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June 4, 1997, Vol 277, No. 21 >
ARTICLE | June 4, 1997

Determination of Deltoid Fat Pad Thickness: Title and subTitle BreakImplications for Needle Length in Adult Immunization FREE

Gregory A. Poland, MD; Aleta Borrud, MD; Robert M. Jacobson, MD; Kristina McDermott, MD; Peter C. Wollan, PhD; Duane Brakke, RT, RDMS; J. William Charboneau, MD
[+] Author Affiliations

Presented in part at the 29th annual meeting of the Infectious Disease Society of America, Los Angeles, Calif, May 16, 1995.

Reprints: Gregory A. Poland, MD, Mayo Vaccine Research Group, Clinical Pharmacology Unit, 601B Guggenheim Bldg, 200 First St SW, Rochester, MN 55905.


JAMA. 1997;277(21):1709-1711. doi:10.1001/jama.1997.03540450065037
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Article
References

Objective.  —To measure deltoid fat pad thickness and determine the optimal needle length for deltoid intramuscular immunization in healthy adults.

Design, Setting, and Participants.  —Prospective study of 220 healthy health care workers (126 women, 94 men) at the Mayo Medical Center, Rochester, Minn.

Main Outcome Measures.  —Deltoid fat pad thickness determined by highresolution ultrasound scanning, weight, height, and mid-deltoid arm circumference.

Results.  —We found a highly significant difference between women and men in deltoid fat pad thickness, with women having a thicker deltoid fat pad (11.7 vs 8.3 mm; P<.001). Women had a greater deltoid skin-fold thickness than men (34.7 vs 17.2 mm, P<.001) and an equal body mass index. According to the ultrasound findings, a standard 16-mm (5/8-in) needle would not have reached 5 mm into muscle in 17% (16/94) of men and 48.4% (61/126) of women in this study.

Conclusions.  —Among healthy adults of the age range we studied, the following needle lengths appear to be appropriate for true deltoid intramuscular immunization: For men across the weight ranges we studied (59-118 kg), use of a 25-mm (1-in) needle would result in at least 5 mm of muscle penetration in all subjects. For women who weighed less than 60 kg, a 16-mm (5/8-in) needle would be sufficient to achieve muscle penetration of 5 mm. For women between 60 and 90 kg, a 25-mm (1-in) needle would be sufficient, and women greater than 90 kg would require a 38-mm (1.5-in) needle to ensure intramuscular administration.

REFERENCES

1 +
Centers for Disease Control and Prevention.  General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Morb Mortal Wkly Rep . 1994;;43( (RR-1) ):1-38.
2 +
ACP Task Force on Adult Immunization and Infectious Diseases Society of America. Guide for Adult Immunization . ed 3. Philadelphia, Pa: American College of Physicians; 1994;:1.
3 +
Report of the Committee on Infectious Diseases. ed 23. Elk Grove Village, Ill: American Academy of Pediatrics; 1994.
4 +
National Advisory Committee on Immunization. Canadian Immunization Guide . ed 3. Ottawa, Ontario: Health Protection Branch, Laboratory Centre For Disease Control; 1989;.
5 +
Fried AM, Coughlin K, Griffen WO.  The sonographic fat/muscle ratio . Invest Radiol . 1986;;21:71-75.
6 +
Sjöström L.  Measurement of fat distribution . In: Bouchard C, Johnston FE, eds. Fat Distribution During Growth and Later Health Outcomes . New York, NY: Alan R Liss Inc; 1988;:43-61.
7 +
Ramirez ME.  Familial aggregation of subcutaneous fat deposits and the peripheral fat distribution pattern . Int J Obes . 1993;;17:63-68.
8 +
Borkan GA, Hults DE, Cardarelli J, Burrows BA.  Comparison of ultrasound and skinfold measurements in assessment of subcutaneous and total fatness . Am J Phys Anthropol . 1982;;58:307-313.
9 +
Weits T, Van Der Beek EJ, Wedel M.  Comparison of ultrasound and skinfold caliper measurement of subcutaneous fat tissue . Int J Obes . 1986;;10:161-168.
10 +
Weiss LW, Clark FC.  Three protocols for measuring subcutaneous fat thickness on the upper extremities . Eur J Appl Physiol . 1987;;56:217-221.
11 +
Heckmatt JZ, Pier N, Dubowitz V.  Measurement of quadriceps muscle thickness and subcutaneous tissue thickness in normal children by realtime ultrasound imaging . J Clin Ultrasound . 1988;; 16:171-176.
12 +
Hayes PA, Sowood PJ, Belyavin A, Cohen JB, Smith FW.  Sub-cutaneous fat thickness measured by magnetic resonance imaging, ultrasound, and calipers . Med Sci Sports Exerc . 1987;;20:303-309.
13 +
Hick JF, Charboneau JW, Brakke DM, Goergen B.  Optimum needle length for diphtheria-tetanus-pertussis inoculation of infants . Pediatrics . 1989;;84:136-137.
14 +
Lo Y-S, Lu C-C, Chen L-Y, Huang L-Y, Jong Y-J.  Quantitative measurement of muscle and subcutaneous fat thickness in newborn by real-time ultrasonography . Kaohsiung J Med Sci . 1992;;8:75-81.
15 +
Hattori K, Numata N, Ikoma M, Matsuzaka A, Danielson RR.  Sex differences in the distribution of subcutaneous and internal fat . Hum Biol . 1991;;63:53-63.
16 +
Kohrt WM, Malley MT, Dalsky GP, Holloszy JO.  Body composition of healthy sedentary and trained, young and older men and women . Med Sci Sports Exerc . 1992;;24:832-837.
17 +
Szmuness W, Stevens CE, Zang EA, Harley EJ, Kellner A.  A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B): a final report . Hepatology . 1981;;1:377-385.
18 +
Francis DP, Hadler SC, Thompson SE, et al.  The prevention of hepatitis B with vaccine . Ann Intern Med . 1982;;97:362-366.
19 +
Dienstag JL, Werner BG, Polk BF, et al.  Hepatitis B vaccine in health care personnel . Ann Intern Med . 1984;;101:34-40.
20 +
Pead PJ, Saeed AA, Hewitt WG, Brownfield RN.  Low immune responses to hepatitis B vaccination among healthy subjects . Lancet . 1985;;1:1152.
21 +
Ukena T, Esber H, Bessette R, Parks T, Crocker B, Shaw FE Jr.  Site of injection and response to hepatitis B vaccine . N Engl J Med . 1985;;313:579-580.
22 +
Lindsay KL, Herbert DA, Gitnick GL.  Hepatitis B vaccine: low postvaccination immunity in hospital personnel given gluteal injections . Hepatology . 1985;;5:1088-1090.
23 +
Weber DJ, Rutala WA, Samsa GP, Santimaw JE, Lemon SM.  Obesity as a predictor of poor antibody response to hepatitis B plasma vaccine . JAMA . 1985;;254:3187-3189.
24 +
McLean AA, Guess HA, Scolnick EM.  Suboptimal response to hepatitis B vaccine given by injection into the buttock . MMWR Morb Mortal Wkly Rep . 1985;;34:105-113.
25 +
Shaw FE Jr, Guess HA, Roets JM, et al.  Effect of anatomic injection site, age and smoking on the immune response to hepatitis B vaccination . Vaccine . 1989;;7:425-430.
26 +
Horowitz MM, Ershler WB, McKinney P, Battiola J.  Duration of immunity after hepatitis B vaccination . Ann Intern Med . 1988;;108:185-189.
27 +
Pasko MT, Bean TR Jr.  Persistence of anti-HBs among health care personnel immunized with hepatitis B vaccine . Am J Public Health . 1990;;80:590-593.
28 +
Senden TF.  Response to intradermal hepatitis B vaccination . Vaccine . 1990;;8:612-613.
29 +
Lemon SM, Weber DJ.  Immunogenicity of plasma-derived hepatitis B vaccine: relationship to site of injection and obesity . J Gen Intern Med . 1986;;11:199-201.
30 +
Wahl M, Hermodsson S.  Intradermal, subcutaneous or intramuscular administration of hepatitis B vaccine . Scand J Infect Dis . 1987;;19:617-621.
31 +
Greenblatt DJ, Allen MD.  Intramuscular injection-site complications . JAMA . 1978;;240:542-544.
32 +
Haramati N, Lorans R, Lutwin M, Kaleya RN.  Injection granulomas: intramuscle or intrafat? Arch Fam Med . 1994;;3:146-148.
33 +
Michaels L, Poole RW.  Injection granuloma of the buttock . Can Med Assoc J . 1970;;102:626-628.
34 +
Ipp MM, Gold R, Goldbach M, et al.  Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length . Pediatrics . 1989;;83:679-682.
35 +
Greenblatt DJ, Koch-Weser J.  Intramuscular injection of drugs . N Engl J Med . 1976;;295:542-546.
36 +
Frisancho AR.  Triceps skin fold and upper arm muscle size norms for assessment of nutritional status . Am J Clin Nutr . 1974;;27:1052-1058.
37 +
Cockshott WP, Thompson GT, Howlett LJ, Seeley ET.  Intramuscular or intralipomatous injections? N Engl J Med . 1982;;307:356-358.

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Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Centers for Disease Control and Prevention.  General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Morb Mortal Wkly Rep . 1994;;43( (RR-1) ):1-38.
2 +
ACP Task Force on Adult Immunization and Infectious Diseases Society of America. Guide for Adult Immunization . ed 3. Philadelphia, Pa: American College of Physicians; 1994;:1.
3 +
Report of the Committee on Infectious Diseases. ed 23. Elk Grove Village, Ill: American Academy of Pediatrics; 1994.
4 +
National Advisory Committee on Immunization. Canadian Immunization Guide . ed 3. Ottawa, Ontario: Health Protection Branch, Laboratory Centre For Disease Control; 1989;.
5 +
Fried AM, Coughlin K, Griffen WO.  The sonographic fat/muscle ratio . Invest Radiol . 1986;;21:71-75.
6 +
Sjöström L.  Measurement of fat distribution . In: Bouchard C, Johnston FE, eds. Fat Distribution During Growth and Later Health Outcomes . New York, NY: Alan R Liss Inc; 1988;:43-61.
7 +
Ramirez ME.  Familial aggregation of subcutaneous fat deposits and the peripheral fat distribution pattern . Int J Obes . 1993;;17:63-68.
8 +
Borkan GA, Hults DE, Cardarelli J, Burrows BA.  Comparison of ultrasound and skinfold measurements in assessment of subcutaneous and total fatness . Am J Phys Anthropol . 1982;;58:307-313.
9 +
Weits T, Van Der Beek EJ, Wedel M.  Comparison of ultrasound and skinfold caliper measurement of subcutaneous fat tissue . Int J Obes . 1986;;10:161-168.
10 +
Weiss LW, Clark FC.  Three protocols for measuring subcutaneous fat thickness on the upper extremities . Eur J Appl Physiol . 1987;;56:217-221.
11 +
Heckmatt JZ, Pier N, Dubowitz V.  Measurement of quadriceps muscle thickness and subcutaneous tissue thickness in normal children by realtime ultrasound imaging . J Clin Ultrasound . 1988;; 16:171-176.
12 +
Hayes PA, Sowood PJ, Belyavin A, Cohen JB, Smith FW.  Sub-cutaneous fat thickness measured by magnetic resonance imaging, ultrasound, and calipers . Med Sci Sports Exerc . 1987;;20:303-309.
13 +
Hick JF, Charboneau JW, Brakke DM, Goergen B.  Optimum needle length for diphtheria-tetanus-pertussis inoculation of infants . Pediatrics . 1989;;84:136-137.
14 +
Lo Y-S, Lu C-C, Chen L-Y, Huang L-Y, Jong Y-J.  Quantitative measurement of muscle and subcutaneous fat thickness in newborn by real-time ultrasonography . Kaohsiung J Med Sci . 1992;;8:75-81.
15 +
Hattori K, Numata N, Ikoma M, Matsuzaka A, Danielson RR.  Sex differences in the distribution of subcutaneous and internal fat . Hum Biol . 1991;;63:53-63.
16 +
Kohrt WM, Malley MT, Dalsky GP, Holloszy JO.  Body composition of healthy sedentary and trained, young and older men and women . Med Sci Sports Exerc . 1992;;24:832-837.
17 +
Szmuness W, Stevens CE, Zang EA, Harley EJ, Kellner A.  A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B): a final report . Hepatology . 1981;;1:377-385.
18 +
Francis DP, Hadler SC, Thompson SE, et al.  The prevention of hepatitis B with vaccine . Ann Intern Med . 1982;;97:362-366.
19 +
Dienstag JL, Werner BG, Polk BF, et al.  Hepatitis B vaccine in health care personnel . Ann Intern Med . 1984;;101:34-40.
20 +
Pead PJ, Saeed AA, Hewitt WG, Brownfield RN.  Low immune responses to hepatitis B vaccination among healthy subjects . Lancet . 1985;;1:1152.
21 +
Ukena T, Esber H, Bessette R, Parks T, Crocker B, Shaw FE Jr.  Site of injection and response to hepatitis B vaccine . N Engl J Med . 1985;;313:579-580.
22 +
Lindsay KL, Herbert DA, Gitnick GL.  Hepatitis B vaccine: low postvaccination immunity in hospital personnel given gluteal injections . Hepatology . 1985;;5:1088-1090.
23 +
Weber DJ, Rutala WA, Samsa GP, Santimaw JE, Lemon SM.  Obesity as a predictor of poor antibody response to hepatitis B plasma vaccine . JAMA . 1985;;254:3187-3189.
24 +
McLean AA, Guess HA, Scolnick EM.  Suboptimal response to hepatitis B vaccine given by injection into the buttock . MMWR Morb Mortal Wkly Rep . 1985;;34:105-113.
25 +
Shaw FE Jr, Guess HA, Roets JM, et al.  Effect of anatomic injection site, age and smoking on the immune response to hepatitis B vaccination . Vaccine . 1989;;7:425-430.
26 +
Horowitz MM, Ershler WB, McKinney P, Battiola J.  Duration of immunity after hepatitis B vaccination . Ann Intern Med . 1988;;108:185-189.
27 +
Pasko MT, Bean TR Jr.  Persistence of anti-HBs among health care personnel immunized with hepatitis B vaccine . Am J Public Health . 1990;;80:590-593.
28 +
Senden TF.  Response to intradermal hepatitis B vaccination . Vaccine . 1990;;8:612-613.
29 +
Lemon SM, Weber DJ.  Immunogenicity of plasma-derived hepatitis B vaccine: relationship to site of injection and obesity . J Gen Intern Med . 1986;;11:199-201.
30 +
Wahl M, Hermodsson S.  Intradermal, subcutaneous or intramuscular administration of hepatitis B vaccine . Scand J Infect Dis . 1987;;19:617-621.
31 +
Greenblatt DJ, Allen MD.  Intramuscular injection-site complications . JAMA . 1978;;240:542-544.
32 +
Haramati N, Lorans R, Lutwin M, Kaleya RN.  Injection granulomas: intramuscle or intrafat? Arch Fam Med . 1994;;3:146-148.
33 +
Michaels L, Poole RW.  Injection granuloma of the buttock . Can Med Assoc J . 1970;;102:626-628.
34 +
Ipp MM, Gold R, Goldbach M, et al.  Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length . Pediatrics . 1989;;83:679-682.
35 +
Greenblatt DJ, Koch-Weser J.  Intramuscular injection of drugs . N Engl J Med . 1976;;295:542-546.
36 +
Frisancho AR.  Triceps skin fold and upper arm muscle size norms for assessment of nutritional status . Am J Clin Nutr . 1974;;27:1052-1058.
37 +
Cockshott WP, Thompson GT, Howlett LJ, Seeley ET.  Intramuscular or intralipomatous injections? N Engl J Med . 1982;;307:356-358.

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