Children and nurses often view the administration of injections as a traumatic procedure. Nurses aim to avoid administering injections to children unnecessarily. However, certain medications may only be administered by injection, as alternative routes are not viable or may not facilitate absorption.¹ Correct injection technique can reduce complications, injury and discomfort for the child. 

Recent years have seen a reduction in the use of intramuscular injections in particular. The introduction of alternative analgesia techniques, such as epidurals, intravenous infusions, and patient and nurse controlled analgesia has reduced the volume of injections administered. Despite this, the administration of injections remains a fundamental nursing practice and children’s nurses need to update their knowledge and skills. 

Necessary skills for good injection technique include knowledge of: anatomy and physiology; pharmacology; suitable injection sites and injection techniques for children; clinical holding; and effective communication skills. 

Evidence-based nursing guidelines for the administration of both intramuscular (IM) and subcutaneous (SC) injections were created within Our Lady’s Children’s Hospital to support best practice and safe administration of medication.

Individual child assessment

The nurse should initially assess whether an injection is the optimum route for the child. There is no universal agreement on optimum injection site, needle size or injectable volumes, therefore, children’s nurses must recognise the importance of individual child assessment and clinical judgement to ensure best practice when administering IM and SC injections to children (see Table 1).

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An injection is the percutaneous introduction of a medicine via needle and syringe but may also involve newer devices, such as an auto-injector² (see Table 2).

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An IM Injection is a method of administering medication directly into muscle tissue.¹ The rate of medication absorption is faster than the SC route and muscles tolerate a greater volume of fluid³ (see Table 3).

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An SC injection delivers medication below the epidermis and dermis layers into subcutaneous tissue¹. The rate of absorption is slower than the IM route, as SC tissue has less blood supply.⁴ SC injections are often self-administered by the child or given by a family member or caregiver. Education and support are vital. Some children use an automatic injection device when administering an SC injection (see Table 4).

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Injection sites for children 

Individual assessment is recommended to select the appropriate injection site for children and use of the correct injection site is a major factor in limiting complications.⁵ When identifying an injection site, position the child to allow relaxation of the limb. 

Factors to consider

Child

• Size/age: the muscle should be accessible, well-perfused, well-developed and able to tolerate the volume of the medication.^1,3 For IM injections, the vastus lateralis is recommended for children under two years of age.³ For children over three years, the deltoid may be more appropriate⁶
• Child/parent’s preference: Encourage involvement, when appropriate. Research has shown that children who are sitting up and infants who are held by their parents appeared to experience less pain during injections⁷
• Child’s position: Correct positioning may minimise anxiety or discomfort¹ and assist in accurate landmarking of the site. Consider the child’s ability to maintain the required position safely.³

Medication

• Frequency of injections – sites must be rotated to avoid fibrosis of the injection site
• For the administration of more than one injection, use separate sites. If using one limb, allow a distance of 25mm between sites to reduce local reactions⁶
• Type of medication and specific manufacturer’s instructions for administration.

Volume of injection

This is poorly researched for children. Individual assessment of the child and the medication is essential.⁹ For IM injections, 0.5-2ml may be injected depending on the age and size of the child.³ The Z-track technique can reduce pain and prevent complications associated with IM injections. This technique avoids potential back flow of medication as the needle track is sealed off after injecting the medication.³ It is useful for medication that may stain the skin, such as iron (see Table 5). 

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Potential complications 

The majority of complications are associated with IM injections, but complications may occur after any type of injection. These may be due to local trauma from the injection itself or from the medication.¹⁰ Adverse events may be due to incorrect site, inappropriate injection depth or rate of injection.⁹ Complications include:

• Pain 
• Nerve damage, tissue necrosis, intramuscular haemorrhage, abscess, allergic reaction, needle phobia 
• Granuloma, intravascular injection, cellulitis 
• Muscle fibrosis with repeated use of the same site 
• Medication errors with use of low dose syringes (measure in units not millilitres). 

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Updating knowledge and skills

Children’s nurses are encouraged to update their knowledge and skills in relation to the practice of administering injections. Sound clinical judgement and individualised assessment is essential to ensure safe practice. The information within this article is based on Nursing Guidelines on the Administration of IM and SC injections within Our Lady’s Children’s Hospital, Crumlin. 

References

1. Ford L, Maddox C, Moore E, Sales R. The safe management of medicines for children. In: Practices in Children’s Nursing: Guidelines for Community and Hospital. Churchill Livingstone, Edinburgh, 2010: 417-45
2. World Health Organisation. WHO Best Practices for Injections and Related Procedures Toolkit. WHO, Geneva, 2010
3. Barron C, Hollywood E. Drug administration. In: Clinical Skills in Children’s Nursing. Oxford; Oxford University Press, 2010: 147-81
4. Barrett G, Fletcher T, Russell T. Fundamental aspects to safe administration of medicine. In Fundamental Aspects of Children’s and Young People’s Nursing Procedures. London; Quay Books, 2007: 123-80 
5. Wynaden D, Landsborough I, McGowan S et al. Best Practice Guidelines for the Administration of Intramuscular Injections in the Mental Health Setting. Int J Mental Health Nursing, 2006; 15(3): 195-200
6. National Immunisation Advisory Council. Immunisation Guidelines for Ireland. 2010. Available at http://www.immunisation.ie/en/Downloads/NIACGuidelines/PDFFile_15498_en.pdf  
7. Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V. Physical interventions and injection techniques for reducing injection pain during routine childhood immunisations: systematic review of randomised controlled trials and quasi-randomised controlled trials, Clinical Therapeutics, 2009; 31: Supplement B: 48-76
8. Royal Children’s Hospital. Diabetes Manual, 2011. Available at: http://www.rch.org.au/diabetesmanual/manual.cfm?doc_id=2733 
9. Malkin B. Are techniques used for intramuscular injection based on research evidence? Nursing Times 2008; 104(50-51): 48-51
10. Barron C, Cocoman A. Administering intramuscular injections to children: what does the evidence say? J Children’s and Young People’s Nursing 2008; 2(3): 138-44
11. Parboteah S. Safety in practice. In Foundations of Nursing Practice, Making the Difference. Hampshire; Palgrave Macmillan, 2002