 So I'm just gonna give the briefest hello. I think there's an echo, but maybe we're okay. But Scott, thank you so much for coming today. I know personally people are talking to me and they're saying, well, kids really don't get sick. And I try to sort of engage with them and talk to them, but really I just wanna start telling people, it's like children get sick. We've had 43,000 children hospitalized with COVID as of June 9th, 1,000 children have died. I mean, we need to be vaccinating. I'm so happy this vaccine is here. Oh, here's Lisa Wolf, okay. So with that, I thought we could just briefly go through, hi Lisa, everybody and they could introduce themselves. And if they have vaccinated this age group. So I'm just gonna start. I have vaccinated young children and I haven't done a great job, but I really learned from Julie Federman, my prior boss and she just was all about soothing the parents and then soothing the child and boom, would vaccinate them. Maybe this age is a little easier than the sort of a six year olds that can get up and start kicking at you. So yeah, Maureen, have you vaccinated this age group? No, I've been in the holder position with some kicking children of my own. No, never. Rich, have you? No, I have never vaccinated this age group, at least not that I can remember. Yeah, and Diane? I have not, am I on mute now? I have not vaccinated. I've given injections, but not vaccinated. Good distinction. Robin, how about you? Yes, particularly newborns, but I have vaccinated this population. Oh, you have newborns. And well, I've been in my Holyoke hospital days. Yeah, yeah. How about it, Mary? What have you done? A year ago, I worked at Amherst Peeds and used to vaccinate this age group. It was a while ago. Gotcha. And hello, Lisa. Thank you for joining us. Lisa, you vaccinate this group. Well, I've been an ER nurse for 25 years. So we do injections of all kinds of things, including vaccinations on really little kids. So I'm pretty comfortable with that. That's great. Great. Well, thank you. The agenda I sent out recently, or actually Lillian sent out, thank you, Lillian, for coordinating all of this, has some referrals, references that the state has put out. And they're pretty recent. So I updated it. There's new IM injection sites for 11 months and older, one to two years. So it's the Vastus lateralis. It's the, and then the deltoid. And then there's some, the CDC video. So I feel like I know the web. This stuff may have been there, but maybe it was hidden. So with that, I'd like to turn it over to Scott. And just if there's anything you want to start with, or if you want to start with questions, but thank you. Well, let me go ahead and say what I had prepared to say. And then it won't be that long. There'll be plenty of time for questions. And one thing that I will say is if you guys who have had experience vaccinating young kids have other suggestions as we go, by all means chime in. If you think what I'm saying makes no sense, by all means say so. Some of you probably have more experience vaccinating young kids than I do. Where I work, it's the nurses who give the vaccines. I do occasional vaccines. Many years ago, I did all my own vaccines. It's been a long time since I've done that. And I'm often the helper when a nurse has a tough time with it. So please chime in. The other thing I will say is if you've looked at the information that Lillian sent out, both the handout type things in the videos, I don't think anything that I say will be very new to you. If you haven't looked at them yet, I think it's a good idea to look at them. So let's start with location of the vaccines where you usually do them. And I think the CDC makes it a little more complicated that it needs to be. I think if you think of anybody under 36 months of age or three years, the preferred site is really the thigh, the upper outer thigh. Certainly it's an option over 12 months to do the deltoid. In the second year of life, there isn't a huge deltoid muscle in the third year between age two and three, there's a bit more. And some parents may really prefer it. And if the mom says I want the shot to go in the arm and the kid is two years old, I think it's fine to do that. But the outer quadrant of the thigh is the biggest muscle mass. It's the biggest target. It's kind of just the easiest way to do it. So it is an option over 12 months to do the deltoid. Although I think certainly underage two, the thigh is the choice and really underage three. If you just think of underage three, it's just aim on doing them all unless parents choose otherwise. Or the near three year old may hold onto his pants and not allow you to bring them down and then maybe you want to do the deltoid. I think that's the easiest way to remember it is under three. Needle size, I think you mentioned that we'll be having one inch needles. Is that my understanding, correct? We have some five eighths that we've ordered. So we have about 300 of those. But yeah, the CDC's given us one inch. Yeah, so if you're doing the upper outer thigh, the one inch needle is certainly the best choice. You can't go too deep when you're doing the thigh and you want to get in beyond the fat pads. So one inch, if you're doing a deltoid muscle and it's a fairly small kid then five eighths is probably a good choice. Although one inch is fine. You just may need to be a little bit careful about not going too deep. Although I will say the biggest danger is not going deep enough. You want to go beyond the connective tissue and the fat pad into the muscle. If you happen to hit the bone, it's not a big deal, just back up a little bit and give the shot. I know in our vaccination clinics, I've had some elderly ladies who had less of a deltoid than some of our three-year-olds have. And I hit a bone or two. And as long as you're doing it gently, you're not going to hurt anybody. And just pull back a little bit, give a shot and you're done. So with the thigh, always a one inch. You have a choice either way with a deltoid. If it's a chunky kid, lots of fat or a big muscle, I would do a one inch. Otherwise, five eighths is good. Finding the site is pretty easy. I mean, the deltoid or rather the thigh, really if you just kind of draw across, across the front of the thigh, upper outer quadrant is what you want to do. The most important thing is make sure that you're going 90 degrees to the skin as we do in the deltoid as well. If you go straight up and down and you're doing the lateral side of the thigh, you may not get into the muscle. So go perpendicular to the skin. So you're kind of going at an angle when you're doing the thigh. If you want to make sure you're finding the right spot on the deltoid, you can do a finger or two finger breaths below the chromium. And you should be right there. And you should feel the muscle right under your finger. Any questions about where to get the shot or needle sizes, that sort of thing? It's pretty straightforward. So the biggest deal really is positioning for safety and comfort, I think. And your parents are gonna be an active participant here. A lot of parents may have a position they like to hold their kids in. So no matter what we're telling you or what the CDC is telling you, if the parents have a way to do it that works for them, it's great with me. And these parents about a lot of experience giving their kids shots or having their kids get shots. So it's good to listen to them. Although I will say sometimes parents say, this works for me. And then the moment the child struggles, parents are gonna be sorry. You never know. So be prepared for anything. But certainly listen to what the parents have to say. If they're getting a child into a position that looks like it's gonna work for you, then go for it. So positions and I'm gonna try to demonstrate it a little bit. I used to have a three year old sized rag doll that worked for this kind of a thing. And I can't find it, it seems to be gone. So I'm gonna use my pillow here as my child. I'm gonna move this camera away a little bit. Maybe you can see me a little bit better. Thank you so much Scott for doing this. You are, sure. I hope this works, you can sort of see me. So this is my child. If you think of one end, this is the head. This is the hips, legs are coming down from below. There's an arm coming out here. There's an arm coming out here. The CDC videos show three different positions for infants, one for toddlers and one for three years and up. But they're all really variations on the same position. I find for many kinds of procedures, parents really have better control. If kids are sitting sideways on their lap, parents often wanna sit their kids this way and they don't seem to be able to control them as well. So when I'm doing whatever, looking at ears, things like that, this is often sideways as a better position. So with infants, generally on their back, on the mom's lap goes well. The arm that's closest to you can be just tucked between their body and the mom or dad's belly. And the parent has an arm under the head and then around and really holding that opposite arm really firmly. Legs can be tucked in between the parent's knees and then they're holding the knees with their other hand. So arm is secure between their body and yours. The other arm with the parent's hand. Legs secure between the knees and hand right over the knees. And they should be able to hold pretty firmly. Don't be afraid to tell the parents to hold firmly just for a minute. It's kind of an act of love to do that. Some parents are afraid to really restrict their kids but it's gonna go a lot better if they do. For toddlers, it's not much different. Kids toddlers wanna be a little more upright and that's just fine. The biggest difference is the arm close to you can be tucked in around the parent's back. And if they then hold each other closer then that arm is stuck back there and can't do very much. And then the same thing, the parent's arm is around holding the arm firmly against them legs between their legs. Thigh is right here holding onto the knees and they've got a pretty good grasp. And then with older kids, it's really about the same thing. They just really wanna be all the way upright. And again, the kids can sort of hug their parents with the arm, the close arm behind the parent's back. Parents can hold the other arm down. And in this age group, you're gonna be doing the deltoids so the parents have to have a really good hold on that forearm. You're gonna be controlling the upper arm. And some kids really hate the restriction of their legs being between a parent's legs. If they can stay still, it's certainly okay to have legs kind of dangling down. And again, if kids are side facing, they're not gonna kick you. So that's fine if they're moving their legs a little bit. But if they need restraint, they can certainly have their legs between parents' knees and again, control those legs with the other arm. So it's really just giving a nice control to hug with that close arm for infants right between the two bodies for toddlers and older kids' arm behind the parent's back and then you're ready to go. There are certain, there are a lot of positions that you can use. Some parents do prefer having kids sitting back against them. And if they can wrap their arms and really control the arms, they may not control the legs very well, but if they can control things pretty well, it works for them, it's okay with me. Occasionally, kids who are really frightened, all they wanna do is give their mom a big hug. If you wanna turn them around, face the mom and just let them hug, arms kind of around your neck or the mom's neck and the mom's just holding the body that way, you'll need to control the arm, but certainly that's an option if kids just won't get into a position like this. What else have I got here? And then of course, older kids, are we gonna be a vaccinating older kids above four in these clinics or is it just gonna be six months to age four? We're gonna do just the little pediatrics as we're calling them. If there's a need, we'll expand, but at this point, just focusing on that. Older kids can certainly be sitting next to parents or whatever, we won't talk about that. A couple of suggestions, no matter what the parents are doing, make sure you have a really good grip on the extremity that you're doing a shot on because you just never know what's gonna happen and you can avoid problems if that arm or leg doesn't move. I don't know what the staff is gonna be like, but I think it's always a good idea if there's somebody kind of roaming in case somebody needs any help. There have been many times, as I mentioned, if I hear that our nurses have and trouble giving shots, I'll just walk in, hold the extremity firmly and in two more seconds, it's done. So if there were somebody around who can just be aware of anybody who needs some help, I think that's a really... That's a great suggestion. I'll be available for you. In the ER, I mean, and it's probably just because of the circumstances, but we often have parents who are just so distressed that their kids being upset that they just check out. So if there's two people available, you can just go out in the hallway, come back in two minutes, we'll be done. It's always an option. Yeah, I think in this kind of a clinic situation, if you could include the parent, I think it's optional. I think the parents who are bringing their kids are more likely to be on board. But if they can't do it, it's okay to say we can do it for you if you want. A couple of simple things. I'd have everything really ready before you flag the kid in. I would have your alcohol swab opened. I would have your band-aid opened. I'd have your needle and syringe within reach. I think if the kid is sitting there with mom or dad and you're fiddling with those things, that's giving the kid a child a sign that something bad is coming. So I think if you have it already, you can get things done that much faster. The thing that I try to do more than anything else is to be really positive. Hi, it's great to see you. You're gonna do so good today. Why don't you come and have a seat with us and we'll get this done. And I know you're going to do great is the kind of thing that I often say. When I'm done, no matter how awful the kid may have behaved, I'm gonna tell him he did a great job because he did. If he kept his arm still, that's all we're asking of him. I don't care if he screams and he's kicked, he builds his arm or his leg still. That's all that I asked. And if the kid is behaving badly, it's not his fault. Who knows? But give him praise after you're done. There was a comment on the agenda. Is it okay to let mom breastfeed by all means? If mom wants to breastfeed while you're giving a shot? Sure, it's a great distraction. It's the most comforting thing a child can do. And holding an infant like this, it's a perfect position for breastfeeding. So yeah, it's okay. If the child wants to pacify or it's okay, if mom wants to just talk to the child, talk about what they're gonna do, what's coming up for the vacation, whatever, I think it's great. Fortunately or unfortunately, many of these kids these days walk in with screens in their own hands and as much as I don't like them, if they wanna watch something on the screen while you're giving a shot, it's a great distraction. It's certainly okay. I know we had shot blockers available at the schools when we did the vaccines, but we have these available? I don't know. Can you remind me what they are? I don't know if we did have those, Scott. We did, I mean, I used them. They were there. This is a little thing with spikes on one side of it. I don't know, you probably can't see it. Yeah, I can see them. And you just, if we're doing a shot on my forearm, say, you just place it right on the forearm and you press firmly and then the shot goes in this little slot between the two sides. I don't know if you can see there's a little slot there. And it just provides a little bit of neurological distraction. The kids feel the little nubby things on the bottom of this and they don't feel the shot as well. And I think it's great for all ages, not just the kids who might be old enough to really be afraid, but if you can diminish the sensation of pain, even in a six-month-old, I think it's a nice idea to use these. I don't know where they went, the ones that we had for the school clinics, but if there were some around, it would be nice to have those. The kids who were old enough for you to talk them about it, I'll tell them I've got this magical little thing here that's gonna make your shot hurt a little bit less or make your immunization hurt less. I try not to use the word shop. And if I put this on your skin and give you the shot, it's not gonna hurt very much. And kids will believe you, they'll believe almost anything you say, so it works. So I think- You use sugar water on pacifiers? I mean, are we going full hog with this? I don't know. It can be done, but it may be something where we would need to be set up for and it may not involve much, but you'd have to have some sugar water. I forget, remind me what they see dosages. How many, what are we putting in? I have to say, I'm not up on that. Yeah, it's 0.25. Okay, so yeah, this is a second. This is- It's a tiny, tiny dose, yeah. And there's no reason not to go, boom, right? Right, no, it's really fast, you know. Yeah, so, you know. Yeah, the other thing that I will say often do is I just, you know, I'll just tell the kids what I'm doing as I'm doing it. All right, this is my little alcohol swab. I'm gonna clean your skin. Now I'm gonna take my little dry pad and dry your skin. Now we're gonna do the immunization. Boom, it's done. And then here's your Band-Aid and just talking as you're doing it, it's impressive. I don't see that this is gonna be that different than the five-year-old, so I don't know. And the younger seems to me it's gonna be easier because they're not that, I mean, I don't know. The younger ones are easy. It's really a matter of trying to make it as pain-free as possible. You know, a shot always hurts and anything you can do that makes the experience a little bit better for a baby if nothing else might make future interactions with people giving shots easier. So that's the reason I talk about it. Sure, six-month-old baby, you put him on the table, boom, you do a shot and you can do that. If you add a little extra thing like a shot blocker or just having mom hold the baby rather than put him on the table so that the next time he's put on the table he doesn't expect a shot right away. That shot blocker looks good. Yeah, think to be a little clumsy but try him and you'll kind of figure out how to use it. I'm sorry, I interrupted somebody. I wonder what do you have to do between patients with the shot blocker? How does that work? Do you have to clean it? Do you have to do anything? I don't. I wouldn't think of doing that but I'm just asking because it was clinic setting. I don't know, Jennifer, you have any thoughts about that? No, I don't know unless just sort of an alcohol wipe. I think even the smell is sort of reassuring. You could do that, that would be easy, yeah. I'm more concerned with, I mean, these babies have had vaccines before. Do you think, what do you think the chance of anaphylaxis is? I think if they, I think the chance is as low as it is for adults. I mean, I don't think we've experienced anaphylaxis as any of our vaccine clinics. It's extremely, extremely. Okay, I just want to be prepared for this. Yeah. That's more my concern that, you know, we haven't had to deal with that for so long for the boosters, but at the beginning, I mean, the first shots, we certainly in North Hampton dealt with that every day, every time. Yeah. Not on anaphylaxis, but someone conking out. Sure, you know, these children who are six months and older have all had at least three different experiences with vaccines, if not four. So they've all had vaccines. So we should have an idea whether there might be a problem with any adverse reaction. But the only young people I've ever seen, and this is not an anaphylaxis, but it's more fainting who, people who faint at the vaccines are almost always teenagers. That's been my personal experience. I don't know if it's science. Or the mothers. Find that. I haven't seen the mothers. I haven't seen the mothers get woozy. But babies and young children, I have to say in my 28, 29 years of doing this, I've never seen them have a problem with wooziness at all. Anaphylaxis, it would be a one in a million event. It's something that you have to be ready for. Yeah, yeah. And I will say that most kids underage five or so are pretty blissfully unaware of what you're gonna be doing. So it's, I think speed is really a good idea. Come on in, it's great to see you. We're gonna do great here. I'm cleaning your skin. I'm wiping it down. Here's your vaccine and we're done. Sometimes parents may need more talking than the kids do. So that's all I have to say. I don't have any questions. I will say, I think many of you, if any of you, I never know who's who. Nurses tend to be more tuned into comfort measures than doctors. And if you have other thoughts about comfort measures, by all means chime in. Robin and Mary, Lisa, do you have anything to add? We just have them like blow through a straw, like the little teeny ones, right? You have them like blow out or if you have bubbles, you know, you're like one, two, three, blow some bubbles as you're doing the shot, like stuff like that. Yeah, we use pinwheels in the office, you know, blowing pinwheels. The blowing seems to really help at the moment of the infection. So, but I think sort of the big thing is, as Scott was saying, you know, like the moment between, okay, parent hold and you giving the injection has to be almost instantaneous, right? You can't give them any time to build up any anxiety. You know, just do it and be done with it. Yeah. That's what I was gonna say too. I think the anticipation is worse than the vaccination. Right, absolutely. So just don't even do it. Yep, one, two, three, boom, great job. Here's your bandage, see you later. Yeah, yeah. Yep, I completely agree. Right, like the whole talking them through it. No. One of my worst experiences was in the schools and there was a school person who knew this child really well and she was trying to explain and every detail was gonna happen and how to stay calm. This kid had the worst time with this vaccine and I couldn't tell this woman to be quiet. I just wasn't appropriate, but it didn't make it any easier. I know in the schools there were some private areas that were used just to keep a very distracting child and whatever out of the mainstream. Is that an option in our setting at all? So, you know, that's a really good idea. I'm gonna, I'm writing down clinic day tips. There will be because we're gonna be, Lillian's gonna be posting the clinics, which we can announce after this, but they'll be in room 101 upstairs and then we'll have that outer office outside of what was Lillian's office that we can bring people to. So that's a good point. We'll have something, yes. Anything that might be helpful to have is a table, a padded table. There may be an occasional infant where it's just easier to put them on a table and hold them down. Yeah, that's good. Hopefully that won't happen much, but. Okay, padded table, yeah. Rich, you're muted. So are you going to have an extra person floating around to give help with holding like we did with the high school or with the elementary school? I'm gonna be the extra person. Absolutely, yeah. I'll be in the room because I know sometimes when the vaccinators are here for the Thursday clinics, I'm catching up on work in front of my computer, but I'll be actively in the room for the sage group. That's a great point. Super. You've gotten requests. What's that? Have you gotten requests from the town people? So we've gotten a lot of folks interested. We're about to, I think it's next week. We're gonna start with the, just letting people know what's going on and advertising it. We have a great IT department, but I think Northampton Area Pediatrics is using just Pfizer and we are gonna be Moderna. That's why people know that we're Moderna. So we anticipate the first clinic like middle of July. July 13th is gonna be our first and then a month later, we'll have a follow-up and then Lillian, our second clinic will be when? July 27th, right? The second of the July months, you mean? Yeah, yeah, and we'll have month after that. Our public health nurses starting next week. So I'm really happy to introduce Olivia Peters. So she's gonna start transitioning, taking this over. So if there's a great need for this, we're just gonna continue this as long as we need. The health department is really, we wanna be helping vulnerable populations. So what can we do to reach that demographic? But we're starting with this little pilot series. Great, great. I have to go to, I'm sorry, I have to go to another meeting, but thank you for both the 13th and the 27th. I can do those. I'm excited to help. Thank you. Good to see you. Thank you so much, God, for the information. Thank you. Anyone else with questions? I'm away before, slightly before, I think just after. But I may stop in and just get a quick observation. That's okay. Do you wanna be the floater, Rich? Is that what you were talking about? I might be the floater for the first session. Oh, you are welcome to do that. And I'll let you know for sure, because I'm leaving the next day, so. Okay. You know, I signed up for the first session as a vaccinator, and I'm thinking now that I think somebody who's done this before, you know. Don't worry. It would be a good idea. Yeah. And I also wouldn't mind being there just to kind of help and see. Yeah. I don't think it's gonna be hard, but I know Diane is doing it, and she's maybe had a little more experience with this age group than I have, but. Just with the circumcisions. That's when I gave all my shots. I know, but I just never did painful things to babies before, you know. Not on purpose, anyway. So I wouldn't mind getting a feel for things. So if someone else wants to step up, I didn't realize how infrequent the schedule is at the beginning. So it's just a couple of clinics. And I would rather just kind of let someone whose experience kind of lead us off. We wanna have a very successful first day. We do. All right, we'll see who else is available, Maureen. Thank you very much. It seems like there are plenty of the pediatrician nurses and whatever around, so. I had to tell you, I'm gonna be away both of those weeks in July. I'm afraid. Yeah, I think I'll be away both of those weeks in July. I am as well. I'm away those. If you can't find somebody else, I'll do it. But if it's just thinking about, you know, this isn't for me, this is for this clinic to be successful. I'd like to do it. I'd like to learn how, but, you know, this is really for the babies. I hear what you're saying. So I'll follow up with you and thank you, you know, for volunteering, so. Yeah, I said to Maureen, I said to her, I said, they're signing up. Do you want to sign up with me? So, thank you. But I feel comfortable because I'm used to acting quickly. And I also have grandkids. And I'm always think of, I don't, I want to do things the least disruptive. Once someone said to me, I was doing a circumcision. You did it so quickly. And I said, this is not something you want to take a long time, you know? And I always think of that, you know, that to do it accurately, but also to be able to do it quickly is really important. So I feel okay. Good. I think, you know. You guys will all do fine. Yeah, good. I think the elementary schools were good practice for thinking on the fly. They were, yes. They were harder. So, you know, that if I hadn't done that, I might actually feel differently. But having to just figure out stuff and work quickly and work as a team, that really I feel prepared for a lot of things. And I think this will be easier than the elementary schools. Yeah, I do too. Yes. I bet it will be. Yeah. The kids won't be there with their friends, you know? That's right. Yeah. So I think after this, Lily and I will send out sort of an official, thanks for coming and a sign up. We'll get that back out. And just anything else we need to do. Great. Will you tell Carol we say hello? I will, thank you. Okay. Okay, well, thank you so much, everybody. And email me with any questions. Scott, thank you very much. Thank you, thank you, thank you. Are there little reactions that we can do? Oh, yeah. I don't know what they are. Okay. All right. All right, everyone. If you want the recording, let me know. Bye-bye. Bye-bye.