range and no less than 40 mg/dL Potential Complications Pain medical dictionary. Cry length was timed by the Lorus stopwatch to the nearest tenth of a second and defined as onset of a vocalization to cessation of vocalization for five seconds or more. (Shah 1997) enrolling 27 infants reported on this outcome. The need for more than one skin puncture and sampling times were recorded. Eight infants had received oxygen support, three by ventilator and five by cannula, and all were still being cared for in Montgomery warmers in the one room NICU that housed all infants, regardless of severity of illness. than 2.4 mm. One of the tests the hospital will perform on your infant within a day or so of birth is a "heel stick" test, also simply known as a heel stick or heel prick. Blinding of the intervention was not possible while blinding of outcome assessment was ensured. The typical RD for requiring more than one skin puncture for venepuncture versus heel lance (reported in 4 studies; n = 254) was 0.34 (95% CI 0.43 to 0.25; I 2 = 97%). Crying was defined as audible vocalization of a whimper, cry, or hard cry as detected by a voice-activated recorder. Before embarking on such a study, adequate training of the personnel undertaking heel lances and venipunctures would be required. 2001 Hyperalgesia and allodynia in infants. Neonatal pain response to heel stick vs. venepuncture for routine blood sampling, Exposure to invasive procedures in neonatal intensive care unit admissions, Physiologic responses to cutaneous pain in neonates, Rocking and pacifiers: Two comforting interventions for heel stick pain. Comforting measures were associated with less crying (Field 1984, Campos 1994) and use of sucrose (2 ml of 12% solution) two minutes prior to the procedure reduced composite pain measures (Stevens 2010). RxList does not provide medical advice, diagnosis or treatment. Outcomes were reported for 117 out of 120 infants. Medical Definition of Heel stick - MedicineNet Metaanalysis showed a significant reduction in the venepuncture versus the heel lance group (SMD 0.76, 95% CI 1.00 to 0.52; I2 = 0%). 10 Things People With Depression Wish You Knew. Venepuncture, when performed by a skilled phlebotomist, appears to be the method of choice for blood sampling in term neonates. Cry characteristics such as duration of first cry, total duration of cry, number of neonates who cried during the procedure, duration of cry in the first three minutes after skin puncture and sampling time were all significantly reduced in favour of VP in infants who did not receive a sweet tasting solution. Blood Specimen via Heel Stick Vegh P, Bethesda, MD 20894, Web Policies Pain response using a combination of one or more of NIPS, NFCS and or PIPP. The heel-stick method for drawing capillary blood is the most common way to draw newborns' blood. Consenting mother-infant pairs were randomized by sealed envelope (Zellen, 1974) technique into two groups. The cross-over design controlled for all threats to internal validity except the interaction of selection and treatment, but assignment to group A or B independently and randomly by the Zellen technique insured balanced representation in both treatment sequences. SNAP-II and the SNAPPE-II: Simplified newborn illness severity and mortality risk scores. Factors Explaining Lack of Response to Heel Stick in Preterm Newborns home If needed, we planned to explore the impact of the level of bias through undertaking sensitivity analyses. Adequate random sequence generation was only reported in one trial (Shah 1997). Edwinson Mansson M. Can venepuncture reduce the pain of neonatal PKUsampling? For continuous outcomes we would use the test proposed by Egger 1997 (Egger 1997) , and for dichotomous outcomes we would use the test proposed by Harboard 2006 (Harboard 2006 ). Behavioral state differed significantly during baseline (Mann Whitney U = 2.89, p 0.04), and during post-stick (Mann Whitney U =1.73; p 0.05) with infants being calm and quiet more often during skin-to-skin periods than warmer periods. In three (Larsson 1998; Shah 1997; Eriksson 1999) of the five studies included in this review, the procedures were performed by a single investigator, respectively a paediatrician or a nurse. For eligible studies, the two review authors extracted the data using the agreed form. A composite outcome of Infant Pain Scale (NIPS), Neonatal Facial Action Coding System (NFCS) and/or Premature Infant Pain Profile (PIPP) score was reported in 288 infants, who did not receive a sweet tasting solution. Speidel BD. For infants who received a sweet tasting solution (in both VP and HL groups) only the outcome of "Number of neonates who cried during the procedure" was statistically significant in favour of VP. Data regarding infants enrolled in the VP and HL groups with or without the administration of glucose were available from Eriksson (Eriksson 1999). Between study heterogeneity was reported including the I squared (I2) test. It is used to collect blood for newborn screening tests, usually before the baby leaves the hospital. Do cry features reflect pain intensity in preterm neonates? starting the procedure. For this update the outcome of "Total duration of cry (seconds)" was added. View LeDuca F, One study measured parents' judgement regarding their own anxiety and their infant's pain using a categorical rating scale. behind the heel and your second finger just Saththasivam 2009 gave all infants sucrose prior to HL or VP. No adverse events occurred during or after the bloodtaking. Automated piercing devices (Harpin 1983, Paes 1993), behavioural interventions such as pacifiers (Field 1984) and rocking (Campos 1994), sucrose (Stevens 2010), glucose (Skogdal 1997), nonsucrose sweet tasting solution (Ramenghi 1996), anaesthetic cream such as lignocaine (Rushforth 1995) and EMLA (Larsson 1995, McIntosh 1994), and paracetamol (Shah 1998) have been studied. The PIPP score assigns points for changes in three facial expressions (brow bulge, eye squeeze and nasolabial fold), heart rate, oxygen saturation, PMA and behavioral state with a higher score indicating more pain. VP was performed by one investigator, Pain assessments were made using the duration of cry within the first 3 minutes after the skin puncture, the Premature Infant Pain Profile (PIPP) score and by changes in the heart rate, Infants were randomised using a block randomisation technique with sealed envelopes into one of the four groups HL and VP with and without oral administration of 1 ml of 30% glucose, Random sequence generation (selection bias), No information provided about sequence generation, except for using a block randomisation technique, Sealed envelops were used but no information if they were opaque and sequentially numbered, Blinding (performance bias and detection bias), High risk for VP versus HL; Low risk for glucose administration or not, Outcomes reported for all randomised infants, The study was not registered in a trials registry and the protocol was not available to us, Healthy full term infants undergoing PKU screening (n = 90), VP with large calibre needle (n = 30) (results not reported), NIPS (Neonatal Infant Pain Scale) reported at the beginning of each minute, the first minute starting at the moment of puncture, Infants were randomised using consecutively numbered envelopes, No information provided about sequence generation, Sealed opaque lottery tickets, identical on the out side were used but no information if the were sequentially numbered, Outcome data not reported on all randomised infants, The study was not registered in a trials registry, Healthy term infants undergoing blood testing for phenylketonuria (n=120), VP (n=50). Collecting peripheral blood samples via heel stick is used for several blood tests on neonates. Test for heterogeneity not applicable. In that investigation, skin-to-skin contact was given for 30 minutes and effectively reduced the pain score by 2 points, a value that reached statistical and clinical significance. Outcome measures: Pain during heel stick was measured with the Neonatal Infant Pain Scale. The total volume of blood collected with automated device was significantly larger than with lancet device. Saththasivam (Saththasivam 2009) Randomization was based on the availability of staff who could perform VP or HL. Test for heterogeneity not applicable. One trial This outcome was reported in three studies (Shah 1997; Ogawa 2005; Saththasivam 2009) in 137 infants. This minimally invasive procedure tests a blood sample for various genetic diseases. Shah 1997 and Kvist 2002 used the NIPS. Heel stick samples can be used for general chemistries and liver function tests, complete blood counts (CBCs), toxicology, newborn screening, bedside glucose monitoring, and blood gas analysis.. Unpublished data on the six patients that were excluded (because more than two skin punctures were required) in the trial by Kvist 2002 could not be obtained. Ilersich AL, There was no statistically significant difference for total duration of cry between the VP and the HL groups [mean difference 3.0 seconds (95% CI 10.96 to 16.96). official website and that any information you provide is encrypted For dichotomous data the statistical methods included relative risk (RR), risk difference (RD), number needed to treat to benefit (NNT) and to harm (NNH). For all outcomes, we carried out analyses, as far as possible, on an intentiontotreat basis, i.e. Premature infant pain profile: development and initial validation, Sucrose for analgesia in newborn infants undergoing painful procedures. In most countries, a blood sample from newborn babies is needed for screening tests. HHS Vulnerability Disclosure, Help The heel stick is now the most common way to draw newborn's blood. Comparison of Warmed and Un-warmed Heel Stick Capillary Blood Glucose Samples in Neonates. The heel stick is now the most common way to draw newborn's blood. Voralu K, odd or even date of birth; hospital or clinic record number); Unclear risk no or unclear information provided. Minder C. Bias in metaanalysis detected by a simple, graphical test, Pacifying effects of nonnutritive sucking on term and preterm neonates during heel stick procedures, Pain expression in neonates: facial action and cry, A modified test for smallstudy effects in metaanalyses of controlled trials with binary endpoints. Canadian Paediatric Society, Bennett S, There was a significant reduction in the sampling time in the VP versus the HL group [mean difference 65 seconds, 95% CI 110 to 20). Nakano M, Use a lancet that is 1.0mm deep by 2.5mm long for healthy infants. We assessed whether each study was free of other problems that could put it at risk of bias as: Low risk no concerns of other bias raised; High risk concerns raised about multiple looks at the data with the results made known to the investigators, difference in number of patients enrolled in abstract and final publications of the paper; Unclear concerns raised about potential sources of bias that could not be verified by contacting the authors. Cardiorespiratory and crying data for each period under both SSC and warmer conditions are shown in Table 1. The authors provided us with outcomes data as means and standard deviations, Neonates were allocated to either the VP group or the HP group depending on the availability of the assigned staff, Performance bias high; Detection bias low Video recordings assessed blinded to groups, NFCS scores, total duration of cry and number of punctures reported for all infants; duration of first cry and total duration of cry reported for 15 infants in the VP group and 15 in the HL group, Healthy neonates of > =37 weeks PMA (n=27), Pain assessments were made using Neonatal Infant Pain Scale (NIPS), One investigator (welltrained paediatrician) performed all procedures, Outcomes reported for all 27 infants included, The study was stopped after 27 infants had been enrolled from the preset sample of 50 infants. Group B received three hours of warmer care for the first interfeeding interval and then spent three hours in skin-to-skin contact for the second interfeeding interval. Newborn babies can develop low blood sugar (glucose) which can lead to brain injury and poor developmental outcomes. These results augment the Premature Infant Pain Profile findings of the only other study of skin-to-skin contact to reduce premature infant heel stick pain 3(Johnston et al., 2003). We categorized the methods used with regards to detection bias as: Low risk adequate followup was performed with assessors blinded to group assignment; High risk inadequate assessors at followup were aware of group assignment; Attrition bias: For each included study and for each outcome, we described the completeness of data including attrition and exclusions from the analysis. We designed a form to extract data. The scale has been tested for validity and reliability in preterm and term infants subjected to capillary, venous or arterial punctures (Lawrence 1993). Anaesthetic cream (Rushforth 1995, Larsson 1995, McIntosh 1994) and paracetamol (Shah 1998) have been ineffective in decreasing pain scores with HL. Ogawa 2005 was a single centre study performed in Osaka, Japan. Unpublished data were included from the studies by Shah (Shah 1997), Eriksson (Eriksson 1999), Kvist (Kvist 2002) and by Saththasivam (Saththasivam 2009). The decision was made to include this study in the review as most infants were term. et al. NIPS scores were not provided for this group. Further well designed randomised controlled trials should be conducted in settings where several individuals perform the procedures. The https:// ensures that you are connecting to the (Eriksson 1999) enrolling 60 neonates reported on this outcome. The difficulty and duration of the heel stick was subjectively appraised as being similar between the two conditions because the heel stick was conducted by the same person using the same technique to draw the same amount of blood. Future studies might . Taddio A, Comparison 1 Pain response during skin puncture to VP vs. HL in infants who did not receive a sweet tasting solution, Outcome 12 Infant's pain score as rated by the mother. Comparison 1 Pain response during skin puncture to VP vs. HL in infants who did not receive a sweet tasting solution, Outcome 10 Brusing/hematoma at local site. Population: Healthy fullterm neonates undergoing blood glucose monitoring. If there were 10 or more studies in the metaanalysis we would have investigated reporting biases (such as publication bias) using funnel plots. Sequence B group had incubator care and heel stick before skin contact care and heel stick. In conclusion, this study adds one more piece of evidence that pain, as measured by physiologic and behavioral responses, is significantly reduced in preterm infants undergoing heel stick when they are given three hours of SSC before the heel stick and have the heel stick performed in SSC.