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ARTICLE

Vaccination Site and Risk of Local Reactions in
Children 1 Through 6 Years of Age
AUTHORS: Lisa A. Jackson, MD, MPH,a Do Peterson, MS,a WHAT’S KNOWN ON THIS SUBJECT: Previous evaluations of local
Jennifer C. Nelson, PhD,a,b S. Michael Marcy, MD,c Allison L. reactions after the fifth diphtheria-tetanus-acellular pertussis
Naleway, PhD,d James D. Nordin, MD, MPH,e James G. (DTaP) vaccine in children 4 to 6 years of age have revealed that
Donahue, DVM, PhD,f Simon J. Hambidge, MD, PhD,g vaccination in the thigh is associated with a lower risk of local
Carolyn Balsbaugh, MPH,h Roger Baxter, MD,i Tracey reactions compared with vaccination in the arm.
Marsh, MS,a Lawrence Madziwa,a and Eric Weintraub,
MPHj
WHAT THIS STUDY ADDS: Among children 12 to 35 months of age,
aGroup Health Research Institute, Seattle, Washington;
bDepartment of Biostatistics, University of Washington, Seattle,
injection of DTaP vaccine in the thigh is associated with a lower
Washington; cKaiser Permanente Southern California, Pasadena,
risk of local reactions compared with vaccination in the arm.
California; dKaiser Permanente Northwest, Portland, Oregon;
eCenter for Health Research, HealthPartners Research

Foundation, Minneapolis, Minnesota; fMarshfield Clinic Research
Foundation, Epidemiology Research Center, Marshfield,
Wisconsin; gInstitute for Health Research, Kaiser Permanente
Colorado and Denver Health Community Health Services, Denver, abstract
Colorado; hDepartment of Population Medicine, Harvard Pilgrim
OBJECTIVE: Our objective was to assess whether the occurrence of
Health Care Institute and Harvard Vanguard Medical Associates,
Boston, Massachusetts; iKaiser Permanente Vaccine Study Center, medically attended local reactions to intramuscularly administered
Oakland, California; and jImmunization Safety Office, Centers for vaccines varies by injection site (arm versus thigh) in children 1 to 6
Disease Control and Prevention, Atlanta, Georgia years of age.
KEY WORDS
diphtheria-tetanus-acellular pertussis vaccines, injections,
METHODS: This is a retrospective cohort study of children in the Vac-
intramuscular, vaccine safety, children cine Safety Datalink population from 2002 to 2009. Site of injection and
ABBREVIATIONS the outcome of medically attended local reactions were identified from
ACIP—Advisory Committee on Immunization Practices administrative data.
CI—confidence interval
DTaP—diphtheria-tetanus-acellular pertussis RESULTS: The study cohort of 1.4 million children received 6.0 million
ICD-9-CM—International Classification of Diseases, Ninth Revi- intramuscular (IM) vaccines during the study period. The primary anal-
sion, Clinical Modification yses evaluated the IM vaccines most commonly administered alone,
IM—intramuscular
MCO—managed care organization
which included inactivated influenza, hepatitis A, and diphtheria-
RR—relative risk tetanus-acellular pertussis (DTaP) vaccines. For inactivated influenza
VSD—Vaccine Safety Datalink and hepatitis A vaccines, local reactions were relatively uncommon,
(Continued on last page) and there was no difference in risk of these events with arm
versus thigh injections. The rate of local reactions after DTaP
vaccines was higher, and vaccination in the arm was associated
with a significantly greater risk of this outcome compared with
vaccination in the thigh, both for children 12 to 35 months (relative
risk: 1.88 [95% confidence interval: 1.34–2.65]) and 3 to 6 years of
age (relative risk: 1.41 [95% confidence interval: 0.84–2.34]), although
this difference was not statistically significant in the older age group.
CONCLUSIONS: Injection in the thigh is associated with a significantly
lower risk of a medically attended local reaction to a DTaP vaccination
among children 12 to 35 months of age, supporting current recommen-
dations to administer IM vaccinations in the thigh for children younger
than 3 years of age. Pediatrics 2013;131:283–289

PEDIATRICS Volume 131, Number 2, February 2013 283
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Kaiser Permanente Northwest previous VSD study of medically at- children 3 years of age and older should (Portland.2) assigned to an Control and Prevention and 10 managed ologically implausible extreme values outpatient medical encounter on the care organizations (MCOs) in the United were identified by using World Health day after vaccine administration (day 1) States that was established in 1991 to Organization age and gender stan.6. other unspecified disorder of cinations administered to children 1 to To account for body habitus. pre- The VSD collects data. vaccinations. 2016 . For pared with vaccination in the thigh. vaccination was defined by an ICD-9-CM evaluate the association between site of ministered combination vaccines. Classification of Diseases.8). Two previous cohort. health plan regression models as a 3-category teria who also had an ICD code for enrollment. Ninth Re- mass is adequate. BMI plications of medical care (999. Less commonly ad. cluded in the analyses. were at least 1 and not more than 6 curring within 4 days of the vaccination jection sites for children and that the years of age during the study period of visit. by using methods employed in the muscular (IM) vaccinations given to CO). medically at- toddlers aged 12 months to 2 years the Kaiser Permanente (Oakland. serum reaction (999. monitor and evaluate vaccine safety. were identified from the reactions. and given during the confirmed medically attended local tussis (DTaP) vaccine. limb swelling (729.3 based only on that ICD-9-CM code al- each vaccination.81.3. MA). have revealed that VSD data files. allergy unspecified a retrospective cohort study of IM vac. 83% of events presumptively 4 to 6 years of age. including infor. Among the study were then confirmed by chart review. all vaccinations given on orafter In that study. (995.6.9).3 In that study.6). and those presumptive events risk of local reactions after vaccination 2002 through 2009. Clinical Modification (ICD-9-CM) indicates that in actual practice there enrolled at a participating VSD MCO who diagnosis codes assigned to visits oc- is variability in choice of vaccine in.8. site of injection attended local reaction after an IM earlier doses of DTaP vaccine.3. a higher risk of local reactions com.81). Therefore. WI). pain in limb. CA). can vary by injection site.5. local reactions to other IM vaccines vaccination. oral. when available. and excluded. we conducted combination vaccine. Harvard Organization Child Growth Standards. pain attended local reactions. WA). or population. Marshfield Clinic tended local reactions to the fifth DTaP be administered in the deltoid. 682.4–6 dardized BMI percentile thresholds to exclude preexisting conditions. algorithm was highly predictive of fifth diphtheria-tetanus-acellular per. Group Health (Seattle. months of the vaccination date were lymphadenitis (289. without confirmatory chart between site of vaccination and risk of child’s age in months at the time of review. 785. enth birthday. and 785. in this study.1 Available evidence The study cohort included children vision.5). 683. were not in. and for (Marshfield. cellulitis. The outcome event of a medically Advisory Committee on Immunization HealthPartners (Minneapolis. and vaccines were cat.9 729. OR). 682.9).9). obtained. To further (arm or thigh). allergy MCO members annually. Datalink (VSD) population.8 BMI was included in sumptive cases defined by these cri- mation on demographics.2. Bi. from data infection after infusion or vaccination METHODS recorded in the electronic health (999. egorized by type of administration (IM. CA). the child’s skin (709. through day 5. Kaiser Permanente Colorado (Denver. unspecified disorder of 6 years of age in the Vaccine Safety height and weight recorded within 3 skin and subcutaneous tissue (709. or intranasal). and. and medical variable. the outcome of a medically recommended for children and to where applicable. Northern California vaccine.3. vaccination and risk of medically example hepatitis A and hepatitis B and 682. date of vaccination.5). encounters. limb swelling. Southern California Kaiser Permanente sumptively identified by International but the deltoid can be used if the muscle (Los Angeles. 709. The VSD is a collaborative was calculated based on identified adverse effect of a medication or bi- project between the Centers for Disease valid height and weight indicators. 729. MN).3). and 995.3. Accordingly.3). with BMI cutoff points estab. for diagnosis code of cellulitis (682. given to children study period.3) assigned 284 JACKSON et al Downloaded from by guest on December 20.9. attended local reaction was identified Practices (ACIP) indicate that intra. the outcome definition is subcutaneous. identified by diagnosis codes were vaccination in the arm is associated with confirmed by chart review.Current recommendations of the US Pilgrim Health Care (Boston. As in the previous study. The VSD MCOs and 85th percentiles (by age and gen. com- This study was conducted in the VSD records of the participating MCOs. ologic substance (995. in limb (729. 709. 683. 682. or lymphadenitis (289. the diagnosis code evaluations of local reactions after the the first birthday and before the sev. information collected There are few data on the relationship from the VSD data files included the gorithm.7. on more than 9 million lished a priori corresponding to 25th unspecified skin disorders.9.6. participating in this study included der) according to the World Health 682. and tended local reactions were first pre- anterolateral thigh muscle is preferred. unspecified.

5 13.2 1. 5.4 20. e 2.9 2.4 45.9 5 13. the each of the 3 vaccine types. 2004 5.4 Evaluations of the relationship of in.8 12. PEDIATRICS Volume 131. reactions were relatively uncommon. of which 6.0 using robust SEs estimated using gen.7 eralized estimating equations to ac. vaccines administered alone.2 jection site (arm versus thigh) with risk 2005 10. The risk of local reactions after a DTaP without other concomitant vaccines.8 11. to allow calculation of BMI at the time of vaccination.8 confidence intervals (CIs) from ad. ARTICLE on the day of vaccination or within the MCOs when they were 1 to 6 years of For inactivated influenza and hepatitis A previous 30 days were excluded.0 43.4 million a Measurements of both height and weight recorded within 3 months of the vaccination date were available from electronic children enrolled in the 8 participating medical record data.4 10.5 48. 2016 .2 were conducted.3 30. cinations).4 29. medically attended local 2002 through 2009. The characteristics of chil. Subanalyses stratified by 6 13. Statistical Analysis ceived 9.9 2007 15. example.4 2.9 16.9 7. age and during the study period of vaccines.9 1.7 13.4 6. % DTaP.88 [95% CI: 1.5 b 38.5 1. February 2013 285 Downloaded from by guest on December 20.42–2.1 38.49]). whereas among the smaller subgroup received both vaccines in the leg.4 80.9 outcomes.9 2003 8.3 7. Secondary analyses vaccines most commonly administered of children 1 to 6 years of age.1 2.3 million vaccinations during and there was no difference in risk of The primary analyses evaluated IM the study period.1 14. n 932 776 91 510 816 815 diagnosis codes.4 4.0 conducted by using Stata 12.6 16.6 9.9 of the outcome of local reactions were 2006 13. For children 12 to 35 months of age. that is. Of those. % tion could not be determined from the Count of vaccines.2 0.5 24. That cohort re. with administration in the thigh (RR: given either in the arm or the leg.5 RESULTS h 3. y 1 23. among children who received vaccines without other concomitant In analyses stratified by age.0 (Stata d 2.4 13.8 further explore the relationship of MCO patterns of injection to adverse events a 3. istration of DTaP vaccine in the arm children who received exactly 2 vac. 2002 4.4 10.1 based on relative risks (RRs) and 95% 2008 15. 2 17.4 7.2 9. admin- evaluated the risk of local reactions in alone (without other concomitant vac. both of which were influenza and hepatitis A and DTaP higher risk of this outcome compared administered IM and both of which were vaccines.8 justed Poisson regression models by Age at vaccination. was compared with that in children who with age (Fig 1).4 g 40. % Hepatitis A. 2009 25. the rate influenza vaccine on the same day. For dren identified as receiving those 1.0 million these events by site of injection (Table 2).7 f 3. Number 2. The analyses were c 5.5 52.9 16.5 6. than with influenza and hepatitis A sociation of injection site and risk of The primary analyses evaluated the IM vaccines.7 48.0 0. among a hepatitis A vaccine and an inactivated vaccines are shown in Table 1. Chil- dren who were given 1 vaccine in the TABLE 1 Characteristics of Children and IM Vaccines Given in Arm or Thigh With No Other arm and 1 in the thigh were excluded Concomitant Vaccines because the location of the local reac- Flu.8 3. of injection site reactions after DTaP risk of local reactions in the children portion of vaccines administered in vaccination was significantly higher who received both vaccines in the arm the arm versus the thigh increased with arm than with thigh administration.2 BMI availablea 41.5 count for within-child correlation of 4 14.7 12.3 16.8 4. the pro.5 47.5 1.6 9. 3 17.6 Corp.6 11.7 the occurrence of the reaction could not Year of vaccination be linked to the injection site. TX).0 age groups and BMI percentiles to Gender: girl 47. leg. which included inactivated was associated with a significantly cines on a given day.4 The study cohort included 1. College Station.6 million vaccines had a site vaccine given without other concomi- These analyses allowed the most of administration recorded as arm or tant vaccines was several fold higher straightforward assessment of the as.6 4. Among the study population local reactions. and so in those cases Injection site: arm 57.5 39.7 4.1 0. were administered intramuscularly.

Rates of local reactions af.7 Referent — — Arm 8916 76 85. conducted.3 Referent — — Arm 241 439 159 6. there was a trend higher in the older versus the younger the results of multivariable models toward a higher risk of local reactions age group. In contrast. or $ 85th percentile).83–1.3 Referent — — Arm 147 713 111 7.8 1.88 1. by month of age. $85th percentile [RR: 2. DTaP.05)]).13 0.08 0. for both arm and thigh that included or did not include BMI. The risk of a local reaction suggesting that BMI is not a con.20 0. gender. DTaP.28 .23]).59 (95% CI: 1.3 Referent — — Arm 97 924 92 9. MCO. when both vaccines were given in the injections.91 (95% CI: 1.29 1 DTaP Thigh 68 007 154 22. arm versus the thigh. BMI $ 85th percentile was in- dependently associated with a higher risk of a local reaction after DTaP vaccine (RR: 1. and injection site.77–1.4 Referent — — Arm 535 539 524 9.0 1.5 1.30 .43)].2 a In model adjusting for month of age.9 1.34–2.42–2. also revealed a generally higher injection site reactions was also higher restricted to the subgroups of chil- rate of medically attended local reac- with arm than with leg administration.09 0. dren for whom BMI on the date of tions with combinations that included but this difference was not statistically vaccination could be calculated were a DTaP vaccine. with both given either in the arm or in the of children 3 to 6 years of age.85th percentile [RR: 1.0 Referent — — Arm 389 442 270 6.56 [95% CI: 1. 2016 .2 1. by Age Group Age Group Vaccine Injection Site Number Number Rate of Outcomes RR of Local Reactionsa P of Vaccines of Outcomes per 10 000 Vaccinations RR 95% CI 1–6 y Inactivated influenza Thigh 397 237 373 9.7 3–6 y Inactivated influenza Thigh 110 980 108 9. In analyses stratified by BMI (. hepatitis A vaccine without other concomitant vaccinations. 286 JACKSON et al Downloaded from by guest on December 20.9 1.49 . the association of arm vaccination and risk of a local reaction after DTaP vaccination was similar in the 2 strata (. and this asso- after a DTaP vaccine did not vary by founder in the association of injection ciation was statistically significant for gender. gender. the rate of and risk of local reactions. Among those subgroups. site and risk of local reactions (Table the DTaP plus hepatitis A vaccine To evaluate the possible influence of 3).4 12–35 mo Inactivated influenza Thigh 286 257 265 9. BMI on the association of injection site a binary variable for BMI $ 85th when the vaccine combination did not TABLE 2 Association of Site of Vaccination and Risk of a Medically Attended Local Reaction After Receipt of Inactivated Influenza. or 6..2 Hepatitis A Thigh 110 802 70 6.88 1.00 0.92–1. received a DTaP vaccine together with ter DTaP vaccine were significantly there was essentially no difference in another vaccine. Among children who significant.09–2.63 .06–3.8 1.65 .84–2. or Hepatitis A Vaccine Without Other Concomitant Vaccinations..91–1.6 Referent — — Arm 9799 49 50. analyses thigh.89–1.43 .7 Referent — — Arm 437 615 432 9.6 1. In a multivariable model including combination (Table 4).3 Referent — — Arm 18 715 125 66. and MCO.3 DTaP Thigh 4788 30 62. percentile for age that also adjusted for age.11– FIGURE 1 Proportion of vaccinations given in the arm to children who received inactivated influenza.34 .001 Hepatitis A Thigh 427 373 300 7.32 .001 Hepatitis A Thigh 315 187 230 7.4 1. Analyses of children who received 2 IM vaccinations on the same day.3 DTaP Thigh 72 795 184 25.89–1.05 0.41 0.

age and older should be administered ies. b Defined as a categorical variable (. arm nated in the arm were significantly reaction for the other 2 vaccine types. study that followed 1315 children after hepatitis A vaccine and that injection of their fifth DTaP vaccination and col- a DTaP vaccine in the arm was asso. we used the unique data Our results indicate that there was in.2 Referent — Referent — Arm 81 127 61 7. which revealed tions to IM vaccines commonly given to only a minority of children 12 to 36 that that injection in the arm was as- children 1 to 6 years of age. state that vaccinated children.7 1. American Academy of Pediatrics stated the 3. of this outcome was relatively un.15 1. in Models Unadjusted and Adjusted for BMI Vaccine Injection Site Number Number Rate of Outcomes RR of Local Reactionsa of Vaccines of Outcomes per 10 000 Vaccinations In Model Without BMI In Model With BMIb RR 95% CI RR 95% CI Inactivated influenza Thigh 195 036 203 10. occurring in less than 1% of nated limb (53% vs 48%) than children which were adopted in 2011.10. there was no deltoid can be used if the muscle risk of medically attended local reac- evidence of an increased risk of mass is adequate. but the years of age (an age group with a higher studies. and for toddlers aged 12 may be derived from thigh adminis.and 4–year-old outcome.25th percentile. sociated with an approximately two- tions of IM vaccines given alone. children vacci- tion of injection site and risk of a local vaccine. least 5 cm of redness at the injection vaccine combinations that included ministration. ARTICLE TABLE 3 Association of Site of Vaccination and Risk of a Medically Attended Local Reaction Following Receipt of Inactivated Influenza.33–3. and MCO. Among this age group.16 0.28 DTaP Thigh 34 414 91 26.to 35-month-old age group). likely to complain of pain in the vacci- The current ACIP recommendations.82–1. and $85th percentile) based on World Health Organization child growth standards. and those of previous stud.4 Referent — Referent — Arm 187 255 220 11. we found that the deltoid muscle was the pre. or Hepatitis A Vaccine Without Other Concomitant Vaccinations. This is consistent with resources of the VSD to evaluate the consistent adherence to those recom. Among with arm administration.63 1. tions to the fifth DTaP. the tions after DTaP vaccine than that in the a medically attended local reaction recommendations of the ACIP and the 12.2 In that study. common.00 0. months of age.1 Before that. whereas there was no associa.2 2. 2016 .48 2. DTaP. Among the Subgroup of Children for Whom BMI at the Date of Vaccination Could be Determined.31–3. Our results support the current pref- lected information on the presence ciated with a significantly higher risk erence for thigh administration of IM and severity of local reactions from compared with administration in the vaccinations to children 12 to 35 daily study diaries completed by thigh. include a DTaP vaccine. DTaP vaccine. gender. Together. and even among 3.82–1. February 2013 287 Downloaded from by guest on December 20. Number 2.85th percentile.to 6-year age group. $25th and .44 Hepatitis A Thigh 164 903 119 7.01 0.5 1.78–1.79–1. In evalua- months of age who received DTaP vac. at least 20% received the vaccine in the thigh. for DTaP vaccine.4 Referent — Referent — Arm 5168 43 83. although the absolute risk site (38% vs 6%) but were no more a DTaP vaccine.3 Our findings are also con- more frequently after a DTaP vaccine sistent with those of a prospective than after an inactivated influenza or children.28 1. we also found that higher BMI PEDIATRICS Volume 131. we fold increase in the risk of that found that local reactions occurred cine alone received the vaccine in the arm.11 reaction with arm administration of In this study. a trend toward an increased risk of DISCUSSION ferred site for IM vaccinations given to a medically attended injection site children 1 year of age and older. as. across all sites. the results of a previous VSD evalua- association between injection site and mendation during our study period of tion of medically attended local reac- risk of medically attended local reac- 2002 through 2009. tion should extend to children through months to 2 years the anterolateral tration of DTaP vaccine to children 3 to 6 6 years of age. findings suggest that. also suggest that a similar benefit the preference for thigh administra- in the deltoid.13 1. these IM vaccines given to children 3 years of Our results. A administration of DTaP vaccine was more likely to have local reactions higher risk of local reactions with arm associated with a nearly twofold in. As in those previous thigh muscle is preferred. characterized by any degree of redness administration of DTaP vaccine was also crease in risk of a medically attended at the injection site (65% vs 40%) and at suggested by the results of analyses of local reaction compared with thigh ad. vaccinated in the thigh.62 a In model adjusting for month of age. particularly for DTaP parents.16 0.

Jackson LA. Lastly. and gender. Baggs J.15 .127(suppl risk of local reactions to the fifth 4.16 0. and so BMI. Coleman KJ. PCV7. Dunstan M. Without Other Concomitant Vaccinations Vaccine Combination Injection Site for Number Number Rate of Outcomes RR of Local Reactionsa P Both Vaccines of Episodes of Outcomes per 10 000 Episodes RR 95% CI DTaP + Hepatitis A Thigh 48 095 101 21. was associated with an increased risk between BMI and risk of a local re.pediatrics. providers may have elected to vaccinate in the arm or thigh based on factors that influence the risk of these reactions on the basis of ICD-9-CM codes patient characteristics. 7 valent pneumococcal conjugate vaccine. DeStefano F.7 Hepatitis A + Hib Thigh 8209 10 12. or other injection in the thigh is associated our capture of medically attended local reactions was likely not 100% complete.28–2. project. thigh. but should be considered when interpret. Pediatrics. cination.02 0. Nelson JC. but it is possible group.8 Hib. Vaccine Safety Datalink Re- Advisory Committee on Immunization Prac.5 0.. Safety Datalink Team. MMWR Recomm Rep. When we controlled for the a medically attended local reaction to medical record review.4 Referent — — Arm 2192 7 31. Sumaya CV. the association years of age. Vaccine Safety Datalink: immunization re. possibly subgroup with this information. 2016 .29 .10(5):403–406 2. among our study pop- relatively little is known regarding ing the findings.07 0. supporting current formation on height and weight was not of arm injection site with a significantly recommendations for thigh adminis- available for the majority of the study higher risk of medically attended local tration of IM injections in this age population and so the relationship reactions persisted.60 risk of medically attended local reac. Pediatrics.4 2. Jackson LA.127(3). DeStefano F.2 2.55–2. et al.3 1. 2000.81 0. action could only be evaluated in the findings.2 Referent — — Arm 2147 2 9. 2001. Haemophilus influenza type b vaccine. Lawrence JM. 2011.3 Referent — — Arm 4444 6 13. The Vaccine Safety Datalink tices (ACIP).2 Referent — — Arm 3473 8 23. Smith N.47–8.pediatrics. Our findings indicate that assigned to medical encounters.17 .44–3. et al.11 .1 DTaP + inactivated influenza Thigh 12 050 11 9.9 2. 7. Kroger AT. deltoid muscle mass. et al. REFERENCES 1. We identified local ulation.0 0. Injection site and search Group.51 . Pediatrics. and so some characteristics we could define in DTaP vaccination among children 1 to 2 events were likely misclassified. 2008. jection site. age. Vaccine 5. Bull World Health Organ.7 DTaP + Hib Thigh 18 735 27 14. Lewis E. Available at: 6.TABLE 4 Association of Site of Vaccination and Risk of a Medically Attended Local Reaction After Receipt of 2 IM Vaccines in the Arm Compared With Receipt of the Same Combination of 2 IM Vaccines in the Thigh. 2011. multivariable models.7 Hepatitis A + PCV7 Thigh 14 645 21 14. that bias may have influenced the of a local reaction.15 0.org/cgi/content/full/121/ in the USA. Available search in health maintenance organizations Body weight and height data in electronic 288 JACKSON et al Downloaded from by guest on December 20. independent of in. The 1):S45–S53 diphtheria-tetanus-acellular pertussis vac. reactions.3 Hepatitis A + inactivated influenza Thigh 67 112 52 7. received multiple vaccinations con- Local reactions are the most common There are limitations of this study that comitantly in both the arm and the adverse events after vaccination.001 DTaP + PCV7 Thigh 25 693 52 20. et al.121(3).0 Referent — — Arm 9411 51 54. We due to inadequate IM penetration in also could not evaluate children who CONCLUSIONS children with higher BMI.26–5. In.7 Referent — — Arm 34 316 24 7. Chen RT.org/cgi/content/full/127/ Safety Datalink: a model for monitoring im- needle length and injection site on the 3/e581 munization safety.0 1. Starkovich P. at: www.72 . Davis RL. Yu O. (2):1–64 tions to acellular pertussis vaccine.83–5. a In model adjusting for month of age and gender.78 Atkinson WL.53–1.42 . et al. such as age. Gee J.1 Referent — — Arm 1638 4 24. factors such as local standards and with a significantly lower risk of and we did not validate the reactions by practices. General recommendations on 3/e646 (2):186–194 immunization—recommendations of the 3. Pickering LK.89 0. Pharmacoepidemiol Drug Saf. 2011. The Vaccine Prospective assessment of the effect of www.13 1.

55(RR-15):1–48 Prevalence of extreme obesity in a multi. FUNDING: Supported by the Centers for Disease Control and Prevention (contract 200-2002-00732). the other authors have indicated they have no financial relationships relevant to this article to disclose. Available at: www. Red 9.pediatrics. and GSK and has received travel support from Pfizer to present findings from an unrelated study. Dr Naleway has received research funding from GSK. Dr Hambidge assisted in the development of the protocol. Pfizer. Dr Baxter has received research funding from Sanofi Pasteur. int/childgrowth/standards/technical_report/ 11. supervised data collection at his site. and drafted the initial and final articles. Int J Pediatr age. World Health Organization Multicentre Pickering LK. weight-for-length. and approved the final article as submitted. reviewed and revised the article. MD. interpreted the results. Advisory Committee on Im. Seattle. critically reviewed the article. Koebnick C. Baker CJ. weight-for-height recommendations of the Advisory Commit- Obes. and approved the final article as submitted. Mr Madziwa reviewed the data collection programs. Dr Nordin assisted in the development of the protocol. critically reviewed the article. supervised data collection at his site. Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: Dr Jackson has received research funding from Sanofi Pasteur. Gen. Dr Marcy assisted in the development of the protocol. and Mr Weintraub reviewed the original study concept. MMWR Recomm Rep. supervised data collection at his site. Disease Control and Prevention (CDC). E-mail: jackson. Long SS.org PEDIATRICS (ISSN Numbers: Print. Elk Grove Vil- Health Organization child growth stan. ARTICLE medical records of children. supervised data collection at her site. en/index.org/cgi/doi/10. Marcuse EK. Novartis. Group Health Research Institute. Coleman KJ. 28th ed.who. through America’s Health Insurance Plans.1542/peds. critically reviewed the article. IL: American Academy of Pediatrics.e2 10. WA 98101. www. MPH. Dr Baxter assisted in the development of the protocol. received the data from sites and performed checks for errors and accuracy. et al and development. lage. critically reviewed the article. Suite 1600. Dr Donahue has received research funding from MedImmune. and Merck. 2010. critically reviewed the article. interpreted the results.l@ghc. and do not necessarily represent the official position of the Centers for Disease Control and Prevention. GSK. Kimberlin DW. World munization Practices (ACIP) Centers for Infectious Diseases. Dr Naleway assisted in the development of the protocol. Number 2. critically reviewed the article. and approved the final article as submitted. reviewed draft protocols and assisted in the development of the study. performed the statistical analyses. supervised data collection at his site.2012-2617 Accepted for publication Oct 1. PEDIATRICS Volume 131. weight-for. developed the protocol. performed initial testing of those programs. and approved the final article as submitted. Atkinson WL. In: Pickering LK. 2012 Address correspondence to Lisa Jackson. and approved the final article as submitted. supervised data collection at his site. Book: 2009 Report of the Committee on Growth Reference Study Group. 8. critically reviewed the article. and approved the final article as submitted. and approved the final article as submitted. Accessed November 15. and approved the final article as submitted. critically reviewed the article. Online. critically reviewed the article. MedImmune. interpreted the results. supervised data collection at her site. Kroger AT. 1730 Minor Ave. and approved the final article as submitted. reviewed and revised the article.157(1):26–31. American Academy of Pediatrics. J Pediatr. 1098-4275). The findings and conclusions in this report are those of the authors. Smith N. Mr Peterson created the programming instructions for data collection. 2016 . 2012 passive immunization. and approved the final article as submitted. Active and ethnic cohort of children and adolescents. Ms Balsbaugh assisted in the development of the protocol. eds.2012-2617 doi:10. 2006. Dr Nelson provided oversight and statistical consultation for the data collection and analytic methods. critically reviewed the article. 0031-4005. and approved the final article as submitted. and approved the final article as submitted.1542/peds. 2010. Pfizer. cleaned the study data. February 2013 289 Downloaded from by guest on December 20.html. dards: length/height-for-age. Novartis.5(3):237–242 and body mass index-for-age: methods tee on Immunization Practices (ACIP). Dr Donahue assisted in the development of the protocol. eral recommendations on immunization: 2009:17–20 (Continued from first page) Dr Jackson conceptualized and designed the study. performed data checks and data cleaning. Ms Marsh created the data collection programs.

Naleway.html References This article cites 9 articles. Downloaded from by guest on December 20. Print ISSN: 0031-4005. Nordin.full. Lawrence Madziwa and Eric Weintraub Pediatrics 2013. originally published online January 14. tables) or in its entirety can be found online at: /site/misc/Permissions. appears in the following collection(s): Infectious Disease /cgi/collection/infectious_diseases_sub Vaccine/Immunization /cgi/collection/vaccine:immunization_sub Permissions & Licensing Information about reproducing this article in parts (figures. Hambidge.283. Allison L. Tracey Marsh. Roger Baxter. Illinois. 141 Northwest Point Boulevard. Jackson. Online ISSN: 1098-4275. published.2012-2617 Updated Information & including high resolution figures. A monthly publication.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. DOI: 10. Donahue. All rights reserved. 60007. Nelson. 2016 .html#ref-list-1 Post-Publication One P3R has been posted to this article: Peer Reviews (P3Rs) /cgi/eletters/131/2/283 Subspecialty Collections This article. James D. Jennifer C. and trademarked by the American Academy of Pediatrics.xhtml Reprints Information about ordering reprints can be found online: /site/misc/reprints.full. S.131. Do Peterson. 2013.1542/peds. James G. it has been published continuously since 1948. can be found at: Services /content/131/2/283. PEDIATRICS is owned. along with others on similar topics. Carolyn Balsbaugh. 3 of which can be accessed free at: /content/131/2/283. Michael Marcy. Elk Grove Village. Simon J. Copyright © 2013 by the American Academy of Pediatrics.Vaccination Site and Risk of Local Reactions in Children 1 Through 6 Years of Age Lisa A.

Illinois. originally published online January 14.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication. published. Michael Marcy. 2016 .full. along with updated information and services. Donahue. it has been published continuously since 1948. and trademarked by the American Academy of Pediatrics. DOI: 10. PEDIATRICS is owned. Jennifer C. Copyright © 2013 by the American Academy of Pediatrics. 141 Northwest Point Boulevard. Simon J. is located on the World Wide Web at: /content/131/2/283. Nelson.283. Online ISSN: 1098-4275.131. Print ISSN: 0031-4005.2012-2617 The online version of this article. 60007. Tracey Marsh. S. 2013. Hambidge. All rights reserved. Lawrence Madziwa and Eric Weintraub Pediatrics 2013. Nordin. James D. Downloaded from by guest on December 20. Roger Baxter. Do Peterson. Carolyn Balsbaugh. Naleway. James G. Allison L.1542/peds. Jackson. Elk Grove Village.Vaccination Site and Risk of Local Reactions in Children 1 Through 6 Years of Age Lisa A.