Your Captain Speaking: Pediatric COVID-19 Shots—Getting It Right

“Samantha, we’ve seen some news that mistakes are being made when giving pediatric doses of the COVID-19 vaccine. When someone takes their kiddo in for the shot, is there anything we should have them look for or verify?”

“How about we start with the five Rs: the right patient, right drug, right dosage, right time, and right route of administration?”

We’re not going to talk here about whether you should vaccinate. What we want to cover is where there are chances for mistakes in delivering the vaccine and where they can be prevented. A few EMS organizations administer the COVID-19 vaccine, and lots of us have kids in the eligible age range. And as it turns out, there are plenty of opportunities in this process for providers to make mistakes.

The Vaccine for Kids

The Pfizer-BioNTech COVID-19 vaccine is now authorized for children ages 5–11. Kids 12 and above receive the adult dosage, a two-shot sequence, 21 days apart. Lots of medications are weight-based for children, but not here—it’s strictly by age. The adult dosage is 30 mcg, while the pediatric dose is 10 mcg. Sounds simple, but reality of the procedure is much different.

The Pfizer-BioNTech vaccine for adults comes in a vial with a purple cap. The vial for pediatric doses come with an orange top. Both need to be diluted with normal saline, but with different amounts. If the vial is diluted with the wrong amount, the dosage is wrong. A vial with a gray top is prediluted for pediatrics. Once the vial is first mixed, the colored cap is tossed. Label colors reflect cap colors, but only if you’re looking for them.

The vials are stored in ultracold conditions, then refrigerated after thawing. It might be tempting to store the adult/adolescent and pediatric vials together. Don’t—this will predictably cause a mix-up in dosage when the wrong vial is picked up. Pediatric patients, defined here as ages 5–11, should never receive vaccine from the same vial as adults.

If a provider has been giving many COVID-19 vaccines, they may prepare the syringe in the same way when, in fact, the procedure set forth by the CDC is different for those 5–11. An insulin syringe should not be used. While the needle is very fine and less painful, they are for the most part not long enough to use intramuscularly. The manufacturer authorized IM injection only in the deltoid muscle or anterolateral thigh. A 1-mL syringe is the standard, and adults/adolescents should receive an injection volume of 0.3 mL. The pediatric injection volume is 0.2 mL. How is that a third of the adult dose? They are diluted differently, and the prefilled volumes of the purple- and orange-capped vials are different.

As in real estate, location matters. Look through some of the many pictures of people getting their vaccines, and you will notice the injection sites are sometimes wrong—many are too far back or below the deltoid muscle. Small arms that are wiggling all around as a parent holds an upset and reluctant child can be really tough. It can help to grasp the deltoid muscle using an inverted C to bunch it up.

For clarity and everyone’s protection, you may wish to articulate what you’re doing before you deliver the shot. One experienced provider told me she announces, “I’m going to give you the pediatric [or adult/adolescent] COVID-19 vaccine.” This eliminates any confusion or possible disagreement later—smart!

Summary

Here’s the takeaway for your kids, friends, and anyone else who needs to know: Moderna is for those 18 and older at this time. Pfizer-BioNTech uses the same dose and preparation (0.3 mL) for those 12 and older. Pfizer-BioNTech vaccines for those 5–11 must be taken from a pediatric vial—either a properly diluted orange-top vial or a prediluted gray-top vial. Confirm that the pediatric injection volume is 0.2 mL, it is the COVID-19 vaccine, and have the person administering it point to where they will inject the vaccine. They should read all documentation and written instructions carefully and make sure any questions are resolved before the needle is delivered.

Here’s a link that to verify the exact procedure from the CDC. Find an infographic for the pediatric vaccine here.

Dick Blanchet, BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (Ill.) EMS, and a full-time paramedic at the St. Louis South City Hospital emergency department.