When most folks think about getting a vaccine, they typically picture someone getting a shot.
It is important to remember that not all vaccines are shots though.
And even for those vaccines that are given as shots, not all of them are given intramuscularly (IM).
Some vaccines are also given orally, nasally, and subcutaneously.
Which Vaccines can be Given SQ?
Vaccines that are given by subcutaneous injection include:
ProQuad (MMR/V combination of MMR and chickenpox vaccines)
Pneumovax* (Pneumococcal vaccine)
IPV* (polio vaccine)
Varivax (chickenpox vaccine)
Zoster (shingles vaccine)
*The Pneumovax and IPV vaccines can be given either IM or Subcutaneously (SQ). And there are some other exceptions too. Kids with hemophilia can get the hepatitis A and B vaccines SQ, instead of IM.
Where to Give SQ Injections?
After asking how many shots they are going to get, kids often ask where they are going to get them?
While infants get their subcutaneous injections in the fatty tissue over their anterolateral thigh muscle, toddlers and older children get them in the fatty tissue over their anterolateral thigh muscle or triceps.
Be sure to use the correct needle size, length and gauge (typically 5/8″ and 23-25 gauge), and insert the needle with a quick thrust at a 45° angle to the skin (rapid injection technique), pinching up on the SQ tissue to avoid hitting the muscle, and instead injecting in the subcutaneous tissue between the skin and muscle.
Also keep in mind that it is not necessary to aspirate after injecting the needle and that multiple injections in the same extremity should be separated by at least one inch.
What to Know About SQ Vaccines
It is important to know which vaccines need to be given subcutaneously (SQ) and both how and where to give these shots.
There is plenty of evidence that the standard immunization schedule is safe and effective.
What about the alternative vaccine schedules that some folks push?
Is there any evidence that is safe to delay or skip any of your child’s vaccines?
Alternative Vaccine Schedules
Many people think of Dr. Bob Sears when they think of alternative vaccine schedules.
He created both:
Dr Bob’s Selective Vaccine Schedule
Dr Bob’s Alternative Vaccine Schedule
He didn’t invent the idea of the alternative vaccine schedule though.
Well before Dr. Bob appeared on the scene, Dr. Jay Gordon had been on Good Morning America with Cindy Crawford to discuss vaccines and how she had decided to delay vaccinating her baby.
Where did she get the idea?
After the segment, Dr. Jay stated:
“They edited the segment to make me sound like a vaccination proponent. We also have to understand the impact of a person as well-known as Cindy Crawford delaying vaccines for over six months.”
Dr. Jay has long talked about only giving infants one vaccine at a time and waiting until they are “developmentally solid” before vaccinating.
Similarly, other folks have pushed ideas about delaying and skipping vaccines before Dr. Bob, including:
Donald Miller and his User-Friendly Vaccination Schedule – no vaccines until age two years and no live vaccines and when you begin vaccinating your child, give them one at a time, every six months (first published in 2004)
Stephanie Cave – starts at 4 months and delays many vaccines
homeopaths with immunization schedules that say to wait until six months and then start giving nosodes every five days
chiropractors with immunization plans that say to get regular chiropractic adjustments instead of vaccines
Of course, Dr. Bob is the one who popularized the idea of the alternative vaccine schedule in 2007, when he published The Vaccine Book: Making the Right Decision for Your Child.
That’s when parents started to bring copies of his schedule into their pediatrician’s office, requesting to follow Dr. Bob’s schedule instead of the standard immunization schedule from the CDC.
What’s the Evidence for Alternative Vaccine Schedules?
There is no evidence that following an alternative vaccine schedule is safe for your kids.
“No alternative vaccine schedules have been evaluated and found to provide better safety or efficacy than the recommended schedule, supported by the Advisory Committee on Immunization Practices of the CDC and the Committee on Infectious Diseases of the AAP (the committee that produces the Red Book).
Pediatricians who routinely recommend limiting the numbers of vaccines administered at a single visit such that vaccines are administered late are providing care that deviates from the standard evidence-based schedule recommended by these bodies.”
American Academy of Pediatrics
What’s the first clue that these so-called alternative vaccine schedules have absolutely no evidence behind them?
They are all different!
Paul Thomas, for example, doesn’t even offer his patients the rotavirus vaccine. Dr. Bob, on the other hand, has it on his list of vaccines that “that could protect a baby from a very potentially life-threatening or very common serious illness” and is sure to give it at 2, 4, and 6 months.
How slow should you go?
Both Dr. Bob and Dr. Paul give two vaccines at a time with their schedules, but Dr. Jay and Dr. Miller say to give just one at a time.
“Would any scientist give SIX vaccines at once to a baby? Asking for trouble. One at a time makes so much more sense.”
And while some start their schedules at 2 or 4 months, others delay until 6 months or 2 years.
There is also the fact that the folks who create these schedules admit that there is no evidence for what they are doing…
“No one’s ever researched to see what happens if you delay vaccines. And do babies handle vaccines better when they’re older? This is really just a typical fear that parents have when their babies are young and small and more vulnerable. Since I don’t know one way or the other, I’m just happy to work with these parents, understand their fears and their worries, and agree to vaccinate them in a way that they feel is safer for their baby.”
Unvaccinated kids aren’t healthier – they just get more vaccine preventable diseases. Most of which are life-threatening, even in this age of modern medicine, with access to good nutrition and sanitation.
So whether you only get one or two vaccines at a time; delay until four months, six months, or two years before you get started; skip all live vaccines or just wait until your child is “developmentally solid” to give them; or go with some other non-standard, parent-selected, delayed protection vaccine schedule, the only things that you can be sure of is that there is no evidence to support your decision and that you will leave your kids unprotected and at risk for getting a vaccine-preventable disease.
“…when I give your six-week-old seven different vaccines with two dozen antigens, I am supposed to try to convince you that the adverse reactions you have heard about are just coincidences.”
Better yet though. Find a pediatrician who will listen and answer your questions about vaccines, concerns about vaccine myths and misinformation, explain that no vaccine is optional, and not just simply pander to your fears.
What to Know About the Evidence for Alternative Vaccine Schedules
There is no evidence that skipping or delaying any vaccines with an alternative vaccine schedules can keep your kids safe from vaccine preventable diseases.
More on the Evidence for Alternative Vaccine Schedules
ITP is an abbreviation for idiopathic thrombocytopenic purpura.
It is a condition in which our platelets get destroyed, leading to excessive bruising and bleeding, since platelets are needed for normal blood clotting.
What Causes ITP?
To understand what causes ITP, it is important to know it is also often referred to as immune thrombocytopenic purpura, because it is typically the cells of our own immune system that destroys our platelets.
Well, that’s where the idiopathic part comes in.
We don’t know why people develop ITP, although classically, ITP is thought to follow a viral infection, including Epstein-Barr virus (mono), influenza, measles, mumps, rubella, and varicella (chicken pox). ITP has also been associated with many other viral infections, from Dengue fever to Zika.
“Often, the child may have had a virus or viral infection approximately three weeks before developing ITP. It is believed that the body’s immune system, when making antibodies to fight against a virus, “accidentally” also made an antibody that can stick to the platelet cells. The body recognizes any cells with antibodies as foreign cells and destroys them. Doctors think that in people who have ITP, platelets are being destroyed because they have antibodies.”
These children with ITP, usually under age 5 years, develop symptoms a few days to weeks after their viral infections. Fortunately, their platelet counts usually return to normal, even without treatment, within about 2 weeks to 6 months. Treatments are available if a child’s platelet count gets too low though.
Can Vaccines Cause ITP?
The measles vaccine is the only vaccine that has been clearly associated with ITP.
“The available data clearly indicate that ITP is very rare and the only vaccine for which there is a demonstrated cause-effect relationship is the measles, mumps and rubella (MMR) vaccine that can occur in 1 to 3 children every 100,000 vaccine doses.”
Cecinati on Vaccine administration and the development of immune thrombocytopenic purpura in children
Even then though, the risk of ITP after a measles containing vaccine, like MMR or ProQuad, is much less than after getting a natural measles infection, so worry about ITP is a not a good reason to skip or delay getting vaccinated.
What about other vaccines?
There is no good evidence that other vaccines, including the chicken pox vaccine, DTaP, hepatitis B vaccine, or flu vaccine, etc., cause ITP.
What about Gardasil? ITP is listed in the package insert as an adverse reaction for Gardasil, but only in the postmarketing experience section, so it does not mean that the vaccine actually caused the reaction, just that someone reported it.
Several large studies have actually been done that found no increased risk for ITP after getting vaccinated with Gardasil.
What to Know About Vaccines and ITP
Although measles containing vaccines can rarely cause ITP, vaccines prevent many more diseases that can cause ITP.
For any study, you have to review and judge the quality of the evidence it provides.
Is it a case report (a glorified anecdote), case series, or animal study (lowest quality evidence)?
Or a systemic review or meta-analyses (highest quality evidence)?
“The first and earliest principle of evidence-based medicine indicated that a hierarchy of evidence exists. Not all evidence is the same. This principle became well known in the early 1990s as practising physicians learnt basic clinical epidemiology skills and started to appraise and apply evidence to their practice. Since evidence was described as a hierarchy, a compelling rationale for a pyramid was made.”
Murad et al. on the New Evidence Pyramid
What about case control studies, cohort studies, and randomized controlled trials?
They lie somewhere in between on the hierarchy of evidence scale or pyramid.
And there are other factors to consider when judging the reliability of a study.
“Ultimately, the interpretation of the medical literature requires not only the understanding of the strengths and limitations of different study designs but also an appreciation for the circumstances in which the traditional hierarchy does not apply and integration of complementary information derived from various study designs is needed.”
Ho et al. on Evaluating the Evidence
For example, you might also have to take into account the sample size of the study.
A study can be underpowered if it doesn’t have enough subjects. Unfortunately, even an underpowered study will give you results. They likely won’t be statistically significant results, but folks don’t always realize that.
Even a meta-analysis, usually considered to be at the top of the hierarchy of evidence pyramid, can have problems that make their results less useful, such as not using appropriate inclusion criteria when selecting studies and leaving out important studies.
All in all, there are many factors to look at when reading a medical paper and considering if the results are valid and should influence what you do and how you think. This is especially true when looking at low quality vaccine papers, many of which the anti-vaccine movement uses to scare people, even though they are often poorly designed, and several of which have been retracted.
What to Know About the Hierarchy of Evidence
Learning about the hierarchy of evidence can help you better evaluate medical studies and vaccine papers and understand that there is more to doing your research about vaccines than searching PubMed and reading abstracts.
*The Pneumovax and IPV vaccines can be given either IM or Subcutaneously (SQ).
There are exceptions though. Kids with hemophilia can get IPV and the hepatitis A and B vaccines SQ, instead of IM.
Where to Give IM Injections?
After asking how many shots they are going to get, kids often ask where they are going to get them.
While newborns, infants, and younger toddlers get their IM injections in their anterolateral thigh muscle, older children typically get them in their anterolateral thigh muscle or in the deltoid muscle of their arm.
Be sure to use the correct needle size, length and gauge, and insert the needle with a quick thrust at a 90° angle to the skin (rapid injection technique). Keep in mind that it is not necessary to aspirate after injecting the needle and that multiple injections in the same extremity should be separated by at least one inch.
What to Know About IM Vaccines
It is important to know which vaccines need to be given intramuscularly (IM) and both how and where to give these shots.
“…it is important to recognise that the balance of media reporting does not necessarily reflect the balance of the argument among the involved professionals – by this is meant that equal weighting might be given by the media (and thus the lay community) to those for and against the vaccine although opponents of vaccination might be a very small number, as for example happened with both pertussis and MMR.”
David Baxter on Opposition to Vaccination and Immunisation the UK Experience – from Smallpox to MMR
understand the hierarchy of evidence and that a small study done in mice or a case report is probably not newsworthy, whereas a systemic review or meta analyses, especially if it was published in a high impact journal, is something we might need to hear about
Are you ready to cover your next story about vaccines or the next measles outbreak?
What to Know About Reporting on Vaccines
The way that health journalists cover vaccines and vaccine-preventable disease outbreaks can influence the behavior of people, either helping them understand that vaccines are safe and necessary, putting them on-the-fence about vaccines, or scarring them away from getting vaccinated and protected.
They bleed into their joints, into their skin (hematoma), and from their mouth and gums. They can bleed after surgery and even after getting their vaccinations.
Vaccines and Hemophilia
Having hemophilia is certainly not a contraindication to getting vaccinated though.
“Your child should get regular immunizations with necessary precautions to prevent bleeding from the injection sites.”
There are some precautions that are recommended before giving vaccines to a child with hemophilia, including:
using a 23-gauge or smaller caliber fine-gauge needle – consider a 25- or 27-gauge needle
when possible, giving the vaccine SQ instead of IM – for example, although the IPV (polio), hepatitis A, and hepatitis B vaccines are usually given IM, studies have shown that they can be given SQ to kids with hemophilia
applying firm pressure, without rubbing, after the vaccine is given for at least two minutes and up to 5 to 10 minutes
giving acetaminophen for pain relief, if necessary, instead of ibuprofen
warning about the risk of a hematoma developing at the injection site
Most importantly, if the child with hemophilia is already getting routine prophylaxis to prevent bleeding, schedule their vaccines around the same time to decrease the risk of bleeding.
Your child’s hematologist will likely give you specific instructions to provide to your pediatrician regarding immunization precautions.
What to Know About Vaccines and Hemophilia
Kids with hemophilia should get all of their vaccines on schedule, but precautions should be taken to decrease the chance of bleeding after getting an immunization.