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Venepuncture versus heel lance for blood sampling in term neonates.

Abstract

BACKGROUND

Heel lance has been the conventional method of blood sampling in neonates for screening tests. Neonates undergoing this procedure experience pain. Despite various studies evaluating the role of pharmacological and non-pharmacological interventions to date, there are no effective and practical methods to alleviate pain from heel lance.

OBJECTIVES

To determine whether venepuncture or heel lance is less painful and more effective for blood sampling in term neonates.

SEARCH STRATEGY

Systematic search was performed in accordance with the Cochrane Neonatal Collaborative Review Group. Randomized controlled trials which compared pain response to venepuncture vs. heel lance were identified using MEDLINE (1966 - June 2007), EMBASE (1980 - June 2007), CINAHL (1982 - June 2007), Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), reference lists of identified trials and personal files. No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials which compared pain response to venepuncture vs. heel lance were selected for this review.

DATA COLLECTION AND ANALYSIS

Data regarding the primary outcome of pain response to venepuncture vs. heel lance as assessed by validated pain measures were abstracted. Secondary outcomes included the need of repeat blood sampling, bruising/hematoma at local site, and parental perception of their own anxiety and infant's pain. All data were analysed using RevMan 4.2.10. When possible, meta-analyses were performed using relative risk (RR) and risk difference (RD), along with their 95% confidence intervals (CI). If RD was significant, number needed to treat (NNT) was calculated. Weighted mean difference (WMD) was used for continuous data. When present, statistically significant between study heterogeneity was reported including the I squared (I(2)) test.

MAIN RESULTS

Five trials were eligible for inclusion in the review (including one additional trial identified in this update). Pain assessments were made using validated pain measures including Neonatal Infant Pain Scale (NIPS), Neonatal Facial Action Coding System (NFCS), Premature Infant Pain Profile (PIPP) score and cry characteristics. Two trials did not report on outcomes for all enrolled infants (not intention to treat analyses). Despite the many different pain measures used, all studies showed statistically significantly lower pain scores for venepuncture as compared to heel lance. A meta-analysis of the NIPS scores during the first minute of the procedure (reported in two studies) was statistically significantly lower in the venepuncture group compared to the heel lance group [typical WMD -1.84 (95% CI -2.61, -1.06)]. There was no statistically significant heterogeneity for this outcome (p = 0.22; I(2) 33.3%). The typical RR for requiring more than one skin puncture for venepuncture vs. heel lance (reported in 4 studies) was 0.30 (95% CI 0.18, 0.49). The RD was -0.31 (95% CI -0.41, -0.22). For this outcome there was statistically significant between study heterogeneity (for RR, p = 0.02, I(2)74.3%; for RD, p < 0.00001, I(2) 96.6%). The number needed to treat (NNT) to avoid one repeat skin puncture was 3 (95% CI 2, 5). In one study, maternal anxiety was noted to be higher in the venepuncture group as compared to heel lance group prior to the procedure; however, after observing the procedure, mothers rated their infant's pain to be lower in the venepuncture group.

AUTHORS' CONCLUSIONS

Venepuncture, when performed by a skilled phlebotomist, appears to be the method of choice for blood sampling in term neonates. For each three venepunctures instead of heel lance, the need for one additional skin puncture can be avoided.Further well designed randomized controlled trials need to be conducted. The interventions should be compared in settings where several individuals perform the venepuncture and/or the heel lance.

Authors+Show Affiliations

Mount Sinai Hospital, Department of Paediatrics, Room 775A, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5. vshah@mtsinai.on.caNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

17943752

Citation

Shah, V, and A Ohlsson. "Venepuncture Versus Heel Lance for Blood Sampling in Term Neonates." The Cochrane Database of Systematic Reviews, 2007, p. CD001452.
Shah V, Ohlsson A. Venepuncture versus heel lance for blood sampling in term neonates. Cochrane Database Syst Rev. 2007.
Shah, V., & Ohlsson, A. (2007). Venepuncture versus heel lance for blood sampling in term neonates. The Cochrane Database of Systematic Reviews, (4), CD001452.
Shah V, Ohlsson A. Venepuncture Versus Heel Lance for Blood Sampling in Term Neonates. Cochrane Database Syst Rev. 2007 Oct 17;(4)CD001452. PubMed PMID: 17943752.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Venepuncture versus heel lance for blood sampling in term neonates. AU - Shah,V, AU - Ohlsson,A, Y1 - 2007/10/17/ PY - 2007/10/19/pubmed PY - 2008/1/18/medline PY - 2007/10/19/entrez SP - CD001452 EP - CD001452 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 4 N2 - BACKGROUND: Heel lance has been the conventional method of blood sampling in neonates for screening tests. Neonates undergoing this procedure experience pain. Despite various studies evaluating the role of pharmacological and non-pharmacological interventions to date, there are no effective and practical methods to alleviate pain from heel lance. OBJECTIVES: To determine whether venepuncture or heel lance is less painful and more effective for blood sampling in term neonates. SEARCH STRATEGY: Systematic search was performed in accordance with the Cochrane Neonatal Collaborative Review Group. Randomized controlled trials which compared pain response to venepuncture vs. heel lance were identified using MEDLINE (1966 - June 2007), EMBASE (1980 - June 2007), CINAHL (1982 - June 2007), Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), reference lists of identified trials and personal files. No language restrictions were applied. SELECTION CRITERIA: Randomized controlled trials which compared pain response to venepuncture vs. heel lance were selected for this review. DATA COLLECTION AND ANALYSIS: Data regarding the primary outcome of pain response to venepuncture vs. heel lance as assessed by validated pain measures were abstracted. Secondary outcomes included the need of repeat blood sampling, bruising/hematoma at local site, and parental perception of their own anxiety and infant's pain. All data were analysed using RevMan 4.2.10. When possible, meta-analyses were performed using relative risk (RR) and risk difference (RD), along with their 95% confidence intervals (CI). If RD was significant, number needed to treat (NNT) was calculated. Weighted mean difference (WMD) was used for continuous data. When present, statistically significant between study heterogeneity was reported including the I squared (I(2)) test. MAIN RESULTS: Five trials were eligible for inclusion in the review (including one additional trial identified in this update). Pain assessments were made using validated pain measures including Neonatal Infant Pain Scale (NIPS), Neonatal Facial Action Coding System (NFCS), Premature Infant Pain Profile (PIPP) score and cry characteristics. Two trials did not report on outcomes for all enrolled infants (not intention to treat analyses). Despite the many different pain measures used, all studies showed statistically significantly lower pain scores for venepuncture as compared to heel lance. A meta-analysis of the NIPS scores during the first minute of the procedure (reported in two studies) was statistically significantly lower in the venepuncture group compared to the heel lance group [typical WMD -1.84 (95% CI -2.61, -1.06)]. There was no statistically significant heterogeneity for this outcome (p = 0.22; I(2) 33.3%). The typical RR for requiring more than one skin puncture for venepuncture vs. heel lance (reported in 4 studies) was 0.30 (95% CI 0.18, 0.49). The RD was -0.31 (95% CI -0.41, -0.22). For this outcome there was statistically significant between study heterogeneity (for RR, p = 0.02, I(2)74.3%; for RD, p < 0.00001, I(2) 96.6%). The number needed to treat (NNT) to avoid one repeat skin puncture was 3 (95% CI 2, 5). In one study, maternal anxiety was noted to be higher in the venepuncture group as compared to heel lance group prior to the procedure; however, after observing the procedure, mothers rated their infant's pain to be lower in the venepuncture group. AUTHORS' CONCLUSIONS: Venepuncture, when performed by a skilled phlebotomist, appears to be the method of choice for blood sampling in term neonates. For each three venepunctures instead of heel lance, the need for one additional skin puncture can be avoided.Further well designed randomized controlled trials need to be conducted. The interventions should be compared in settings where several individuals perform the venepuncture and/or the heel lance. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/17943752/Venepuncture_versus_heel_lance_for_blood_sampling_in_term_neonates_ L2 - https://doi.org/10.1002/14651858.CD001452.pub3 DB - PRIME DP - Unbound Medicine ER -