Intramuscular injection (IM) in pediatrics is a common route for administering vaccines, antibiotics, and other medications directly into muscle tissue. It allows for rapid absorption, but must be performed with age-appropriate technique, site selection, and safety precautions to minimize pain and complications.
Recommended Injection Sites by Age
| Age Group | Preferred Site | Volume Limit | Notes |
|---|---|---|---|
| Neonates (<18 months) | Vastus lateralis | 0.5–1 mL | Safest and most developed muscle at this age |
| 18 months–3 years | Vastus lateralis or deltoid | 1–2 mL | Deltoid only if muscle mass is adequate |
| 3–11 years | Deltoid or vastus lateralis | 1–2 mL | Deltoid preferred for vaccines |
| >11 years | Deltoid or ventrogluteal | Up to 3 mL | Ventrogluteal safer than dorsogluteal; avoid sciatic nerve |
Advantages
- Absorption of medication is faster than subcutaneous injection.
- Large injections (up to 1-2 mL in child) can be given this way because muscles can absorb more fluid than fatty tissues.
Preferred Sites
- For infants and young children: Rectus femoris muscle or vastus lateralis in the middle third of the thigh.
Clinical alert: Never use the dorsogluteal site in the posterior hip for infants or children who are not yet begin to walk. - For older children and adolescents:
- Ventrogluteal site in the gluteus medius muscle in the posterior hip
- The deltoid muscles (upper and outer part of arm)
Clinical alert: Do not inject more than 1 mL into the arm of the child.
Preparation
- Explain the procedure to the parents and child (appropriate to child’s development).
- Provide privacy: Protect the child’s privacy by putting a sheet over the body parts that do not need to be exposed.
- Show the mother how to hold the child.
Procedure
- Perform hand hygiene.
- Choose a site for the injection that has no broken skin, swelling, tenderness, redness, or warmth.
- Locate the exact site and clean it with an antiseptic swab using circular motion and extending outward.
- Using your hand, stretch the skin at the site. This makes it firmer so that it is easier to insert the needle.
- Insert the needle quickly at a 90° angle through the skin and into the muscle. If the child is a very small infant or has a small muscle mass, use a 45° angle.
- Aspirate by pulling back on the plunger to inject the medication.
- Quickly remove the needle and apply firm pressure to the site using an antiseptic swab.
- Massage site to fasten absorption unless contraindicated as with irritating drugs.
- Place a small adhesive bandage on puncture site.
Post procedure Care
- Hold and cuddle the young child and encourage parents to comfort child; praise older child for successful cooperation.
- Allow expression of feelings.
- Discard syringe uncapped; uncut needle in puncture-resistant container located near the site of use.
- Record time of injection, drug, dose, and injection site.
- Wash hands.
Nurse’s Responsibility in Intramuscular Injection
- Use safety precautions in administering medication, for example, child’s identification.
- Apply EMLA cream topically over site if time permits (at least 60 minutes, preferably 2 hours before injection).
- Select the syringe and needle appropriate to the amount and viscosity of fluid to be administered and amount of tissue to be penetrated.
- Make certain that muscle is large enough to accommodate volume and type of medications.
- Obtain sufficient help in restraining child, children are often uncooperative, and their behavior is unpredictable.
- Place the child in a lying or sitting position; child is not allowed to stand to avoid falling and it is difficult to restrain.
- Use a new, sharp needle with smallest diameter that permits the free flow of the medication.
- Grasp muscle firmly between thumb and fingers to isolate and stabilize muscle for deposition of drug in its deepest part; in obese children spread skin with thumb and index finger to displace subcutaneous tissue and grasp muscle deeply on each side.
- Allow skin preparation to dry completely before skin is penetrated.
- Have medication at room temperature to decrease the intensity of pain.
- Distract child with conversation to decrease the perception of pain.
- Place a cold compress or wrapped ice cube on site about a minute before injection.
- Insert needle quickly, using a dart-like motion in 90° angle unless contraindicated.
- Use separate needle for loading the injection from vial and another new one for administering medication.
- blood is found, remove syringe from site, change the needle, and reinsert it into new location.
- Place the child on side with upper leg flexed and placed in front of lower leg for ventrogluteal.
- Vastus lateralis: Child can be supine, lying on the side, or sitting.
- If medication is given around the clock, the nurse must be careful to wake up the child.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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