Wendy Berg knew it would be hard breaking the news to her two young children that this year they would have to forgo their usual two-squirts-in-the-nose flu vaccine and instead roll up their sleeves for a shot.
She knew there would be whining.
She knew there would be pushback.
Most of all, she knew there would be fear.
So the St. Paul mom came up with a multifaceted plan to help her kids cope with their shot anxiety. First, she reasoned with them — explaining that being sick with the flu bug feels a whole lot worse than a sore arm. She also compared the sting of a flu shot with other experiences they've had with pain. For her 11-year-old daughter, Greta, it was getting her ears pierced. And for her 8-year-old son, Clyde, it was the time when he got stung by a bee.
" 'I'm sure you'll think that's worse than getting a shot,' " Berg told them.
And then she threw in a reward: She promised to take them to see "Finding Dory" after their shots.
After the recent discovery that the popular nasal spray performed poorly against the flu virus over the past three flu seasons, doctors and public health officials are recommending only the flu shot this year. That has left many parents scrambling to calm needle-phobic children.
"I think we're all disappointed," said Kris Ehresmann, director of infectious diseases for the Minnesota Department of Health. "Having the nasal spray as an option was perfect for the pediatric population. But we can't recommend it because it isn't the best choice right now."
The news comes during prime time for flu vaccines. Flu season typically starts in October and ends in May, generally peaking in Minnesota in January and February.
Children and the elderly are especially vulnerable to developing serious complications from flu — underscoring the importance of getting vaccinated, doctors and public health leaders say. The flu kills as many as 49,000 people every year, according to the Centers for Disease Control and Prevention (CDC).
In the past, about a third of all children who receive flu vaccines have opted for the nasal spray. It's unclear whether the no-nasal-spray recommendation will cause some kids — and perhaps even some adults — to skip getting vaccinated altogether.
The American Academy of Pediatrics recently issued a statement stressing that the best protection against the sometimes deadly flu virus is vaccination. Everyone 6 months or older should be vaccinated, the academy urged in its guidelines for the 2016-17 flu season.
Local health care workers echoed that message.
"It may not be a perfect tool, but it's your best tool to protect against a severe influenza infection," said Patsy Stinchfield, a nurse practitioner and senior director of infection prevention and control at Children's Hospitals and Clinics of Minnesota.
Shot anxiety affects children of all ages, but there are ways to reduce fears — and even the pain while getting a shot.
The Centre for Pediatric Pain Research in Canada suggests several methods, including: distracting children by talking to them or having them watch a favorite show while the injection is being administered, encouraging them to take deep breaths before the shot by blowing bubbles, and using topical anesthetics to numb the area where the shot will be given.
Other suggestions include consuming a bit of sugar before the shot, because sugar is believed to release endorphins that can offset feelings of pain; taking a pain reliever such as ibuprofen after the injection to minimize soreness later on, and keep the arm moving after the shot.
A show of arms
Hennepin County Medical Center started giving flu vaccines a couple of weeks ago, and so far, people have been willing to roll up their sleeves and get the shot, said Dr. Stacene Maroushek, a pediatrics infectious disease specialist at HCMC in Minneapolis.
"Parents are a little upset that we don't have the mist. But when we explain that it's not effective, they understand," she said.
The new recommendation is a flip-flop from previous years, when nasal sprays were believed to be more effective than shots for children under 8. But the CDC took a hard look at the data from the past three flu seasons and found that nasal sprays, such as FluMist, had lost their protective punch against the virus.
The data from last winter showed that the spray was only 3 percent effective for ages 2 to 17.
"It really did not do what they thought it was doing," Maroushek said. "I'm not sure why."
Among the theories spreading like, well, a virus, are:
• When the nasal spray came out, it was more effective than the shot because there were mismatched strains of virus that year. "They thought the nasal immunity was able to change and adapt to strains that weren't well-matched," Maroushek said.
• After years of using the nasal spray, the body might build up a resistance to it. "It's because of the adaptive immunity in the nose," she explained. "When you give it in the body [through an injection], it's already in the body. But with the mist it has to replicate in the nose."
The nasal spray works differently than the shot because it contains a live, weakened virus. It's adapted to replicate in the nose, inducing an immune response, without actually giving you the flu because of its weakened form, Maroushek explained.
The flu shot contains dead proteins. Although many people believe that the shot can cause you to get the flu, Maroushek and others insist that's impossible.
"It's not giving you a live virus," she said. "It's like the envelope, or the outside codes of the virus, is what you're getting. But none of the guts, the replicating apparatus."
She added, "You're more likely to pick up something in the waiting room of the clinic."
Enough supply
Stinchfield, of Children's Hospitals and Clinics of Minnesota, is on the CDC working committee that issues recommendations regarding vaccinations. She said she understands the disappointment over not having the nasal spray option this year — especially when dealing with children.
"It was quick and easy. People appreciated the lack of poke, if you will," she said. But the evidence could not be ignored.
"We really didn't have any choice," she said.
Many parents find the reversal from the previous pro-spray endorsement confusing.
"This is a hard message for the community," she acknowledged. "We had a vaccine that we favored. And now we don't have it at all. It raises questions of trust."
Dealing with the ever-changing flu virus is tricky business, she said, and it requires a willingness to change tactics as the virus adapts.
"Our policies are there to be reassessed every year," she said. "They're evidence-based. If we have to change, we will change."
For now, the supply of vaccine in hospitals is keeping up with demand. Before the injection-only recommendation, half of the supply of vaccines at Children's Hospitals and Clinics of Minnesota for this flu season was for the nasal spray. But there have been new orders for shots.
"We've had no problem," Stinchfeld said. "The manufacturers have been responsive. We have injectionable, so that we can give kids who come in right now their shots. At this point, we have no concern about supply or shortages."
Allie Shah • 612-673-4488 • @allieshah
