At what age should the upper arm M Deltoideus be used as the vaccine injection site in a child?

The vaccines that are recommended for routine immunization by the Centers for Disease Control and Prevention (CDC) in all children from birth through age 6 years are discussed below. [1] For more detailed information, including exceptions and other considerations, see the CDC’s full vaccines and immunizations guidelines.

The vaccines listed below are administered via intramuscular (IM) injection unless otherwise stated. IM administration in the anterolateral thigh muscle is preferred in neonates, infants, and small children. IM administer in the deltoid muscle is preferred in young children (eg, aged 4-6 years) who are of normal weight.

Hepatitis B vaccine (HepB)

• Minimum age: Birth [1]

• 3 doses

• First dose of monovalent HepB before hospital discharge*

• Second dose with monovalent or combination vaccine at age 1 or 2 months

• Third dose at age 6-18 months

• *If mother is HBsAg-positive, also administer hepatitis B immune globulin (HBIG) 0.5 mL within 12 hours of birth

• *If mother’s HBsAg status is unknown, also administer HBIG to infants weighing < 2 kg within 12 hours of birth; determine mother’s HBsAg status as soon as possible, and, if mother is HBsAg-positive, also administer HBIG in infants weighing ≥2 kg as soon as possible, but no later than age 7 days

Rotavirus vaccine (RV)

• Minimum age: 6 weeks

• 2 or 3 doses administered orally

• If Rotarix is used, administer a 2-dose series at age 2 and 4 months

• If RotaTeq is used, administer a 3-dose series at age 2, 4, and 6 months

• If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered

Diphtheria, tetanus, acellular pertussis vaccine (DTaP)

• Minimum age: 6 weeks

• Doses at ages 2 months, 4 months, 6 months, and 12-15 months

• Final dose at age 4-6 years

• If the fourth-dose DTaP vaccine was administered 4 month or more after the third dose, at an appropriate age, it can be counted as valid and need not be repeated after the recommended 6-month interval between doses 3 and 4. [2]

Haemophilus influenza type b vaccine (Hib)

• Minimum age: 6 weeks

• 2- or 3-dose primary series and 1 booster dose (dose 3 or 4 depending on vaccine used for primary series) at age 12-15 months

• Doses at ages 2 months, 4 months, 6 months (brand dependent), and booster at 12-15 months

Pneumococcal vaccine 13-valent (PCV13)

• Minimum age: 6 weeks

• Doses at ages 2 months, 4 months, 6 months, and 12-15 months

In 2015, the Advisory Committee on Immunization Practices provided recommendations on the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13), summarized as follows: [3]

• The ACIP currently recommends that a dose of PCV13 be followed by a dose of PPSV23 in persons aged 2 years or older who are at high risk for pneumococcal disease because of underlying medical conditions.

• Children with an immunocompromising condition or functional or anatomic asplenia should receive a second dose of PPSV23 5 years after the first PPSV23 dose.

Inactivated poliovirus vaccine (IPV)

• Minimum age: 6 weeks

• 4 doses administered IM (may administer SC or IM in deltoid in older children)

• Doses at ages 2 months, 4 months, 6-18 months, and age 4-6 years

Influenza vaccines

• Children aged 6 months to 8 years who are receiving their first influenza vaccination should receive 2 doses (separated by at least 4 weeks) and then 1 dose in subsequent years [2]

ACIP recommends return of intranasal flu vaccine in the United States for the 2018-2019 season

• The Advisory Committee on Immunization Practices (ACIP) recommended return of the intranasal flu vaccine in the United States for the 2018-2019 season based on positive results from a US study in children aged 2 years to younger than 4 years that evaluated the shedding and antibody responses of the H1N1 strain in the live attenuated influenza vaccine (LAIV). The study showed that the new 2017-2018 H1N1 LAIV postpandemic strain (A/Slovenia) performed significantly better than the 2015-2016 H1N1 LAIV postpandemic strain (A/Bolivia), which was associated with lower effectiveness and was not recommended during the prior two seasons. [4]

• AIV4 was not recommended during the 2017-2018 or 2016-2017 influenza seasons because it was poorly effective against circulating strains of influenza in the United States. [5, 6, 7]

Measles, mumps, and rubella vaccine (MMR)

• Minimum age: 12 months

• Administer by SC into the outer aspect of the arm

• Two dose series at ages 12-15 months and 4-6 years

Varicella virus vaccine

• Minimum age: 12 months

• Administer by SC injection into the outer aspect of the upper arm or the anterolateral thigh

• Two-dose series at ages 12-15 months and 4-6 years

Hepatitis A vaccine (HepA)

• Minimum age: 12 months

• Two-dose series beginning at ages 12-23 months; second dose is given 6-18 months later

The following clinical practice guidelines were released in 2015 by Help Eliminate Pain in Kids: [8]

• No aspiration should be used during intramuscular vaccine injections in individuals of all ages.

• Inject the most painful vaccine last (rather than first) during vaccine injections in individuals of all ages.

• Breastfeeding should be used during vaccine injections in children aged 2 years and younger.

• Holding should be used (rather than the child lying supine) during vaccine injections in chil­dren aged 3 years and younger.

• Sitting upright should be used (rather than the individual lying supine) during vaccine injections in children aged 3 years and older and adults.

• Apply topical anesthetics before vaccine injections in children aged 12 years and younger.

• Give sucrose solution before vaccine injections in children aged 2 years and younger.

• Educate parents about pain management before the day of vaccination and on the day of vaccination.

• Educate children aged 3 years and older about pain management on the day of vaccination.

• Parents should be present during vac­cine injections in children aged 10 years and younger.

What age can you give a deltoid injection?

What is the preferred site for an IM injection on an infant or child?

Which site is most appropriate when giving an intramuscular IM injection to an older child?

Which muscle is used for the IM injection in infants and children younger than 3 years?