What is the recommended injection site for the rabies vaccine in children?

Rabies Vaccine Injection Site in Children

For children, rabies vaccine should be administered intramuscularly in the anterolateral thigh for infants and young children, and in the deltoid muscle for older children—never use the gluteal area as this produces inadequate antibody response and vaccine failure. 1, 2

Recommended Injection Sites by Age

Infants and Young Children

• The anterolateral aspect of the thigh is the preferred site for infants and small children receiving rabies vaccine 1, 3
• This site ensures adequate muscle penetration and optimal immune response in younger pediatric patients 2, 4
• The anterolateral thigh location is specifically recommended by the CDC's Advisory Committee on Immunization Practices (ACIP) for this age group 1

Older Children and Adolescents

• The deltoid muscle becomes the preferred site for older children who have adequate deltoid muscle mass 1, 3
• The transition from thigh to deltoid typically occurs as children grow, though specific age cutoffs are not rigidly defined in guidelines 2, 3

Critical Site to Avoid

Never Use the Gluteal Area

• The gluteal region must never be used for rabies vaccination in any age group, including children 1, 2
• Administration of rabies vaccine (HDCV or PCECV) in the gluteal area results in significantly lower neutralizing antibody titers and has been associated with vaccine failures 1
• The FDA drug label for rabies immune globulin specifically warns against gluteal injection due to risk of sciatic nerve injury 3

Vaccine Administration Details

Standard Dosing

• Children receive the same vaccine dose volume (1.0 mL) as adults, regardless of age or weight 2, 4, 3
• The vaccine should be administered via intramuscular injection at a 90-degree angle to the skin surface 1

Coordination with Rabies Immune Globulin (HRIG)

• HRIG should be infiltrated around the wound site when anatomically feasible, with any remaining volume given intramuscularly at a site distant from the vaccine administration site 1, 3
• Never administer HRIG and vaccine in the same syringe or at the same anatomical site 1, 2, 3
• However, subsequent vaccine doses in the series can be given in the same anatomic location where HRIG was previously administered 1

Clinical Considerations

Why Site Selection Matters

• Proper intramuscular administration is essential for optimal immune response—subcutaneous deposition results in lower antibody titers 1
• The anterolateral thigh in young children provides adequate muscle depth (10.5-16.5 mm depending on age) to ensure intramuscular delivery 5
• Research demonstrates that muscle thickness at the anterolateral thigh increases with age, from approximately 10.5 mm at 2 months to 16.5 mm at 18 months 5

Alternative Site Evidence

• While some research suggests the ventrogluteal site may be anatomically suitable in children as young as 1-12 months 6, 7, this is not endorsed by CDC/ACIP guidelines and should not be used for rabies vaccination 1, 2
• The established guidelines consistently recommend only deltoid (older children) or anterolateral thigh (young children) 1, 2, 3

Common Pitfalls to Avoid

• Do not use the gluteal area under any circumstances—this is the most critical error and can lead to vaccine failure 1, 2
• Do not reduce the vaccine dose volume for children—they require the full 1.0 mL dose 2, 4, 3
• Do not administer vaccine and HRIG at the same anatomical site on day 0 1, 2, 3
• Do not assume subcutaneous administration is acceptable—intramuscular delivery is essential for adequate immune response 1