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Whether you are looking to learn more about paediatric musculoskeletal problems, or are involved in the care of children, then PMM and PMM-Nursing will help you change your clinical practice for the better.

Subcutaneous Injections

Subcutaneous (SC) injections are increasingly used as a way to gain disease control. This route of administration is effective as 100% of the drug reaches the patient in contrast to oral medicines which may be affected by digestion, absorption from the gut or metabolised by the liver.  Some examples of drugs used in paediatric rheumatology that use the SC route include Methotrexate and Biologics (Etanercept, Adalimumab, Anakinra, Tocilizumab). The use of SC route allows effective treatments to be given at home. Nurses play an important role in the education and support for patients and families as well as strategies and techniques to minimise anxiety and discomfort. Children learn to give their own injections with parent / carer supervision. Nurse-led clinics are important to monitor technique and assess knowledge.

Royal College Nursing Practical guidance on the use of methotrexate is available. There are very useful sections on the use of methotrexate in children and the training of parents for home care.

Royal College of Nursing Practical Guidance on the use of biologics is available.

Key practical tips are given below (Table). 

Child anxiety due to subcutaneous injection.


To reduce child’s anxiety.


  • Explain procedure according to child’s age and understanding.
  • Avoid bargaining and delaying procedure.
  • Avoid long discussion and persuasion.
  • Establish who is going to talk to the child and avoid more than one person talking at the same time. Several adults talking can be intimidating and create confusion.
  • Consider the use of sticker chart, reward system for sitting still.
  • Encourage child to write some achievable “rules” e.g., ‘I will sit still on mummy's lap’, ‘we will sing my favourite song/watch my favourite TV programme’, ‘we will read a story’.
  • Use an ice cube to rub on the skin to cool it prior to the insertion of cannula, useful as a distraction and not as frightening as ethyl chloride spray.

Immunocompromised due to underlying condition and subsequent treatment.



To recognise early signs of illness or infection.

  • Establish if child is fit and well.
  • Parameters for postponing injection include temperature above 37.5 degrees Celsius on two occasions (or 38 degrees on a single occasion), has commenced antibiotics within forty-eight hours, child looks unwell.
  • Contact specialist team for advice or guidance.
  • If in doubt delay until specialist advice has been sought.


Key points to consider are; What training has the family had to do this at home ? What does the parent have to consider to assess whether it is safe to give a dose ? What do they do if they have concerns ? How do they involve the child in the procedure ? What sites are suitable for the injection ? What do they do when they go on holiday ? What do they do if mum is pregnant ? What about vaccinations ? What do they do if they hear there is chicken pox in school ? 

Many of these points are addressed in the Royal College Guidance for Methotrexate