• V Shah and A Ohlsson.
• Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5. ohlsson@mtsinai.on.ca
• Cochrane Db Syst Rev. 2000 Jan 1 (2): CD001452.

BackgroundHeel 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.ObjectivesTo determine whether venepuncture or heel lance is less painful and more effective for blood sampling in term neonates.Search StrategySystematic search in accordance with Cochrane Neonatal Collaborative Review Group. All randomized controlled trials which compared pain response to venepuncture vs. heel lance were searched using MEDLINE, Embase, CINAHL, the Cochrane Library, reference lists of identified trials and personal files. No language restrictions were applied.Selection CriteriaRandomized controlled trials which compared pain response to venepuncture vs. heel lance were selected for this review.Data Collection And AnalysisData regarding the primary outcome of pain response to venepuncture vs. heel lance as assessed by validated pain measures were abstracted. Secondary outcomes including the need of repeat blood sampling, bruising/hematoma at local site, and parental perception of their own anxiety and infant's pain were also abstracted. All data were analysed using Revman 3.1. When possible, meta-analysis was done using relative risk (RR) and event rate difference (ERD), along with their 95% confidence intervals (CI). If ERD was significant, number needed to treat (NNT) was calculated.Main ResultsTwo trials were eligible for inclusion in the review. One study using Neonatal Infant Pain Scale (NIPS) and one study using Neonatal Facial Action Coding System (NFCS) and cry duration showed statistically significantly lower pain scores for venepuncture as compared to heel lance. 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. A meta-analysis was performed on the need for at least one additional skin puncture to obtain the required amount of blood using venepuncture as compared to heel lance. The relative risk for requiring more than one skin puncture for venepuncture versus heel lance was 0.19 [95% confidence interval (CI) 0.10, 0.38]. The risk difference was -53% (95% CI -66%, -40%). The number needed to treat (NNT) to avoid one repeat skin puncture was 1.9 (95% CI 1.5, 2.5).Reviewer's ConclusionsVenepuncture, when performed by a trained phlebotomist, appears to be the method of choice for blood sampling in term neonates. For each two venepunctures instead of heel lance, the need for one additional skin puncture can be avoided. In view of the promising results derived from small studies with some methodological limitations, 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.

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