A subcutaneous injection is given into the subcutaneous fat under the skin.
The skin is made up of different layers. Underneath the epidermis and dermis, which contain sweat glands and hair follicles, is a layer of fat. This is the area into which subcutaneous injections are given.
We use three types of device to give subcutaneous injections at Great Ormond Street Hospital (GOSH): an ordinary syringe, auto-injector and pen device.
This information sheet mainly covers the use of a syringe to give the injections. Information about auto-injectors and pen devices is provided in the packaging and our nurses will teach you how to use them safely.
Why does my child need subcutaneous injections?
Some medicines work best when they are injected under the skin into the fatty layer. These medicines need to be absorbed more slowly than others that are taken by mouth or injected into a vein. Medicines given subcutaneously at GOSH include octreotide, growth hormone, insulin and epinephrine.
Do subcutaneous injections hurt?
Subcutaneous injections can be painful but there are various ways you can reduce this pain. You will find that your child finds them less painful as he or she gets used to them and as your injection technique improves.
Avoiding nerve endings
The skin is full of nerve endings, which can send a pain message to the brain if they are touched by the needle. They branch out throughout the skin but you can work out where they are by gently pressing the skin to see which area is less painful. Some areas of the body also contain fewer nerve endings than others. For instance, most children find that some areas of the thighs are less painful than the abdomen.
Inserting the needle
How you insert the needle can also make a difference. The needles are designed so that the sharp end is cut at a 45 degree angle. If you insert the needle with the cut angle facing towards the skin, this will be painful. However, if you insert it with the cut angle facing upwards (as shown above), the point will be inserted into the skin first and so will be less painful.
Rotation of injection sites
One important factor in making subcutaneous injections less painful and reducing irritation at the injection site is to rotate the position on the body where you give the injections.
There are several areas of the body suitable for giving subcutaneous injections, shown on the diagram. As a general rule, suitable areas are those with a substantial amount of fat below the skin, so the thighs, buttocks and abdomen tend to be most suitable in children.
As your child grows, other areas may become suitable as well, such as the upper arms but these vary from child to child.
At the end of this information sheet there is a site rotation chart for you to use to make which injection sites you use on which day. Work out a pattern for how you will use each area. We tend to suggest that you give an injection in one area on the first day and another area of the body on the second.
Each area is shown by a square on the chart and you should give one injection per square. This makes sure that the injections are not given too close together.
For example, Debbie needs to give her son Nathan one injection each day. On the first day, Nathan chooses to have the injection in his abdomen so Debbie marks one abdomen square on the chart with the date. On the second day, he chooses to have an injection in his left thigh, so Debbie marks off the relevant square. On the third day, Nathan chooses his right thigh for the injection. On the fourth day, Debbie gives him the injection in his abdomen again but in a different square to the one she used on the first day.
Some parents find that it helps to put a small circular plaster over the injection site to mark it as a reminder for the next injection. It is important to rotate the injection sites daily.
Injecting the medicine into the same area all the time will cause a fatty lump (lipohypertrophy) to form. While these are not dangerous in themselves, medicine will be absorbed more slowly through them.
Preparing your child for a subcutaneous injection
There are lots of techniques you can use to prepare your child for injections and to distract them while the injection is happening. Talk to your play specialist or read our Distraction Therapy booklet for ideas.
We will make sure that you feel confident in giving subcutaneous injections by the time you leave GOSH but if you have any concerns, support and advice is always available on the telephone.
Getting ready to give the subcutaneous injection
- Collect together all the equipment you will need:
cotton wool or gauze
site rotation chart
- Wash your hands.
- Wipe the top of the medicine bottle with the alcohol wipe and leave to dry.
- Choose the injection site for this dose.
- Open the syringe package and put on a clean surface.
- Insert the needle into the top of the bottle at an angle of 90°.
- Pull back the plunger and draw up slightly more than the prescribed dosage.
- Remove the needle from the bottle.
Note: If you are using an auto injector or pen device, load it according to the instructions in the package and how you have been taught.
Giving the subcutaneous injection
- Holding the needle upwards, tap the syringe gently to move any air bubbles towards the needle.
- Push the plunger gently to remove the air bubble and squirt a small amount of the medicine into the air.
- Lift the skin in the chosen injection area between your thumb and index finger.
- Holding the needle at a 90º or 45° angle as shown by your nurse, insert the needle into the skin fold
Note: If you are using a 5-6mm needle, you do not need to lift the skin into a skin fold as described above.
- Continue to hold the skin and push the syringe plunger to inject the medicine while counting to 10 slowly.
- Remove the needle from the skin and let go of the skin fold.
- Put a piece of cotton wool or gauze over the injection site for a few seconds.
- Throw the syringe away in a ‘sharps’ bin as you have been taught.
- Mark the injection site on your site rotation chart.
Note: If you are using an auto injector or pen device, after you have given the injection, remove the needle from the device as you have been shown and dispose of it in the sharps bin.
What do I do when the sharps bin is full?
When we taught you how to give subcutaneous injections, we will have explained about disposal of the syringes. We will give you a sharps bin to take home with you but when it is full, please call your community team to ask them to dispose of it and give you a new one.
All other packaging, such as the syringe package and medicine bottles can be disposed of with your normal household rubbish.
Please read this information sheet from GOSH alongside the patient information leaflet (PIL) provided by the manufacturer. If you do not have a copy of the manufacturer’s patient information leaflet please talk to your pharmacist. A few products do not have a marketing authorisation (licence) as a medicine and therefore there is no PIL.
For children in particular, there may be conflicts of information between the manufacturer’s patient information leaflet (PIL) and guidance provided by GOSH and other healthcare providers. For example, some manufacturers may recommend, in the patient information leaflet, that a medicine is not given to children aged under 12 years. In most cases, this is because the manufacturer will recruit adults to clinical trials in the first instance and therefore the initial marketing authorisation (licence) only covers adults and older children.
For new medicines, the manufacturer then has to recruit children and newborns into trials (unless the medicine is not going to be used in children and newborns) and subsequently amend the PIL with the approved information. Older medicines may have been used effectively for many years in children without problems but the manufacturer has not been required to collect data and amend the licence. This does not mean that it is unsafe for children and young people to be prescribed such a medicine ‘off-licence/off-label’. However, if you are concerned about any conflicts of information, please discuss with your doctor, nurse or pharmacist.