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Rapid Responses: Rapid Responses published:
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Maybe they make 'em big in Birmingham
- K Parnell (15 September 2006)
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How long is a piece of string?
- John McCormack (16 September 2006)
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Wrong Picture
- Howard M Friend (2 October 2006)
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K Parnell, GP Sydney, Australia 2064
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I love evidence as much as the next GP, and am aware the recommendation is for longer needles for infant vaccination. However, I remain slightly worried about these findings when confronted with some 2 month old babies, who often dont have a lot of padding. The technique referred to by Diggle is stretching the skin flat between thumb and forefinger, inserting needle at 90 degrees and pushing down into muscle. Did the authors push down until they thought they had hit muscle? Or did they go all the way in until hub met skin? If the former, not very scientific, if the latter, in some full term but petite babies I see, I'd hit either bone or end up in the biceps femoris. The accompanying editorial notes that 'if the subcutaneous and muscle tissue are bunched to minimise the chance of striking bone, as some have recommended, then a 25 mm needle is required to ensure intramuscular administration in infants'. Yet this is not the technique used in the study. Furthermore, at six hours when the greatest number of local reactions were seen, there was no statistical difference between longer and shorter needles. This seems to be glossed over in the paper. I havent had the pleasure of visiting Birmingham, maybe they just make 'em bigger than in Sydney. Competing interests: None declared |
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John McCormack, GP Rosmuc, Connemara, Ireland
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I have to agree with Dr. Parnell. Widespread introduction of longer needles in lean healthy 2 month old infants may indeed reduce the incidence of local cutaneous and subcutaneous reactions such as heat, tenderness, induration and swelling and the associated parental anxiety but if this becomes the norm will we be reading in 5 years time the results of studies showing that shorter needles reduce the incidence of periosteal haematomas. As the immunogenicity of both longer and shorter needles is reported as being the same it may be unwise to recommend widespread use of longer needles only. Surely vaccinator discretion is required as infants to adults vary in the amount of subcutaneous tissue present to get to muscle. I have some frail elderly patients recieving B12 injections with little subcutaneous tissue and even littler muscle mass that I wouldn't dream of using longer needles on. Remember that there is no vaccine licensed for intraosseous administration. I would far prefer that if my own children were to recieve a local reaction to a vaccine that it be a transient cutaneous/subcutaneous discomfort as opposed to an extremely painful and slower to resolve periosteal pain. How about the sensible "fat fleshy kids full length needle" "little lean lads and lassies little lancer". Or am I just becoming a creature of habit afraid to change my modus operandi? Competing interests: None declared |
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Howard M Friend, Regional Medical Officer for the FCO British High Commission. Lilongwe, Malawi
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I'm afraid your front cover picture shows what looks like a short ie 16mm, 25 gauge needle going into the arm of a child who looks less than a year old. This does not accord with the advice given in the text of the article. A case of `Do as I say - not do as I do?' Competing interests: None declared |
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