Administering intramuscular injections to children

This learning resource will cover the process and considerations of administering intramuscular (IM) injections to children. This module does not cover IM medications or safety related to these. The information provided in this module is recommended by evidenced based literature, however you need to administer all medications in compliance with your local hospital policy. There will be a quiz at the end of the module as well as the opportunity for feedback.

Learning Objectives

Learning objectives for this course

•Identify if the injection is appropriate for the child 

•Identify techniques that can be used to make the injection procedure as relaxing and painless as possible for the child. 

•Identify the different intramuscular injection sites and how to locate them. 

•Identify the correct intramuscular injection site based on the child’s age 

•Identify the appropriate needle sizes for intramuscular injections based on the child's age 

•Identify the correct Z track technique method for the use of intramuscular injections


First considerations

Before anything else!

Before giving an injection, the nurse should assess whether an IM injection is the optimum route for the child. There is no universal agreement on the optimum injection site, needle size or injectable volumes, therefore the nurses must recognise the importance of individual child assessment and clinical judgement to decide what is appropriate (1)


IM injections should always be avoided if other routes of administration, especially oral, can be used to provide a comparable level of absorption and effect in any given child’s situation and condition (2)

Ensure consent is gained from the parent/carer for the injection (1).

Consider this

EXAMPLE: Milly, a 3yo girl you are caring for has been ordered a single dose of IM Ceftriaxone by the doctor. You have been looking after Milly for a few of hours and know that she is great at taking oral liquid medications. You check the medication fridge and you know there is a bottle of Ceftriaxone suspension ready to go.

THINK: Is IM the most appropriate route for this medication? Why?


Assessing the child

Family

Consider how the child may react to getting an injection. Encourage the parents/carers/family to assist with the procedure by either comforting, holding, or distracting the child. You should observe the child’s level of agitation and cognitive state (1).

The list is endless, but here are a few ideas to make a more pleasant injection experience for your patient!

Distraction

Babies can be distracted with colourful mobiles and mirrors. Younger children can be distracted with blowing bubbles or party blowers, reading a favourite book, playing with a musical toy or with the use of virtual reality glasses. Older children can choose what they wish to be distracted with: a hand-held video game, for example (1).

Breastfeeding

This is a good time to give the baby an injection. This will make the injection less painful (1)

Sugar mixture (Oral sucrose 24%)

This can make injections less painful for children under 18 months. Place a few drops of the mixture onto the baby’s tongue, a few minutes before the injection. Ask someone assisting you to give a few drops right as you are giving the injection(1, 3)

Pacifier

Let the baby suck on a pacifier during the injection. Many toddlers and babies find this soothing and feel less pain during the injection. You can also dip the pacifier in the Sucrose (as previously discussed) (1).

Topical anaesthetics

These agents help reduce the pain of the injection, such as EMLA, lidocaine (Maxilene®), and tetracaine (Ametop®) (1).

Consider this

EXAMPLE:  Sam, a 5yo boy has been ordered an IM injection. You identify that this injection is appropriate. Sam’s mum tells you he is petrified of needles. When observing Sam, he is already very unsettled.

THINK:  Will you need help from other nurses and Sam’s mum? Should you use distraction techniques to divert Sam’s attention when giving the injection? Would you consider applying Elma cream to the site? Why?

Administering the injection

What are the benefits IM injections?

The route offers a rate of absorption than the subcutaneous route, and muscle tissue can often hold a volume of fluid ( depending on the child’s age and site) than subcutaneous tissue (1)

Needle sizes

A needle used for an IM injection needs to be long enough to go through the skin and tissue and end deep in the muscle. Needles have two measurements: a needle diameter (called a gauge) and a needle length (denoted in inches or mm). The bigger the gauge, the smaller the needle diameter. The smaller the gauge, the bigger the needle diameter. The needle gauge for an IM injection should be 22 to 25 gauge. Needle length depends upon age and size of the child and the injection muscle. If the child is slim with minimal fatty tissue consider a smaller needle length. If the child has a lot of fatty tissue, consider a longer needle (1, 4, 5). This table is a guide to help decide which needle size may be appropriate.

Which needle?

Childs age                                Needle gauge and size

Infants (birth to 12                7/8” to 1” needle, 23-25 gauge

months of age) 


Toddlers (12 to 36                 7/8” to 1” needle, 23-25 gauge

months of age)


Toddlers (>36                          1” to 2” needle, 23-25 gauge                  

months of age),

children

*Needle size may vary depending on the child. This is a guide only (4, 5).


Injection sites

The muscle should be accessible, well-perfused, well developedand able to tolerate the volume of the medication. For IM injections, the vastus lateralis is recommended for children under two years of age. For children over three years, the deltoid may be more appropriate. The gluteus maximus muscle (bottom) is not recommended for IM injections in children, due to the potential for damage to the nearby sciatic nerve and gluteal artery (1, 2, 4)

The deltoid

This muscle is easily accessible but not recommended for repeated injections or large volumes due its small muscle mass. The deltoid site is located laterally on the upper arm and is the recommended site for intramuscular injections to children over the age of two who have acceptable muscle mass development (1,2,4)

Land marking the deltoid

Land marking this site:

1. Expose the arm completely from shoulder to elbow

2. Two finger widths down from acromion process (top of shoulder) place your finger across the arm.


3. With your other hand, make an inverted triangle with your pointer and middle finger joining the finger going across the arm. The middle of this inverted triangle is the injection site (1, 2, 4). Displayed in images.

The vastus lateralis

The vastus lateralis

This stretches from the top of the femur to the lateral condyle of the knee. It is an ideal site as it is easily accessible, a large muscle mass and has no major blood vessels or nerves in the area. Recommended for children under 2 years (1, 2, 4).

Land marking the vastus lateralis

Land marking the site:

1. First expose the whole upper leg.

2. Feel for the childs hip bone. Draw an imaginary line from the middle of the childs knee to the hip bone

3. Draw another 2 imaginary lines horizontally across the upper leg to divide the thigh into 6 equal sections.

4. The injection site is the centre of the outer middle section (1, 4, 5).

This method for land marking is displayed in first image

Z track technique

Z-tracking involves displacing the skin and subcutaneous layer in relation to the underlying muscle to be injected so that the needle track is sealed off when the needle is withdrawn, therefore minimizing reflux. 

Applying Z track technique

-Gently pull/displace the skin with your non-dominant hand,1cm laterally from the land marked injection site. This displaces the tissuesprior to injection

- Hold this position until the medication is administeredand the

needle is removed

- After removing the needle, release the pull on the skin (1,2, 5)

These images show the Z tracking technique 

Is everything ready? Checklist

At this point you should have:

-Identified if the injection is appropriate 

-Your 2nd nurse with you (or 2nd+ 3rd nurse if you are astudent RN)

- Assessed the child to make sure the environment is safe and appropriate, you have taken measures to minimise the pain of the injection, stress, and anxiety of the child (1)

- Asked that a parent/family member is with the child for comfort and that the parent/ carer consents to the injection (1, 2)

 

-Landmarked the appropriate site for the child(1, 4)

-Prepared your IM medication and selected correct needle size (2, 5)

-Swabbed the injection site with alcohol swab if required with local hospital policy. Ensuring the skin is clean with soap and water can be done as an alternative. Some medications require non-alcohol swabbed skin (5)

Now you can inject!

Now you need to:

- Gently pull the skin with your non-dominant hand, 1cm laterally from the land marked injection site. Hold this position until the medication is administered and the needle is removed (z track)

- Inject at a 90º angle

- Aspirate for five seconds (If required with local hospital policy), discard if blood is present

- Inject medication slowly (10 sec/ml)

- Leave needle in place for 5 seconds after injecting medication

- Remove needle and release the pull on the skin.

- Apply gentle pressure with sterile gauze. Do not rub

(1, 2, 4, 5)

After the injection

  • Reassure and praise child

  • Assess child

  • Document procedure (2)

Questions!

1. Sam (3 year old) has been ordered a dose of IM Cefazolin. This also comes in a liquid oral form. Is this IM injection appropriate?

  • a) No, because there is oral available
  • b) No, if you identify that Sam is suitable to take liquid oral medications after assessing him
  • c) Yes, it’s the easiest way for Sam to have the Cefazolin
  • d) Yes, because Sam might not like the taste of the liquid medication.

2.  Which injection site is this?

  • a) Vastus lateralis
  • b) Gluteus maximus
  • c) Deltiod
  • d) Ventrogluteal

3. Which injection site is this?

  • a) Ventrogluteal
  • b) Gluteus maximus
  • c) Vastus lateralis
  • d) Deltoid

4. Why don’t we inject into the gluteous maximus for IM injections?

  • It's more invasive then other injection sites
  • Because its harder to access and land mark especially in children
  • There is potential for damage to the nearby sciatic nerve and gluteal artery
  • Because medications are much slower to absorb in the gluteous maximus due to decreased blood supply to the area

5. Which of these are techniques that can be used to relax the child and reduce pain?

  • Distraction
  • Breastfeeding
  • Pacifier
  • Oral Sucrose
  • Topical anaesthetics
  • All of the above

5. Your are administering an IM injection to Milly, an 14 month old baby. Providing that the site is well developed, where will you inject the medication?

  • a) Deltiod
  • b) Ventrogluteal
  • c) Vastus lateralis
  • d) Both answer a + c

6. Pat is an 11 year old boy who you are administering an IM injection to. Providing the site is well developed, where will you inject?

  • a) Vastus lateralis
  • b) Ventrogluteal
  • c) Gluteus maximus
  • d) Deltoid

7. Match the correct needle gauges and sizes with the correct child’s age

  • Infants (birth to 12 months of age)
    7/8” to 1” needle, 23-25 gauge
  • Toddlers (12 to 36 months of age)
    7/8” to 1” needle, 23-25 gauge
  • Toddlers (>36 months of age), children, and adults
    1” to 2” needle, 23-25 gauge

8. Which of these is the correct method for Z track technique?

  • a) -Gently pull/displace the skin with your non-dominant hand, 1cm laterally from the land marked injection site. - Hold this position until the medication is administered and the needle is removed - After removing the needle, release the pull on the skin.
  • b) -Gently pull/displace the skin with your dominant hand, 2cm laterally from the land marked injection site. This displaces the tissues prior to injection - Hold this position until the medication is administered and then needle is removed - After removing the needle, keep the pull on the skin for 10 seconds
  • c) -Pull the skin 1cm laterally from the land marked injection site. - Hold this position until the needle is injected - Then release the pull on the skin.
  • d) -Gently pull/displace the skin with your dominant hand, 1cm laterally from the land marked injection site. - Hold this position until the medication is administered and the needle is removed. - Rub the area to disperse the medication throughout the tisse

Have you gained confidence in administering IM injections to children after doing this course?

Please provide us with feedback about this course

References

1. Barron, C., & Cocoman, A. Administering intramuscular injections to children: what does the evidence say?. Journal Of Children's & Young People's Nursing.; 2008. 2(3), 138-144

2. Bartley, N. Administering intramuscular and subcutaneous injections in children. World Of Irish Nursing & Midwifery.; 2012. 20(8), 39-42

3. Uzelli, D., & Yapucu Güneş, Ü. Oral glucose solution to alleviate pain induced by intramuscular injections in preterm infants. Journal For Specialists In Pediatric Nursing.; 2015. 20(1), 29-35

4. Ogston-Tuck, S. Intramuscular injection technique: an evidence-based approach. Nursing Standard.; 2014. 29(4), 52-59

5. Rishovd, A. Pediatric Intramuscular Injections: GUIDELINES FOR BEST PRACTICE. MCN: The American Journal Of Maternal Child Nursing.; 2014. 39(2), 107-114