Re: MB12 injection question

[Guest guest]

from what I read the safest way to get methylfolate is from food (I

speak about " whole food therapy " here

http://pursuitofresearch.org/NutriiVeda_Information.pdf and here

http://pursuitofresearch.org/science.html ...that's what I'm going to call it

from now on

While getting this nutrient from food naturally is safe with no risk of any side

effects from all I read -the issue as always is with supplementation -because

then it isn't getting into the body balanced and you can overdo from what I

read. I'll add some of the links from what I read -but I also searched quick at

Google Scholar my new favorite place to search- but running out so don't have

much time. Supplementation of L-Methylfolate should be used with " extreme

caution in children " http://www.drugs.com/cdi/l-methylfolate.html and yes one of

the mild side effects would be fever. Other mild side effects would be " Bloated

feeling; headache; itching; mild diarrhea; mild fever; nausea; vomiting "

http://www.drugs.com/sfx/l-methylfolate-side-effects.html#ixzz0zF6nvwQN

And...from what I can read the reason to even take B12 and folic (which is what

methylfolate provides as a medical food) is so that the body can hydroxylate

(introduce) " the amino acids tyrosine and tryptophan "

http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=1987 ...but

those are just two of the amino acids including all the essential amino acids

needed by the body from whole food sources in NV!

http://pursuitofresearch.org/ingredients.html and again since NV is just whole

food and that is where all the nutrients are from including all the essential

amino acids needed daily per serving (which most of you don't appreciate how

amazing and rare that is alone) and it's water soluble- 100 percent the entire

food NV is water soluble- it is the purest and safest way in my opinion and

probably the opinion of most medical and nutritional experts of getting the body

what it needs. And...it's a natural detox as you can read on the theory

page...or again check with your Dan -or get a second opinion from a

knowledgeable about nutrition MD or PhD in nutrition even. I'm just saying this

in case you have not tried NV first before going to the more extreme and stress

you are (and probably expense too) Just because something is easier and seems

simple- don't underestimate the power of Mother Nature...ever.

If you want to know more about how to serve chocolate or vanilla NV in food or

drink- some simple suggestions including rice krispy treats here

http://pursuitofresearch.org/serving_suggestions.html

If you want to know more about how to give your child shots every day

instead...read on

METHYLCOBALAMIN ( " B12 " ) INJECTION INSTRUCTIONS

TO BE MADE FROM 25 MG/ML METHYLCOBALAMIN, PRESERVATIVE FREE FORM ONLY!

STARTING DOSE TYPICALLY 64.5 MCG/KG EVERY 3rd DAY SUBCUTANEOUSLY (BUTTOCKS)

IMPORTANT: BE SURE TO REQUEST PREFILLED BD 3/10 cc INSULIN SYRINGES CALLED

" SHORTS "

BD ITEM # 328438 (NOT #32418!)

PLEASE NOTE: YOUR CHILD'S DOSE IS THE SMALL CONTENT OF ONE PRE-FILLED SYRINGE

KEY POINTS UNDERLYING SUCCESS OR FAILURE:

a) All types of fat are not equal and different types of fats have different

dissolution and dispersion constants. From my studies, the fat from the region

of the buttocks significantly outperforms the results of injections made into

the fat of the arms, legs, or belly.

Because my clinical research indicates the methyl-B12 phenomenon is due to a

dependency condition, not a deficiency syndrome, subcutaneous injections into

the fat of the buttocks allows for a leaching effect that can provide a " 24/7 "

slow release into the tissues. By contrast, injections into muscle quickly

saturate B12 receptors, correct any deficiency that may be occurring, and

temporarily treat any dependency that is also present. After the B12 receptors

are saturated, the excess methyl-B12 not bound to receptors will be filtered

from the blood by the kidneys and excreted into the urine within 30-45 minutes

after the injection. If the volume of the red methyl-B12 shot is large enough,

the next urine specimen will be red or it will be some color of red depending on

the concentration of the urine. If, however, the volume of the red methyl-B12

shot is small, the urine will not show red or pink even though the methyl-B12 is

filtered through the kidney into the urine within the same 30-45 minutes after

being injected. Unfortunately the effects of intramuscular injections are quite

confusing to parents and clinicians. Many children will show a response to some

degree, often to a very noticeable degree. However, when compared to

subcutaneous shots to the buttocks, the duration of the response is shorter; the

intensity of the response, over time, will be less; and because of this

combination of factors, many parents will discontinue shots months prematurely

before realizing the full effect of methyl-B12 for their child. A couple of

additional points must be made about intramuscular injections. Should you give

your child a shot and see a response within minutes or a couple hours instead of

many hours to days, you are giving the injections intramuscularly. Subcutaneous

adipose tissue in the buttocks is not vascular enough to deliver enough

methyl-B12 fast enough to produce a significant clinical response in such a

short period of time. If my dosing schedule is being followed and you see that

the urine is pink or red, the methyl-B12 shot was undoubtedly delivered into the

muscle no matter how much you believe the injection was given subcutaneously.

Subcutaneous injections cannot deliver enough " red " methyl-B12 fast enough to be

cleared by the kidney and show red in the urine unless the volumes are huge,

significantly greater than any that I commonly use.

c) Because of the above discussions, a constant steady state can be achieved in

most individuals with a shot frequency being adequate once every three days if

fat from the child's buttocks is used. I use the following example, not to be

gross or disgusting, but rather because it allows you to easily visualize and

remember the concept. To visualize what happens to a methyl-B12 shot in the fat

in the buttocks may be hard to do unless we `magnify it " . Therefore, let's

think about an " elephant's butt " instead. Let's say there are 12 inches of fat

between the skin and the muscle below. Our goal is to insert a red lollipop

right in the middle of this foot of elephant butt fat – 6 inches under the skin

and 6 inches above the muscle. Because fat is moist and because lollipops

dissolve whenever they come in contact with moisture, imagine the diameter of

the lollipop gradually getting smaller and smaller until it is totally gone 3

days later. This is analogous to injecting a dense concentration of methyl-B12

into the subcutaneous fat in a child's buttocks – a process of slow steady

release over 3 days. By contrast let's revisit the elephant's butt and insert

the lollipop in the muscle. Because muscle has lymph and blood constantly in

motion, the lollipop continually has blood and lymph " washing over it " and the

lollipop will dissolve much more quickly, similar to what would happen if it

were in a bowl of water that was gently being rocked back and forth. As this

illustration shows, the lollipop in the bowl will be completely melted within an

hour. Should the lollipop have been inserted right at or very close to the

subcutaneous/muscular junction, an effect somewhere in between the two extremes

would be noted.

d) Clinically speaking, methyl-B12 injections, when truly delivered into fatty

tissue in the buttocks, appear to disperse over a 3-day period " on average " .

Therefore, the first place you need to look when the benefits of a methyl-B12

shot seems to wear off too soon is to retry the shots at the same dose and

frequency but make the angle of attack much more severe, much closer to the

horizontal plane, just under the skin. In children that are extremely thin or

extremely young that have essentially no fatty tissue on their buttocks, I have

found that injections given every day or every-other-day, still just under the

skin, seem to overcome the problem and allow the benefits of methyl-B12 to be

seen. However, I do not keep the dose the same. Instead I make the dose of

each shot proportionately less depending on whether it is given every other day

or every day. For example, a dose of 750 mcg per shot every 3 days is

equivalent to a shot of 500 mcg given every other day and equivalent to a shot

of 250 mcg given daily.

e) Common errors in technique:

a. Pinching the fat: Professionals often teach parents to " pinch the fat " to

give a subcutaneous injection. Unfortunately with small children, the " tenting

effect " that occurs not only brings with it subcutaneous fatty tissue but also

" a ribbon of muscle " that is just as likely, if not more likely to receive the

medication that is thought to be being administered into the subcutaneous

tissue. The discussion above has already shown that in my clinical experience

intramuscular injections are significantly inferior to those received in the fat

in the buttocks. Therefore, NEVER PINCH THE FAT to insure a subcutaneous

injection. Instead, go as shallow as necessary, often just under the skin in

order to deliver the methyl-B12 into subcutaneous tissue.

b. Angle of injection too vertical: As discussed above in detail, the angle of

injection may not be severe enough in young children who have very little fat to

deal with in order to hit fatty tissue and not muscle. Therefore, the thinner

the child, the more closely the angle of the shot should be to the horizontal

than the vertical plane as it enters the skin. At times you may need to inject

just under the surface of the skin to accomplish this goal.

f) Safety issues:

a. The safety of the shots is unquestioned if administered from a BD #328438

needle. This needle is only 8 mm in length and when the shot is given at a 30

degree or less, as is the technique taught, the " effective length " is only a

small fraction of the original 8 mm length.

b. Clinicians have always taught patients to use the upper outer quadrant of the

buttocks to avoid injury to the sciatic nerve that could be reached if a regular

sized needle was used in the lower portion of the buttocks. However, with the

BD #328438 extremely short needle length of 8 mm, even if injected " straight in "

over the area of the sciatic nerve, the chances of hitting it in anyone except

the smallest preemie is impossible. With the angle of injection being anything

significant, it is impossible to hit the sciatic nerve.

c. By applying simple trigonometry, one of the professionals whose child is a

patient of mine gave me this " rule of thumb " if a BD #328438 needle is used as

per my protocol: a) shots injected at a 30 degree angle give an effective

needle length of approximately 4 mm ; shots injected at a 20 degree angle

give an effective needle length of approximately 2.7 mm ; c) shots injected at a

10 degree angle give an effective needle length of approximately 1.4 mm.

Special Consideration Regarding The Local Anesthetic You Have Purchased

Do This Before Administering Your First Shot

Parents are able to obtain different types of local anesthetic creams from

different compounding pharmacies as prescribed by different clinicians.

Clinicians " have their favorites " . Some are commercially available and are

standardized as to effectiveness. Those produced by different compound

pharmacies can have different percentages of ingredients and different

combination of ingredients. Therefore, some local anesthetics will act more

quickly and/or wear off more quickly. What I suggest for all my patients is

that they put the cream on the sensitive portion of their inner thighs and take

a pin and make a chart as to how soon they do not feel pain from the pinprick

and how long it takes before they feel it again. With such a chart, the parents

can know with confidence how long they should wait before they give the shot and

how much time they have before the local anesthetic will no longer be active.

Method 1: (Read this first for the " big picture " ; then compare with Method 2)

(Quick; essentially painless; rarely felt by the child at all; and most children

never wake up)

IMPORTANT NOTE: most parents only need to do this until they become comfortable

giving their child the shot. Afterwards, they usually find this procedure not

necessary.

1. Take a Band-Aid. Fold the edges back onto themselves so you can easily pull

the Band-Aid off later without having to " scrape " the edges and awaken your

child.

2. Put some BLT/EMLA cream on a " meaty spot " of the upper outer quadrant of a

buttock just under the diaper or underwear so you can gently slide it over

without later waking your child. Note: EMLA cream is difficult to obtain. Other

local anesthetic creams are available from your pharmacy with a prescription. I

use " BLT cream " from Hopewell Pharmacy. All the compounding pharmacies can make

the same or similar preparation. This works very well.

3. Apply the Band-Aid over the area that contains the local anesthetic cream.

4. Mark the edges of the absorbent part of the Band-Aid so that once you remove

the Band-Aid, you will have made a target where to insert the needle. You do

not want to be off slightly or your child will feel the prick of the needle.

5. Allow the child to go to sleep.

6. The anesthetic cream needs to be in place for approximately 45 minutes to be

maximally effective if it is prilocaine/lidocaine, like EMLA. The effect comes

on much more quickly, usually within 15 minutes if it is a combination of

benzocaine, lidocaine, and tetracaine. The effects of all of them will usually

last another hour.

7. Do the following in quick succession. You may want to practice the moves

first using an orange or the arm of a sofa that is covered with material (not

leather).

a. Gently pull the Band-Aid off and wipe away the anesthetic cream with an

alcohol swab trying not to awaken your child. Be sure that the area and/or the

adjacent area has not been soiled with fecal material. Be careful to clean the

area thoroughly with alcohol.

b. Note the " target area " . With your thumb and 3rd finger holding the middle of

the syringe (similar to holding a pencil or pen but with different fingers) and

your index finger on the plunger of the syringe, quickly insert the needle AT A

10-30 DEGREE ANGLE (this way it is impossible to go " too deep " ) until it stops

at the hub of the needle/syringe. (Think of this move as similar to tossing a

dart.) This also allows for the injection to go into the subcutaneous fat and

because of a " slow-leaching effect " gives better results than if injected into

muscle.

c. Immediately inject all of the solution within 1-2 seconds.

d. Quickly withdraw the needle and immediately put it into the " sharps

container " . (See " Sharps Container " below)

e. If you do everything gently, your child will usually not awaken. If you do

everything quickly and if your child does awaken, you " will be there " to comfort

him/her immediately and your child will not know that an injection has occurred.

METHOD 2: (Easier to do and the PREFERRED METHOD by most parents that continue

to use the cream)

Do everything exactly as above except rather than putting a Band-Aid on, rub the

cream into the area where you are going to give the shot. When using this

method, apply the cream over a larger area so that you don't accidentally miss

your target when you give the shot. The area will be numb in 15-45 minutes but

you should follow your chart [see " Special Consideration " above].

Problem, Type #1: Child That Resists Allowing You To Put On The Local Anesthetic

Cream But Does Not Awaken Once S/He Falls Asleep:

Wait until your child is in a deep sleep. Then apply the anesthetic cream.

Wait 45 minutes and then proceed as above.

Problem, Type #2: If Your Child Is A Light Sleeper And Awakens Whenever You

Attempt To Give The Shot At Night, Switch And Give The Shots During The Day:

I do not recommend alarming a child, scaring a child, or having a child always

needing to " guard his butt " from the boogeyman that's always trying to attack

him while he's attempting to rest in peace! Therefore, with these children it

is much more important just to teach the child that the shot is a part of life,

just as with a diabetic child. I do not recommend a reward system unless it is

absolutely the last straw. The shots are as important as insulin to these

children and therefore they need to be administered. Therefore it is a learning

experience for both the child and the parents how to do this with the least

emotional trauma and the least negotiations possible. After the first few

shots, the child will learn that they do not hurt (if the creams are used) and

will therefore be less resistive or not resistive at all. Surprisingly it is

not uncommon for children to ask for their shots! When children ask for the

shots to be given, obviously something good must be happening!

!PAIN?--?PAIN!--!PAIN?

Your child should feel no pain at all for the majority of the shots you

administer. The following should be considered whenever you are trying to

decide if your child is feeling " movement " by you when you give the shot, a

" sensation of fullness " , or " true pain " .

1. Shots should not hurt if the pH is correct. Occasionally compounding

pharmacies do not adjust for this or a bad batch occurs for other reasons. In

my experience, this is the most common cause for painful shots when they occur.

After prescribing over 50,000 shots and monitoring them personally, I can

undeniably state that pain has only been reported on very rare occasions when

parents used my supplier. I believe other suppliers can also produce " good

shots " . However, in my opinion, there needs to be some type of standardization

between all compounding pharmacies in order to guarantee a painless and potent

formulation so that all parents can administer the shots without the fear of

pain in order to obtain the benefits methyl-B12 frequently provides.

2. Even in perfectly administered shots, at times there may be a set of nerve

fibrils that are closer together or more sensitive than others or at times even

clumps of nerve fibrils that are present in " knots " . One cannot know ahead of

time where these anatomical variations are located. If a child " accidentally "

receives a shot in such a location, some discomfort or mild pain may be felt,

especially if the local anesthetic cream wasn't applied properly, long enough,

or for too long a period of time. As a general rule, if the injection site is

moved an inch or two, the next shot should be fine.

3. The larger the volume of a shot, the more pressure effect/tissue stretching

effect that may occur and in a sensitive child cause a feeling of discomfort.

This is one reason to use the most concentrated shot concentration possible. It

also important to remember that the sensation of " fullness " may cause a child to

" touch the spot " where you administered the shot but this does not necessarily

mean that this is a " painful sensation " . Large children, due to a larger shot

volume of 0.15 cc or greater, may feel this fullness and occasionally slight

pain.

4. If you really think something may be wrong, give yourself a shot and see if

it is painful. If it is, either have the pharmacy give you replacement shots

from a different batch, or use a different pharmacy. Should you receive a new

set of shots from the pharmacy that previously provided the painful shots, ask

for an additional shot so you can inject yourself before injecting your child to

see if the problem has been corrected.

Sharps Container:

It is important to make sure that needles are discarded properly. The following

description will allow you to make a homemade version of a sharps container.

Please do the following:

1. Obtain a large coffee can that has a plastic lid.

2. Throw out the coffee. Wash and dry the container.

3. Make two slits at a 90-degree angle to each other in the center of the

plastic lid.

4. Securely tape the lid to the can.

5. Check to make sure that you can push a syringe through the slits but that the

slits are not wide enough for " little fingers " get through.

6. When the coffee can is full, securely tape it shut by covering the slits.

7. Once secured, the can may be disposed with normal trash. It is perfectly

legal for " personal " medical waste to be disposed in this manner [in contrast to

biohazardous waste generated in a hospital or clinic].

~~~~~~~~~~~~~

=====

[Guest guest]

we give the b12 when julianne (4 years)  is awake sometimes with or without the

numbing cream.  She gets a sticker after and loves it so much she now asks for

her butt pinch and cries when it is not a butt pinch night.  we give it that

same time every day so she is not always wondering when.  we have been doing

this for over 2 years now.  we really like the shots.  She can not talk with

out them.  At all. 

cathy

From: kiddietalk <kiddietalk@...>

Subject: [ ] Re: MB12 injection question

Date: Saturday, September 11, 2010, 11:51 AM

 

from what I read the safest way to get methylfolate is from food

(I speak about " whole food therapy " here

http://pursuitofresearch.org/NutriiVeda_Information.pdf and here

http://pursuitofresearch.org/science.html ...that's what I'm going to call it

from now on

While getting this nutrient from food naturally is safe with no risk of any side

effects from all I read -the issue as always is with supplementation -because

then it isn't getting into the body balanced and you can overdo from what I

read. I'll add some of the links from what I read -but I also searched quick at

Google Scholar my new favorite place to search- but running out so don't have

much time. Supplementation of L-Methylfolate should be used with " extreme

caution in children " http://www.drugs.com/cdi/l-methylfolate.html and yes one of

the mild side effects would be fever. Other mild side effects would be " Bloated

feeling; headache; itching; mild diarrhea; mild fever; nausea; vomiting "

http://www.drugs.com/sfx/l-methylfolate-side-effects.html#ixzz0zF6nvwQN

And...from what I can read the reason to even take B12 and folic (which is what

methylfolate provides as a medical food) is so that the body can hydroxylate

(introduce) " the amino acids tyrosine and tryptophan "

http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=1987 ...but

those are just two of the amino acids including all the essential amino acids

needed by the body from whole food sources in NV!

http://pursuitofresearch.org/ingredients.html and again since NV is just whole

food and that is where all the nutrients are from including all the essential

amino acids needed daily per serving (which most of you don't appreciate how

amazing and rare that is alone) and it's water soluble- 100 percent the entire

food NV is water soluble- it is the purest and safest way in my opinion and

probably the opinion of most medical and nutritional experts of getting the body

what it needs. And...it's a natural detox as you can read on the theory

page...or again check with your Dan -or get a second opinion from a

knowledgeable about nutrition MD or PhD in nutrition even. I'm just saying this

in case you have not tried NV first before going to the more extreme and stress

you are (and probably expense too) Just because something is easier and seems

simple- don't underestimate the power of Mother Nature...ever.

If you want to know more about how to serve chocolate or vanilla NV in food or

drink- some simple suggestions including rice krispy treats here

http://pursuitofresearch.org/serving_suggestions.html

If you want to know more about how to give your child shots every day

instead...read on

METHYLCOBALAMIN ( " B12 " ) INJECTION INSTRUCTIONS

TO BE MADE FROM 25 MG/ML METHYLCOBALAMIN, PRESERVATIVE FREE FORM ONLY!

STARTING DOSE TYPICALLY 64.5 MCG/KG EVERY 3rd DAY SUBCUTANEOUSLY (BUTTOCKS)

IMPORTANT: BE SURE TO REQUEST PREFILLED BD 3/10 cc INSULIN SYRINGES CALLED

" SHORTS "

BD ITEM # 328438 (NOT #32418!)

PLEASE NOTE: YOUR CHILD'S DOSE IS THE SMALL CONTENT OF ONE PRE-FILLED SYRINGE

KEY POINTS UNDERLYING SUCCESS OR FAILURE:

a) All types of fat are not equal and different types of fats have different

dissolution and dispersion constants. From my studies, the fat from the region

of the buttocks significantly outperforms the results of injections made into

the fat of the arms, legs, or belly.

Because my clinical research indicates the methyl-B12 phenomenon is due to a

dependency condition, not a deficiency syndrome, subcutaneous injections into

the fat of the buttocks allows for a leaching effect that can provide a " 24/7 "

slow release into the tissues. By contrast, injections into muscle quickly

saturate B12 receptors, correct any deficiency that may be occurring, and

temporarily treat any dependency that is also present. After the B12 receptors

are saturated, the excess methyl-B12 not bound to receptors will be filtered

from the blood by the kidneys and excreted into the urine within 30-45 minutes

after the injection. If the volume of the red methyl-B12 shot is large enough,

the next urine specimen will be red or it will be some color of red depending on

the concentration of the urine. If, however, the volume of the red methyl-B12

shot is small, the urine will not show red or pink even though the methyl-B12 is

filtered through the kidney into the urine within the same 30-45 minutes after

being injected. Unfortunately the effects of intramuscular injections are quite

confusing to parents and clinicians. Many children will show a response to some

degree, often to a very noticeable degree. However, when compared to

subcutaneous shots to the buttocks, the duration of the response is shorter; the

intensity of the response, over time, will be less; and because of this

combination of factors, many parents will discontinue shots months prematurely

before realizing the full effect of methyl-B12 for their child. A couple of

additional points must be made about intramuscular injections. Should you give

your child a shot and see a response within minutes or a couple hours instead of

many hours to days, you are giving the injections intramuscularly. Subcutaneous

adipose tissue in the buttocks is not vascular enough to deliver enough

methyl-B12 fast enough to produce a significant clinical response in such a

short period of time. If my dosing schedule is being followed and you see that

the urine is pink or red, the methyl-B12 shot was undoubtedly delivered into the

muscle no matter how much you believe the injection was given subcutaneously.

Subcutaneous injections cannot deliver enough " red " methyl-B12 fast enough to be

cleared by the kidney and show red in the urine unless the volumes are huge,

significantly greater than any that I commonly use.

c) Because of the above discussions, a constant steady state can be achieved in

most individuals with a shot frequency being adequate once every three days if

fat from the child's buttocks is used. I use the following example, not to be

gross or disgusting, but rather because it allows you to easily visualize and

remember the concept. To visualize what happens to a methyl-B12 shot in the fat

in the buttocks may be hard to do unless we `magnify it " . Therefore, let's

think about an " elephant's butt " instead. Let's say there are 12 inches of fat

between the skin and the muscle below. Our goal is to insert a red lollipop

right in the middle of this foot of elephant butt fat – 6 inches under the

skin

and 6 inches above the muscle. Because fat is moist and because lollipops

dissolve whenever they come in contact with moisture, imagine the diameter of

the lollipop gradually getting smaller and smaller until it is totally gone 3

days later. This is analogous to injecting a dense concentration of methyl-B12

into the subcutaneous fat in a child's buttocks – a process of slow steady

release over 3 days. By contrast let's revisit the elephant's butt and insert

the lollipop in the muscle. Because muscle has lymph and blood constantly in

motion, the lollipop continually has blood and lymph " washing over it " and the

lollipop will dissolve much more quickly, similar to what would happen if it

were in a bowl of water that was gently being rocked back and forth. As this

illustration shows, the lollipop in the bowl will be completely melted within an

hour. Should the lollipop have been inserted right at or very close to the

subcutaneous/muscular junction, an effect somewhere in between the two extremes

would be noted.

d) Clinically speaking, methyl-B12 injections, when truly delivered into fatty

tissue in the buttocks, appear to disperse over a 3-day period " on average " .

Therefore, the first place you need to look when the benefits of a methyl-B12

shot seems to wear off too soon is to retry the shots at the same dose and

frequency but make the angle of attack much more severe, much closer to the

horizontal plane, just under the skin. In children that are extremely thin or

extremely young that have essentially no fatty tissue on their buttocks, I have

found that injections given every day or every-other-day, still just under the

skin, seem to overcome the problem and allow the benefits of methyl-B12 to be

seen. However, I do not keep the dose the same. Instead I make the dose of

each shot proportionately less depending on whether it is given every other day

or every day. For example, a dose of 750 mcg per shot every 3 days is

equivalent to a shot of 500 mcg given every other day and equivalent to a shot

of 250 mcg given daily.

e) Common errors in technique:

a. Pinching the fat: Professionals often teach parents to " pinch the fat " to

give a subcutaneous injection. Unfortunately with small children, the " tenting

effect " that occurs not only brings with it subcutaneous fatty tissue but also

" a ribbon of muscle " that is just as likely, if not more likely to receive the

medication that is thought to be being administered into the subcutaneous

tissue. The discussion above has already shown that in my clinical experience

intramuscular injections are significantly inferior to those received in the fat

in the buttocks. Therefore, NEVER PINCH THE FAT to insure a subcutaneous

injection. Instead, go as shallow as necessary, often just under the skin in

order to deliver the methyl-B12 into subcutaneous tissue.

b. Angle of injection too vertical: As discussed above in detail, the angle of

injection may not be severe enough in young children who have very little fat to

deal with in order to hit fatty tissue and not muscle. Therefore, the thinner

the child, the more closely the angle of the shot should be to the horizontal

than the vertical plane as it enters the skin. At times you may need to inject

just under the surface of the skin to accomplish this goal.

f) Safety issues:

a. The safety of the shots is unquestioned if administered from a BD #328438

needle. This needle is only 8 mm in length and when the shot is given at a 30

degree or less, as is the technique taught, the " effective length " is only a

small fraction of the original 8 mm length.

b. Clinicians have always taught patients to use the upper outer quadrant of the

buttocks to avoid injury to the sciatic nerve that could be reached if a regular

sized needle was used in the lower portion of the buttocks. However, with the

BD #328438 extremely short needle length of 8 mm, even if injected " straight in "

over the area of the sciatic nerve, the chances of hitting it in anyone except

the smallest preemie is impossible. With the angle of injection being anything

significant, it is impossible to hit the sciatic nerve.

c. By applying simple trigonometry, one of the professionals whose child is a

patient of mine gave me this " rule of thumb " if a BD #328438 needle is used as

per my protocol: a) shots injected at a 30 degree angle give an effective

needle length of approximately 4 mm ; shots injected at a 20 degree angle

give an effective needle length of approximately 2.7 mm ; c) shots injected at a

10 degree angle give an effective needle length of approximately 1.4 mm.

Special Consideration Regarding The Local Anesthetic You Have Purchased

Do This Before Administering Your First Shot

Parents are able to obtain different types of local anesthetic creams from

different compounding pharmacies as prescribed by different clinicians.

Clinicians " have their favorites " . Some are commercially available and are

standardized as to effectiveness. Those produced by different compound

pharmacies can have different percentages of ingredients and different

combination of ingredients. Therefore, some local anesthetics will act more

quickly and/or wear off more quickly. What I suggest for all my patients is

that they put the cream on the sensitive portion of their inner thighs and take

a pin and make a chart as to how soon they do not feel pain from the pinprick

and how long it takes before they feel it again. With such a chart, the parents

can know with confidence how long they should wait before they give the shot and

how much time they have before the local anesthetic will no longer be active.

Method 1: (Read this first for the " big picture " ; then compare with Method 2)

(Quick; essentially painless; rarely felt by the child at all; and most children

never wake up)

IMPORTANT NOTE: most parents only need to do this until they become comfortable

giving their child the shot. Afterwards, they usually find this procedure not

necessary.

1. Take a Band-Aid. Fold the edges back onto themselves so you can easily pull

the Band-Aid off later without having to " scrape " the edges and awaken your

child.

2. Put some BLT/EMLA cream on a " meaty spot " of the upper outer quadrant of a

buttock just under the diaper or underwear so you can gently slide it over

without later waking your child. Note: EMLA cream is difficult to obtain. Other

local anesthetic creams are available from your pharmacy with a prescription. I

use " BLT cream " from Hopewell Pharmacy. All the compounding pharmacies can make

the same or similar preparation. This works very well.

3. Apply the Band-Aid over the area that contains the local anesthetic cream.

4. Mark the edges of the absorbent part of the Band-Aid so that once you remove

the Band-Aid, you will have made a target where to insert the needle. You do

not want to be off slightly or your child will feel the prick of the needle.

5. Allow the child to go to sleep.

6. The anesthetic cream needs to be in place for approximately 45 minutes to be

maximally effective if it is prilocaine/lidocaine, like EMLA. The effect comes

on much more quickly, usually within 15 minutes if it is a combination of

benzocaine, lidocaine, and tetracaine. The effects of all of them will usually

last another hour.

7. Do the following in quick succession. You may want to practice the moves

first using an orange or the arm of a sofa that is covered with material (not

leather).

a. Gently pull the Band-Aid off and wipe away the anesthetic cream with an

alcohol swab trying not to awaken your child. Be sure that the area and/or the

adjacent area has not been soiled with fecal material. Be careful to clean the

area thoroughly with alcohol.

b. Note the " target area " . With your thumb and 3rd finger holding the middle of

the syringe (similar to holding a pencil or pen but with different fingers) and

your index finger on the plunger of the syringe, quickly insert the needle AT A

10-30 DEGREE ANGLE (this way it is impossible to go " too deep " ) until it stops

at the hub of the needle/syringe. (Think of this move as similar to tossing a

dart.) This also allows for the injection to go into the subcutaneous fat and

because of a " slow-leaching effect " gives better results than if injected into

muscle.

c. Immediately inject all of the solution within 1-2 seconds.

d. Quickly withdraw the needle and immediately put it into the " sharps

container " . (See " Sharps Container " below)

e. If you do everything gently, your child will usually not awaken. If you do

everything quickly and if your child does awaken, you " will be there " to comfort

him/her immediately and your child will not know that an injection has occurred.

METHOD 2: (Easier to do and the PREFERRED METHOD by most parents that continue

to use the cream)

Do everything exactly as above except rather than putting a Band-Aid on, rub the

cream into the area where you are going to give the shot. When using this

method, apply the cream over a larger area so that you don't accidentally miss

your target when you give the shot. The area will be numb in 15-45 minutes but

you should follow your chart [see " Special Consideration " above].

Problem, Type #1: Child That Resists Allowing You To Put On The Local Anesthetic

Cream But Does Not Awaken Once S/He Falls Asleep:

Wait until your child is in a deep sleep. Then apply the anesthetic cream.

Wait 45 minutes and then proceed as above.

Problem, Type #2: If Your Child Is A Light Sleeper And Awakens Whenever You

Attempt To Give The Shot At Night, Switch And Give The Shots During The Day:

I do not recommend alarming a child, scaring a child, or having a child always

needing to " guard his butt " from the boogeyman that's always trying to attack

him while he's attempting to rest in peace! Therefore, with these children it

is much more important just to teach the child that the shot is a part of life,

just as with a diabetic child. I do not recommend a reward system unless it is

absolutely the last straw. The shots are as important as insulin to these

children and therefore they need to be administered. Therefore it is a learning

experience for both the child and the parents how to do this with the least

emotional trauma and the least negotiations possible. After the first few

shots, the child will learn that they do not hurt (if the creams are used) and

will therefore be less resistive or not resistive at all. Surprisingly it is

not uncommon for children to ask for their shots! When children ask for the

shots to be given, obviously something good must be happening!

!PAIN?--?PAIN!--!PAIN?

Your child should feel no pain at all for the majority of the shots you

administer. The following should be considered whenever you are trying to

decide if your child is feeling " movement " by you when you give the shot, a

" sensation of fullness " , or " true pain " .

1. Shots should not hurt if the pH is correct. Occasionally compounding

pharmacies do not adjust for this or a bad batch occurs for other reasons. In

my experience, this is the most common cause for painful shots when they occur.

After prescribing over 50,000 shots and monitoring them personally, I can

undeniably state that pain has only been reported on very rare occasions when

parents used my supplier. I believe other suppliers can also produce " good

shots " . However, in my opinion, there needs to be some type of standardization

between all compounding pharmacies in order to guarantee a painless and potent

formulation so that all parents can administer the shots without the fear of

pain in order to obtain the benefits methyl-B12 frequently provides.

2. Even in perfectly administered shots, at times there may be a set of nerve

fibrils that are closer together or more sensitive than others or at times even

clumps of nerve fibrils that are present in " knots " . One cannot know ahead of

time where these anatomical variations are located. If a child " accidentally "

receives a shot in such a location, some discomfort or mild pain may be felt,

especially if the local anesthetic cream wasn't applied properly, long enough,

or for too long a period of time. As a general rule, if the injection site is

moved an inch or two, the next shot should be fine.

3. The larger the volume of a shot, the more pressure effect/tissue stretching

effect that may occur and in a sensitive child cause a feeling of discomfort.

This is one reason to use the most concentrated shot concentration possible. It

also important to remember that the sensation of " fullness " may cause a child to

" touch the spot " where you administered the shot but this does not necessarily

mean that this is a " painful sensation " . Large children, due to a larger shot

volume of 0.15 cc or greater, may feel this fullness and occasionally slight

pain.

4. If you really think something may be wrong, give yourself a shot and see if

it is painful. If it is, either have the pharmacy give you replacement shots

from a different batch, or use a different pharmacy. Should you receive a new

set of shots from the pharmacy that previously provided the painful shots, ask

for an additional shot so you can inject yourself before injecting your child to

see if the problem has been corrected.

Sharps Container:

It is important to make sure that needles are discarded properly. The following

description will allow you to make a homemade version of a sharps container.

Please do the following:

1. Obtain a large coffee can that has a plastic lid.

2. Throw out the coffee. Wash and dry the container.

3. Make two slits at a 90-degree angle to each other in the center of the

plastic lid.

4. Securely tape the lid to the can.

5. Check to make sure that you can push a syringe through the slits but that the

slits are not wide enough for " little fingers " get through.

6. When the coffee can is full, securely tape it shut by covering the slits.

7. Once secured, the can may be disposed with normal trash. It is perfectly

legal for " personal " medical waste to be disposed in this manner [in contrast to

biohazardous waste generated in a hospital or clinic].

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