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Question on Pediatric IM injection sites


I work in a very busy family practice clinic, and a big part of my job is doing pediatric immunizations. Many of our pediatric patients are now getting the H1N1 and seasonal flu vaccine in addition to the required immunizations due for their age. Unfortunately, this results in some of our pediatric patients getting up to 6 injections in one visit! I am experienced in doing pediatric injections, but sometimes I'm not sure where I can safely give some of the IM injections. I understand that the vastus lateralis is the preferred site, and I will normally give no more than 2 IM injections in one leg. Sometimes I get into a situation where I have 6 IM injections to give, and I'm not sure if the deltoid is OK to use, especially in children 6-12 months. I don't normally use the deltoid in children that young, since the muscle may not be as developed. What is the maximum number of IM injections (0.5 ml each) you can safely give in the vastus lateralis? Can the deltoid be used in a child 6-12 months? Thanks for all replies.

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.

I don't know if that issue has ever been considered before. This H1N1 thing has really complicated things, hasn't it? I can't imagine giving a little person six IMs in the same day. Closest to hell that I can think of, next to the toddler in status asthmaticus on back-to-back albuterol facemasks!! I'd be really hesitant to be giving more than two per leg, but your worry about the deltoid is a serious one. Let's see what others have to say...

I wouldnt use the deltoid in a 6-12 month old. If you need to give that many injections - the parent may just need to make another trip to the office.

The deltoid isn't used until age 3.

Who the hell allows their kid to get 6 injections in 1 visit?????

tewdles, RN

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

Agree. save the deltoid area for SQ vaccines in those under 3yr. Sometimes kids get this many injections in one visit because they are seriously behind in the immunization schedule.


Specializes in pediatrics.

Once a child is walking our practice give shots in the deltoid. I have given more than four shots before, but that has usually been on toddlers, at least 15 mos or older, not infants. I always do the MMR & Varivax in the deltoid because they are SC. Many parents have held off on one of the "routine" vaccines in an effort to get the H1N1. If the doctors order more than four vaccines I administer the H1N1 & seasonal flu on the same leg or arm because they are both 0.25 doses. If you are vaccinating a baby with 6 shots, you really dont have anywhere to go but the thigh area, the vastus lateralis being the best choice but you can also use the vastus intermedius.

I don't think I have met a parent yet that has allowed their infant to be stuck more than 4 times. A six month old for example should be getting a combination vaccine such as Pediarix (DTaP, IPV, HEP B) with a separate dose of Hib or Pentacel (DTap, HiB, IPV) with the separate dose of HEP B, and PCV-7, (so far 3 actual "shots") add the H1N1 and seasonal flu...you are up to five. Is it that you don't use combination vaccines? What else are you giving?

Thank You for all replies. I totally agree....I hate giving more than 4 shots to these little kids. I don't even think I'd allow my own child to get 6 shots, but my supervisor wants us to do them all if we possibly can. It makes our clinic look good on reports. We use a lot of Pentacel or Pediarix. I asked my supervisor and another nurse this same question, and I was told to use the front thigh muscle (rectus femoris) for some IM injections if needed. We often give a combination of Pentacel, Hep A, Hep B, PCV. Add on the H1N1 and seasonal flu which the providers will order, and you have a total of 6! It sucks, and many times it makes me feel like a cruel, heartless, person to turn little kids into human pin cushions all day. It's the one part of my job I don't always enjoy...and it takes forever to prepare them....writing down the date, lot number, site, amount, dates for the vaccine information forms, and not to mention NDC numbers on every vaccine. We use Child Profile, so copies are made of the vaccine record and enounter form and attached to the Child Profile summary of vaccinations due. Then we have to grab the vaccine information forms and update the shot card. It can literally take up to 20 minutes to prepare one set of shots (that's just the way our clinic does things).

There should be at least one inch space between injections when giving vaccines in the vastus lateralis (or any muscle). Many clinics and physicians will provide all the vaccines that are recommended for that child at that visit in order to make sure the child is vaccinated appropriately. Studies suggest a greater immune response when vaccines are given together rather than spaced out over time. Also, we don't want to miss opportunities (some clinics are penalized for letting children leave the office without being fully vaccinated) and many parents do not keep up with their children's vaccinations as recommmeded, then wonder why their kid has to get so many shots! I would rather pick a child 6-8 times in one visit than learn later that the child has developed a disease that could have been prevented!


Specializes in school RN, CNA Instructor, M/S.

How would you be able to found out if a patient is having a reaction to the "shot". If they receive so many at once how can you fill oput and more importantly treat a vaccine adverse reaction possibility? i couldn't do that to any patient!

As a nurse, the only thing I can do is submit a VAERS form and let the physician (and the NCVIA if needed) take it from there. It is very rare for true adverse reactions to occur from a vaccine. Still, reactions to a vaccine are easier to treat than the actual disease process.

PedsAtHeart, LPN

Specializes in LPN, Peds, Public Health.

I have been giving pediatric immunizations for 8 years and have on occasion given up to 6 seperate injections at a time. I do not like to do it, but sometimes it needs to be done. i will give up to 3 in the VL, and as another commenter stated, they need to be an inch apart. The way I do this is to make a triangle with the injections instead of trying to do a straight line. Our state guidelines say that is a child is able to walk they can receive IM injections in the deltoid. Personally, I use my own judgement on this. Not every 1 yr old's deltoids are developed enough for this, and I find it easier and less painful for the kids to get them in the VL, its much easier to hold them still and thus reduce the risk of injury or resticking. This is why it is so important for parents to keep their children up to date with their immunizations! If they do, then they wont have to worry about their child being stuck this many times...

With that being said, I have to brag on my son... he turned 4 today and I brought him in to give him his shots (yes I give them to him and yes I did it on his birthday!) and he was such a big boy!! Sat there and took them, 2 in one arm, 1 in the other, and didnt move and only cried a couple of tears on the MMR, which burns like crazy!!! Sorry... but I was so proud of him!!