is overweight?
According to the Centers for Disease Control ad Prevention, overweight and at risk of overweight are the preferred terms to use when referring to children whose excess body weight could pose medical risks. One in five children is the metropolitan Milwaukee area iso considered overweight by this definition and numerous more are at risk for overweight.

Complications of overweight:

• Dyslipidemia.
• Hypertension.
• Insulin resistance and NIDDM.
• Low self-esteem
• Premature atherosclerosis.
• Sleep apnea and fatigue.
• Slipped capital femoral epiphysis.
• Cholecytitis.
• Osteoarthritis.

Referring a patient to the NEW Kids Program at Children's Hospital
If you have a patient who may need the services of the NEW Kids Program, follow this simple referral process.

1. Evaluate the child.
2. Complete the NEW Kids Program referral form.*
3. Fax referral form to the NEW Kids PRogram at Children's Hospital: (414) 266-6228. 
4. Start the referral to child's insurance.
5. The NEW Kids Program staff will contact the family.

*Referral packets, including evaluation information and referral guidelines, now are available at www.chw.org.

If you have questions about the NEW Kids Program or suggestions for meeting the needs of overweight children, contact Stephen Sondike, MD, at (414) 266-3690.

Source: Stephen Sondike, MD, (see below)

To refer a patient:
NEW Kids Program:
(414) 266-9617

To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280

4. Pediatric obesity specialist to lead NEW Kids Program

Stephen Sondike, MD, has been named program director for the NEW Kids Program at Children's Hospital of Wisconsin. Sondike, who joined the Gastroenterology Center at Children's Hospital, also is an assistant professor of Pediatrics (Gastroenterology) at the Medical College of Wisconsin and a member of Children's Specialty Group.

Sondike received his medical degree from State University of New York, Brooklyn, and completed a residency in Pediatrics and a fellowship in Adolescent Medicine at Schneider Children's Hospital, New Hyde Park, N.Y. He served as the director of the Nutrition and Wellness Porgram, Adolescent Health Center, at Mount Sinai Medical Center in New York. Sondike also was an assistant professor of Pediatrics at Mount Sinai School of Medicine.

Board certified in Pediatrics and Adolescent Medicine, Sondike is active in research related to obese adolescents, the ketogenic diet and attitudes of deaf adolescents toward healthcare. He has presented programs and workshops on these topics to medical audiences in New York, Arlingtonn, Va., and Boston.

5. Awards

Jordan N. Fink, MD, on staff in the Asthma/Allergy Center at Children's Hospital of Wisconsin and professor of Pediatrics (Allergy) at the Medical College of Wisconsin, received the Distinguished Achievement Award from the Milwaukee Academy of Medicine. The award is given annually to a Wisconsin physician in recognition of his or her outstanding contributions to the advancement of knowledge and practice in medicine.

Glenn Flores, MD, FAAP, on staff at Children's Hospital of Wisconsin, associate professor of Pediatrics (Epidemiology and Health Policy) at the Medical College of Wisconsin and associate director of the Center for the Advancement of Urban Children, has been awarded grants from the Robert Wood Johnson Foundation and the Commonwealth Fund in support of his project, A Family-centered Approach to Reducing Childhood Asthma Morbidity and Resource Use: A Randomized Control Trial of Community-based Case Management. Community partners in the study include Children's Health Education Center, Congress Elementary School, Starms Early Childhood Center, Allen Field Elementary School, LaCausa Family Resource Center and the 16th Street Community Center. The program supports using parent mentors to manage asthma care for urban minority children.

The palliative care programs of Children's Hospital of Wisconsin, the Medical College of Wisconsin and Froedtert Hospital have been designated as one of the nation's six Palliative Care Leadership Centers by the Center to Advance Palliative Care, a national program of the Robert Wood Johnson Foundation. The program received a three-year, $750,000 grant to provide site visits and hands-on training in Milwaukee for clinicians and hospital administrators throughout the nation who are interested in developing palliative care programs. Bruce Himelstein, MD, is the leader for the pediatric focus of the Palliative Care Leadership Center in Milwaukee. Himelstein is program director of the Palliative Care/Hospice Program at Children's Hospital and associate professor of Pediatrics (Oncology/Hematology) at the Medical College of Wisconsin.

6. New Children's Specialty Group (CSG) members

Marjorie Arca, MD, joined the staff of the Surgery Department at Children's Hospital of Wisconsin and became an assistant professor of Surgery (Pediatric Surgery) at the Medical College of Wisconsin. Arca earned her medical degree at the University of Califronia, Los Angeles, and completed a fellowship in Surgical Critical Care and a residency in General Surgery at the University of Michigan, Ann Arbor. She also completed a fellowship in Laparoscopic Surgery at Cleveland Clinic Foundation and a fellowship in Pediatric General Surgery at C.S. Mott Children's Hospital, Ann Arbor, Mich. She is board certified in general surgery, surgical critical care and pediatric surgery.

Tseghai Berhe, MD, joined the staff of the Endocrinology Department at Children's Hospital of Wisconsin and became an instructor in Pediatrics (Endocrinology) at the Medical College of Wisconsin. Berhe earned his medical degree at the Spartan Health and Sciences University, Vieux Fort, St. Lucia. He completed a residency in Pediatrics at Howard University and a fellowship in Pediatric Endocrinology at Georgetown University, both in Washington D.C. Berhe is board certified in pediatrics.

John N. Jensen, MD, joined the staff of Children's Hospital of Wisconsin as a pediatric plastic surgeon and became an assistant professor of Plastic Surgery at the Medical College of Wisconsin. Jensen earned his medical degree from Washington University School of Medicine in St. Louis where he also completed a residency in Plastic Surgery. He completed research fellowships in Plastic Surgery at Baylor College of Medicine in Houston and at Washington University School of Medicine. In addition, Jensen completed s fellowship in Craniofacial Surgery at New York University in New York City.

Valerie B. Lyon, MD, joined the staff of the Dermatology Department at Children's Hospital of Wisconsin and became an assistant clinical professor of Dermatology at the Medical College of Wisconsin. Lyon earned her medical degree at the University of Chicago, Pritzker School of Medicine. She completed a residency at Children's Hospital of Wisconsin and the Medical College of Wisconsin and a fellowship in Pediatric Dermatology at the University of California, San Diego. She is board certified in Dermatology.

7. FluMist vaccine facts

The new intranasal influenza vaccine, FluMist is an attenuated live viral vaccine, which is administered as a nasal spray. Additional information from the package insert about FluMist includes:

• FluMist is approved for healthy children, adolescents and adults between the ages of 5 and 49.
• At present, FluMist is contraindicated for children receiving aspirin therapy (Reye's Syndrome risk), those with a prior history of Guillain-Barre syndrome and any child with a suspected or known immunodeficiency, including HIV. It also is contraindicated is children receiving corticosteroids or other forms of immune suppression. FluMist should not be given to children or adults with reactive airway or asthma.
• The safety of FluMist in individuals with underlying medical conditions that may predispose them to severe disease following wild-type influenze infection has not been established as yet. According to the ACIP, such individuals include, but are not limited to children and adults with chronic disorders of the cardiovascular and pulmonary systems; pregnant women in their second or third trimester; children and adults who require regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes), renal dysfunction, or hemoglobinopathies; and children and adults with congenital or acquired immunosuppression, caused by underlying disease or immunosuppressive therapy.
• FluMist recipients should avoid close contact (for example, within the same household) with immunocompromised individuals for at least 21 days.

In view of the warnings on the package insert, the CHW Infection Control Committee encourages physicians and others involved in influenza immunization programs to carefully consider the infection control issues raised with the use of this vaccine in the outpatient setting.