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Give intramuscular (IM) injections in children only when the benefits outweigh the pain of injection.
Take steps to eliminate interruptions and distractions during medication preparation.
At the completion of the procedure, ensure all choking hazards (e.g., syringe caps, port caps, adhesive bandages, bits of tape) are removed from the infant’s, toddler’s, and preschool-age child’s bed.
The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. Many medications must be injected intramuscularly because of chemical properties, pharmacokinetics, desired onset, intensity and duration of the effect, and certain patient characteristics related to treatment compliance. An IM injection should be given only when less painful options are not feasible.
The injection site affects how much fluid can be given and how quickly the medication will be absorbed. The most appropriate sites for IM injections are the vastus lateralis (anterolateral thigh) for infants and toddlers and the deltoid muscle for children 3 years old or older.5 Selection of the injection site is based on the child’s age, muscle mass, medication volume, and medication viscosity.
Local anesthesia or tactile stimulation should be considered to decrease pain at the injection site.6 Breastfeeding or giving supplemental breast milk during the injection can reduce pain in infants. The combination of oral sucrose and radiant warmth is effective analgesia for healthy neonates and young infants receiving IM vaccination.3 Diversional activities and education may comfort a child receiving an IM injection. A child life specialist should be enlisted to support the child, if available.
No evidence exists for the practice of aspirating before an IM injection, which has been shown to cause increased pain.5 Because the recommended sites for pediatric IM injections for vaccines have no large blood vessels, the practice for immunization is unnecessary.2 However, aspiration is routinely used and is recommended when medications other than vaccines are administered.
If the child or family expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.
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Ensure that parental or legal guardian consent is obtained for immunizations per the organization’s practice.
Tissue or nerve damage, scar tissue, poor muscle mass or tone, and lack of accessibility may be contraindications to using a particular site.
Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe; otherwise, this may lead to harmful reactions.
Rationale: A filter needle prevents glass and large particles from being drawn into the syringe.
Position the child to relax the muscle. Placing the child’s hand on the hip relaxes the deltoid muscle. For the vastus lateralis site, the child can sit on an adult’s lap. Some distraction techniques involve books, cell phones, tablets, music, videos, pictures, bubbles, and toys.
Rationale: Stretching the skin increases the likelihood of administering the medication into the muscle. Pulling the skin to the side (Z-track) method should be used with medications that are irritating to the tissue.
1 Bunching is useful when there is little muscle tissue. Initial research has shown that applying manual pressure before the injection decreases pain in a small population of children.
Rationale: Injecting the medication over several seconds allows the muscle to stretch and accommodate the volume with less leakage into the subcutaneous tissue.
Rationale: Stretching the skin increases the likelihood of administering the medication into the muscle. The Z-track method should be used with medications that are irritating to the tissue.
1 Initial research has shown that applying manual pressure before the injection decreases pain in a small population of children.
Because the recommended sites do not contain large vessels, aspiration is not necessary when vaccines are administered.
Vaccines take less time to inject than medications, such as penicillin, because vaccines are thinner and have less volume.
Do not massage the site. Use gauze, not an alcohol wipe, to prevent skin irritation.
If the child is an infant or toddler, a bandage can become a choking hazard. If one is applied, explain to the family that it must be removed before the child is left alone.
Reportable conditions: Adverse medication, medication-to-medication interaction, or allergic or anaphylactic reaction
Reportable conditions: Profuse bleeding, hematoma, loss of function, signs and symptoms of infection
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