Assessing Neonatal Pain, Duration of Crying and Procedure Time following Use of Automatic or Manual Heel Lances: A Randomized Controlled Study

Assessing Neonatal Pain, Duration of Crying and Procedure Time following Use of Automatic or... Abstract Objective The objective of this study was to compare neonatal pain, duration of crying and procedure time following use of automatic or manual heel lancets. Methods This randomized trial was conducted with neonates undergoing heel prick procedures in a neonatal intensive care unit for routine blood bilirubin monitoring. An information form, an observation form and the Neonatal Infant Pain Scale (NIPS) were used. Pain before, during and after (1 and 3 min) was assessed using NIPS scoring. Results Seventy neonates were included (automatic lancet, n = 35; manual lancet, n = 35); there was no difference between the groups (p > 0.01). Pain scores were significantly lower, with automatic lancets compared with manual lancets (p = 0.001). The duration of crying after the procedure (p = 0.001) and procedure time (p = 0.001) was significantly shorter with automatic lancets compared with manual lancets. Conclusion Automatic heel lancets in neonates are more effective than manual lancets at reducing pain, and shorten the procedure time and duration of post-procedural crying. heel prick, manual lancet, automatic lancet, pain, cry INTRODUCTION Preterm and term neonates who have to spend the first week of their lives in the neonatal intensive care unit (NICU) are exposed to several invasive procedures (2–3 times or 7–10 times a day). As a result, they experience intensive pain and stress [1–3]. Excess and long-term unrelieved pain arising from these invasive procedures may cause life-threatening problems in all organs and systems [4, 5]. There is evidence that, in general, pain is not appropriately managed in acute care institutions [6]. It is suggested that heel lancing is applied more frequently in neonates and it is more painful than venous blood collection [3, 6]. A variety of complications ranging from regional trauma to systemic infection induced by devices used during this procedure may develop [7, 8]. Manual lancets are usually used during heel lance procedures. Automatic lancets can also be used as an alternative [9, 10]. It is suggested that automatic lancets should be used during heel lance procedures so that safe puncturing can be performed in neonates [11, 12]. Automatic lancets are designed in such a way that they reach superficial blood vessels but avoid deeper dermal pain fibers [13]. Moreover, it has been reported that automatic lancets reduce the amount of bruising in heels, ankles and legs of neonates [12–14], reduce the risk of osteomyelitis [7, 12] and shorten the duration of crying [12] compared with manual lancets. Automatic lancets also reduce the procedure time [7, 9, 15]. The purpose and primary endpoint of this automatic lancet study was to compare the intensity of pain following use of automatic and manual lancets during heel stick procedures for blood sampling in neonates as assessed using the Neonatal Infant Pain Scale (NIPS). In addition, we examined the procedure time for each method. MATERIALS AND METHODS The data were collected at an NICU of a training and research hospital in Istanbul between 10 November 2013 and 16 January 2014. We calculated that a sample size of 78 neonates would achieve 90% power to detect two-tailed significance level of 0.01 with α = 0.05 and β = 0.09. To establish which neonate would be included in which group, numbers from 1 to 78 were randomly assigned to two groups (the manual lancet group and the automatic lancet group) without number repetition using a computer program. Thirty-nine patients were evaluated for each group; however, four of the manual lancet group and four of the automatic lancet group were excluded from the study because they did not meet the inclusion criteria. As a result, the sample of the study comprised 35 neonates in the manual lancet group and 35 in the lancet group. The population of the study constituted neonates admitted to the NICU between the above dates who met the selection criteria. The inclusion criteria for the neonates were as follows: born between 38 and 42 gestational weeks with weights appropriate for their gestational week (appropriate gestational age), undergoing heel prick for routine blood bilirubin monitoring and stable health status. Neonates with congenital anomalies or infections, those who received oxygen treatment and those receiving analgesics or antibiotics were excluded from the study. The study flow chart is shown in Fig. 1. The study included data collection from 70 neonates admitted to the NICU who underwent heel prick procedures for blood bilirubin monitoring. All demographic data of the infants were collected. After obtaining written informed parental consent, the eligible newborns were randomized into two groups: the manual lancet group and the automatic lancet group. Fig. 1. View largeDownload slide Study flow chart. Fig. 1. View largeDownload slide Study flow chart. Allocation concealment was performed by using consecutive numbered opaque sealed envelopes containing the codes for heel prick. Ten minutes before heel prick, information was collected and recorded for neonates in both groups. The families were informed about the procedure. Before the procedure, written consents were obtained from the families. All neonates were taken to a separate and silent room. The temperature of the room was controlled at 23–24 °C to make the environment suitable and the same for each neonate. The neonates had been fed and their diapers were changed. We ensured that all babies were calm and not agitated before the procedure. None of the babies underwent any painful procedures 6 h before the blood sampling. The procedure was performed by two nurses (one implementer, one researcher). Before the procedure, neonates from both groups were laid down straight on the examination couch and videotaped for 1 min by the researcher. During this period, the implementer prepared the materials. During the procedure, blood was drawn from the heel to a capillary tube for bilirubin follow up. This amount of blood was 2 cc for each baby. The procedure took about 1 to 2 min on average. Heel lancing was applied using a manual lancet (Broche Blood Lancet), a routine of the clinic, to neonates in the manual lancet group. In the automatic lancet group, heel lancing was performed using an automatic lancet (BD Quikheel Lancet, depth: 1.0 mm, width: 2.5 mm), which is appropriate for term neonates. Heel lancing was performed by the same experienced neonatal nurse in a single prick taking the same amount of blood for both groups. In both groups, videotaping continued during and after the procedure, for 3 min in total. During and after the procedure (1 and 3 min), the neonate’s pain was evaluated using NIPS. All video analyses for NIPS scores were performed independently by the researcher and implementer. To show whether the evaluation was consistent among the observers, a ‘consistency test’ was performed. The consistency level of both observers was 98.7% during the procedure, which was statistically significant [Intraclass Correlation Coefficient (ICC): 0.987; p < 0.01]. The consistency level of both observers was 93.5% after the procedure, which was statistically significant (ICC: 0.935; p < 0.01). The duration of crying was documented during review of the video. We used the time-track on the video. Data were recorded on the observation form. Outcome measures Information form: This form comprised 13 open-ended multiple-choice questions, including the baby’s date of birth, gestational week, birth weight, birth length, head circumference, sex, manner of delivery, mother’s and father’s age and educational background. Observation form: The observation form, developed by the researcher, was used to record the baby’s name and surname, physiologic parameters including type and duration of procedure, and duration of crying. These parameters were observed and recorded by the researcher during and after the procedure. NIPS: This scale was developed by Lawrence et al. to evaluate behavioral and physiologic pain responses of preterm and term neonates; it was adapted to Turkish by Akdovan. Cronbach’s alpha internal consistency coefficient of the scale was found as 0.83 before and during the procedure and 0.86 after the procedure [16]. In this study, a Cronbach’s alpha coefficient of 0.99 was obtained for both automatic and manual lancets. NIPS is actively used in the clinic where we collect data. It was also preferred because the sampling group matched the age range. Statistical tests: The data were coded and entered into the computer. NCSS (Number Cruncher Statistical System) 2007 & PASS (Power Analysis and Sample Size) 2008 Statistical Software (Utah, USA) were used for statistical analyses. When evaluating the study data, descriptive statistical methods (mean, standard deviation, median, frequency, ratio) as well as Student’s t-test in two-group comparisons of parameters showing normal distribution in comparisons of quantitative data and the Mann–Whitney U test for two-group comparisons of parameters not showing normal distribution were used. The Wilcoxon signed-rank test was used in intragroup comparisons of parameters not showing normal distribution. During comparison of qualitative data, Yates’s continuity correction test (Yates’s corrected chi-square) was used. Significance was evaluated at levels of p < 0.01. Ethics: Before conducting the study, written permission was obtained from the administration department of the hospital as well as ethical permission from the local ethics committee. Informed consent forms were used to inform the parents of all participating neonates about the purpose, plan and period of the study, and how data of the study would be used. RESULTS Participants The distribution of the data on the birth weight, gestation week, postnatal age and type of delivery of the newborns in the study, and a comparison of these characteristics has been provided in Table 1. There was no statistically significant difference between the groups (p > 0.01) (Table 1). Table 1 Distribution of descriptive characteristics of neonates Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) a Mann-Whitney U test (Z). b Student’s t-test (t). c Yates’s Continuity Correction Test (χ2). Table 1 Distribution of descriptive characteristics of neonates Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) a Mann-Whitney U test (Z). b Student’s t-test (t). c Yates’s Continuity Correction Test (χ2). Comparsion of pain scores according to groups When the procedures were compared between the groups, a highly significant difference was found in favor of the automatic lancet group between the mean pain scores during and after the procedure (p < 0.01) (Table 2). Table 2 Comparison of pain scores of neonates during and after the procedure according to lancet type Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** a Mann–Whitney U test (Z). b Wilcoxon signed-rank test. ** p < 0.01. Table 2 Comparison of pain scores of neonates during and after the procedure according to lancet type Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** a Mann–Whitney U test (Z). b Wilcoxon signed-rank test. ** p < 0.01. Comprasion of crying and procedure time according to groups When the distribution of duration of crying after the procedure according to lancet used was examined, the duration of crying after the procedure was 6.34 ± 12.16 s for the automatic lancet group and 19.40 ± 21.91 for the manual lancet group, around a 66% difference in post-procedural crying time. A highly significant difference was found in favor of the automatic lancet group between the mean durations of crying after the procedure (p < 0.01) (Table 3). Table 3 Comparison of crying times during and after procedure in neonates by the lancet type used (N = 70) Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** a Mann-Whitney U test (Z). ** p < .01. Table 3 Comparison of crying times during and after procedure in neonates by the lancet type used (N = 70) Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** a Mann-Whitney U test (Z). ** p < .01. When the procedure time was compared between the groups, a highly statistically significant difference was found in favor of the automatic lancet group (p < 0.01) (Table 4). Table 4 Comparison of processing time by the lancet type used (N = 70) Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Mann-Whitney U test (Z). ** p < 0.01. Table 4 Comparison of processing time by the lancet type used (N = 70) Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Mann-Whitney U test (Z). ** p < 0.01. DISCUSSION Manual lancets or needle tips are usually used during heel lance procedures [17]. Automatic lancets used during heel lancing procedures allow manual lancet incision depth [18, 19]. As such, automatic lancets decrease pain levels [13]. Hyo et al. found that pain scores of 50 preterm babies in whom manual lancets were used for capillary blood gas or bilirubin were higher compared with automatic lancets [13]. Hwang and Seol found that premature infant pain profile scores during and after puncture were significantly lower in the automatic group than in the manual lancet group [20]. Britto et al. used 26-gauge needles and manual lancets during blood drawing from the heel in their work with 40 preterm babies. The pain score of the experimental group using manual lancets was not significantly different [17]. The results of the present study and previous studies [13, 17, 20] showed that the use of automatic lancets was more effective in reducing pain compared with manual lancets. Automatic lancets may reduce the pressure to the heel by increasing the volume of flowing blood, and concordantly, contribute to a reduced pain score. Automatic lancets have been suggested to cause less tissue damage, prevent multiple heel punctures [7], reduce pressure applied to the heel and result in reduced pain and shorter duration crying [12, 15]. Britto et al. reported that heel prick with a manual lancet caused less crying than a 26-gauge needle [17]. Shepherd et al. compared two different types of lancets and demonstrated that neonates who underwent lancing with automatic lancets remained calmer and the difference between their durations of crying was highly significant. In line with that study, the results of the present study were in favor of automatic lancet in terms of reduced duration of crying [12]. In the present study, it was found that the procedure time was significantly reduced in babies for whom automatic lancets were used, as compared with manual lancets (p < 0.01). Automatic lancets used during heel lancing procedures allow a greater amount of blood flow from the puncture site, as compared with manual lancets [21]. The increased blood flow shortens the procedure time by preventing multiple heel punctures [7, 13]. In a randomized manual lancet study conducted on 40 healthy term babies, Paes et al. identified that automatic lancets significantly reduced the duration of the procedure as compared with manual lancets [15]. Similarly, Hyo et al. and Kellam et al. also demonstrated that automatic lancets used in preterm neonates reduced procedure time, as compared with manual lancets [7, 13]. In contrast, Kazmierczak et al. reported that although procedure time was reduced in the use of automatic lancet as compared with manual lancets, there was no significant difference between procedure times in either method [9]. This was ascribed to the increased blood flow due to larger incision width in the heel created by automatic lancets (2.4 mm) compared with those of manual lancets (1.75 mm). Hwang and Seol used manual and automatic lancets to take heel blood in their study performed with 24 preterm babies. Measures of effectiveness were significantly better with automatic lances than with manual lancing, including shorter duration of heel blood sampling [20]. The results of the current study and previous studies [7, 12, 13, 18] show that the use of automatic lancets was more effective in reducing procedure time as compared with manual lancets. CONCLUSION Heel prick is one of the most used and painful procedures in neonates. Of particular importance is the puncture site chosen, and the equipment used in heel lancing. The use of automatic lancet helps to reduce pain scores, shorten the procedure time and significantly shortens post-procedural crying time compared with manual lancets. Therefore, the results of this study show that it is effective both in preventing time loss and reducing pain in neonates undergoing heel prick procedures. LIMITATIONS OF THE STUDY The data obtained and the information in the information forms in the study are limited to the questions posed concerning the 70 neonates in the NICU of a training and research hospital in Istanbul and are not generalizable. ACKNOWLEDGMENTS We thank the parents of the infants who participated in the study and nurses employed in the NICU. FUNDING This study was funded by the researchers. References 1 Jeong IS , Park MS , Lee JM , et al. Perceptions on pain management among Korean nurses in neonatal intensive care units . Asian Nurs Res 2014 ; 8 : 261 – 6 . Google Scholar CrossRef Search ADS 2 Hall RW , Anand KJ. Pain management in newborns . Clin Perinatol 2014 ; 41 : 895 – 924 . http://dx.doi.org/10.1016/j.clp.2014.08.010 Google Scholar CrossRef Search ADS PubMed 3 Obeidat H , Kahalaf I , Callister L , et al. Use of facilitated tucking for nonpharmacological pain management in preterm infants: a systematic review . J of Perinat Neonatal Nurs 2009 ; 23 : 372 – 7 . http://dx.doi.org/10.1097/JPN.0b013e3181bdcf77 Google Scholar CrossRef Search ADS 4 Britto C , Rao Pn S , Nesargi S , et al. PAIN—perception and assessment of painful procedures in the NICU . J Trop Pediatr 2014 ; 60 : 422 – 7 . Google Scholar CrossRef Search ADS PubMed 5 Johnston CC , Fernandes AM , Campbell-Yeo M. Pain in neonates is different . Pain 2011 ; 152 : 65 – 73 . http://dx.doi.org/10.1016/j.pain.2010.10.008 Google Scholar CrossRef Search ADS 6 Sharma M , Bhardwaj P , Singh B , et al. Assessment of pain intensity and its persistence following common needle prick procedures in newborns . Int J Clin Exp Physiol 2014 ; 1 : 226 – 8 . Google Scholar CrossRef Search ADS 7 Kellam B , Walker J , McLaurin C , et al. Tenderfoot preemie vs a manual lancet: a clinical evaluation . Neonatal Netw 2001 ; 20 : 31 – 6 . http://dx.doi.org/10.1891/0730-0832.20.7.31 Google Scholar CrossRef Search ADS PubMed 8 Koklu E , Ariguloglu EA , Koklu S. Foot skin ischemic necrosis following heel prick in a newborn . Case Rep Pediatr 2013 ; 2013 : 1 – 3 . http://dx.doi.org/10.1155/2013/912876 Google Scholar CrossRef Search ADS 9 Kazmierczak SC , Robertson AF , Briley KP. Comprasion of hemolysis in blood samples collected using an automatic incision device and a manual lance . Arch Pediatr Adolesc Med 2002 ; 156 : 1072 – 4 . http://dx.doi.org/10.1001/archpedi.156.11.1072 Google Scholar CrossRef Search ADS PubMed 10 Ballardini G , Spruzzola A , Boneschi L , et al. To reduce the pain of heel prick in the newborn: comparison of six types of lancets . Pediatr Med Chir 2012 ; 34 : 182 – 5 . http://dx.doi.org/10.4081/pmc.2012.71 Google Scholar CrossRef Search ADS PubMed 11 Galas M , Lam JM. Clinical images heel-stick calcinosis cutis . CMAJ 2016 ; 188 : 900. http://dx.doi.org/10.1503/cmaj.151084 Google Scholar CrossRef Search ADS PubMed 12 Shepherd AJ , Glenesk A , Niven CA , et al. A Scottish study of heel-prick blood sampling in newborn babies . Midwifery 2006 ; 22 : 158 – 68 . http://dx.doi.org/10.1016/j.midw.2005.07.002 Google Scholar CrossRef Search ADS PubMed 13 Hyo BL , Mi JR , Ji Mi J , et al. A comparative study of two different heel lancet devices for blood collection in preterm infants . J Korean Soc Neonatal 2010 ; 17 : 239 – 44 . http://dx.doi.org/10.5385/jksn.2010.17.2.239 Google Scholar CrossRef Search ADS 14 Vertanen H , Fellman V , Brommels M , et al. An automatic incision for obtaining blood samples from the heels of preterm infants causes less damage than conventional manual lancet . Arch Dis Child Fetal Neonatal Ed 2001 ; 84 : 53 – 5 . http://dx.doi.org/10.1136/fn.84.1.F53 Google Scholar CrossRef Search ADS 15 Paes B , Janes M , Vegh P , et al. A comparative study of heel-stick devices for infant blood collection . Am J Dis Child 1993 ; 147 : 346 – 8 . http://dx.doi.org/10.1001/archpedi.1993.02160270108032 Google Scholar PubMed 16 Akdovan T , Yıldırım Z. Sağlıklı Yenidoğanlarda Ağrının Değerlendirilmesi, Emzik Verme ve Kucağa Alma Yönteminin Etkisinin İncelenmesi [in Turkish] . Perinatoloji Dergisi 1999 ; 7 : 107. 17 Britto C , Jasmine , Rao Pn S. Assessment of neonatal pain during heel prick: lancet vs needle—a randomized controlled study . J Trop Pediatr 2017 ; 63 : 346 – 51 . Google Scholar PubMed 18 Shah V , Taddio A , Kulasekaran K , et al. Evaulation of new lancet device (bd quickheel) on pain response and success of procedure in term neonates . Arch Pediatr Adolesc Med 2003 ; 157 : 1075 – 8 . http://dx.doi.org/10.1001/archpedi.157.11.1075 Google Scholar CrossRef Search ADS PubMed 19 Barker DP , Latty BW , Rutter N. Heel blood sampling in preterm infants: which technique? Arch Dis Child Fetal Neonatal Ed 1994 ; 71 : 206 – 8 . Google Scholar CrossRef Search ADS 20 Hwang MJ , Seol GH. Cerebral oxygenation and pain of heel blood sampling using manual and automatic lancets in premature infants . J Perinat Neonatal Nurs 2015 ; 29 : 356 – 62 . http://dx.doi.org/10.1097/JPN.0000000000000138 Google Scholar CrossRef Search ADS PubMed 21 Janes M , Pinelli J , Landry S , et al. Comprasion of capillary blood sampling using an automated incision device with and without warming the heel . J Perinatol 2002 ; 22 : 154 – 8 . Google Scholar CrossRef Search ADS PubMed © The Author(s) [2017]. Published by Oxford University Press. 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Assessing Neonatal Pain, Duration of Crying and Procedure Time following Use of Automatic or Manual Heel Lances: A Randomized Controlled Study

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Abstract

Abstract Objective The objective of this study was to compare neonatal pain, duration of crying and procedure time following use of automatic or manual heel lancets. Methods This randomized trial was conducted with neonates undergoing heel prick procedures in a neonatal intensive care unit for routine blood bilirubin monitoring. An information form, an observation form and the Neonatal Infant Pain Scale (NIPS) were used. Pain before, during and after (1 and 3 min) was assessed using NIPS scoring. Results Seventy neonates were included (automatic lancet, n = 35; manual lancet, n = 35); there was no difference between the groups (p > 0.01). Pain scores were significantly lower, with automatic lancets compared with manual lancets (p = 0.001). The duration of crying after the procedure (p = 0.001) and procedure time (p = 0.001) was significantly shorter with automatic lancets compared with manual lancets. Conclusion Automatic heel lancets in neonates are more effective than manual lancets at reducing pain, and shorten the procedure time and duration of post-procedural crying. heel prick, manual lancet, automatic lancet, pain, cry INTRODUCTION Preterm and term neonates who have to spend the first week of their lives in the neonatal intensive care unit (NICU) are exposed to several invasive procedures (2–3 times or 7–10 times a day). As a result, they experience intensive pain and stress [1–3]. Excess and long-term unrelieved pain arising from these invasive procedures may cause life-threatening problems in all organs and systems [4, 5]. There is evidence that, in general, pain is not appropriately managed in acute care institutions [6]. It is suggested that heel lancing is applied more frequently in neonates and it is more painful than venous blood collection [3, 6]. A variety of complications ranging from regional trauma to systemic infection induced by devices used during this procedure may develop [7, 8]. Manual lancets are usually used during heel lance procedures. Automatic lancets can also be used as an alternative [9, 10]. It is suggested that automatic lancets should be used during heel lance procedures so that safe puncturing can be performed in neonates [11, 12]. Automatic lancets are designed in such a way that they reach superficial blood vessels but avoid deeper dermal pain fibers [13]. Moreover, it has been reported that automatic lancets reduce the amount of bruising in heels, ankles and legs of neonates [12–14], reduce the risk of osteomyelitis [7, 12] and shorten the duration of crying [12] compared with manual lancets. Automatic lancets also reduce the procedure time [7, 9, 15]. The purpose and primary endpoint of this automatic lancet study was to compare the intensity of pain following use of automatic and manual lancets during heel stick procedures for blood sampling in neonates as assessed using the Neonatal Infant Pain Scale (NIPS). In addition, we examined the procedure time for each method. MATERIALS AND METHODS The data were collected at an NICU of a training and research hospital in Istanbul between 10 November 2013 and 16 January 2014. We calculated that a sample size of 78 neonates would achieve 90% power to detect two-tailed significance level of 0.01 with α = 0.05 and β = 0.09. To establish which neonate would be included in which group, numbers from 1 to 78 were randomly assigned to two groups (the manual lancet group and the automatic lancet group) without number repetition using a computer program. Thirty-nine patients were evaluated for each group; however, four of the manual lancet group and four of the automatic lancet group were excluded from the study because they did not meet the inclusion criteria. As a result, the sample of the study comprised 35 neonates in the manual lancet group and 35 in the lancet group. The population of the study constituted neonates admitted to the NICU between the above dates who met the selection criteria. The inclusion criteria for the neonates were as follows: born between 38 and 42 gestational weeks with weights appropriate for their gestational week (appropriate gestational age), undergoing heel prick for routine blood bilirubin monitoring and stable health status. Neonates with congenital anomalies or infections, those who received oxygen treatment and those receiving analgesics or antibiotics were excluded from the study. The study flow chart is shown in Fig. 1. The study included data collection from 70 neonates admitted to the NICU who underwent heel prick procedures for blood bilirubin monitoring. All demographic data of the infants were collected. After obtaining written informed parental consent, the eligible newborns were randomized into two groups: the manual lancet group and the automatic lancet group. Fig. 1. View largeDownload slide Study flow chart. Fig. 1. View largeDownload slide Study flow chart. Allocation concealment was performed by using consecutive numbered opaque sealed envelopes containing the codes for heel prick. Ten minutes before heel prick, information was collected and recorded for neonates in both groups. The families were informed about the procedure. Before the procedure, written consents were obtained from the families. All neonates were taken to a separate and silent room. The temperature of the room was controlled at 23–24 °C to make the environment suitable and the same for each neonate. The neonates had been fed and their diapers were changed. We ensured that all babies were calm and not agitated before the procedure. None of the babies underwent any painful procedures 6 h before the blood sampling. The procedure was performed by two nurses (one implementer, one researcher). Before the procedure, neonates from both groups were laid down straight on the examination couch and videotaped for 1 min by the researcher. During this period, the implementer prepared the materials. During the procedure, blood was drawn from the heel to a capillary tube for bilirubin follow up. This amount of blood was 2 cc for each baby. The procedure took about 1 to 2 min on average. Heel lancing was applied using a manual lancet (Broche Blood Lancet), a routine of the clinic, to neonates in the manual lancet group. In the automatic lancet group, heel lancing was performed using an automatic lancet (BD Quikheel Lancet, depth: 1.0 mm, width: 2.5 mm), which is appropriate for term neonates. Heel lancing was performed by the same experienced neonatal nurse in a single prick taking the same amount of blood for both groups. In both groups, videotaping continued during and after the procedure, for 3 min in total. During and after the procedure (1 and 3 min), the neonate’s pain was evaluated using NIPS. All video analyses for NIPS scores were performed independently by the researcher and implementer. To show whether the evaluation was consistent among the observers, a ‘consistency test’ was performed. The consistency level of both observers was 98.7% during the procedure, which was statistically significant [Intraclass Correlation Coefficient (ICC): 0.987; p < 0.01]. The consistency level of both observers was 93.5% after the procedure, which was statistically significant (ICC: 0.935; p < 0.01). The duration of crying was documented during review of the video. We used the time-track on the video. Data were recorded on the observation form. Outcome measures Information form: This form comprised 13 open-ended multiple-choice questions, including the baby’s date of birth, gestational week, birth weight, birth length, head circumference, sex, manner of delivery, mother’s and father’s age and educational background. Observation form: The observation form, developed by the researcher, was used to record the baby’s name and surname, physiologic parameters including type and duration of procedure, and duration of crying. These parameters were observed and recorded by the researcher during and after the procedure. NIPS: This scale was developed by Lawrence et al. to evaluate behavioral and physiologic pain responses of preterm and term neonates; it was adapted to Turkish by Akdovan. Cronbach’s alpha internal consistency coefficient of the scale was found as 0.83 before and during the procedure and 0.86 after the procedure [16]. In this study, a Cronbach’s alpha coefficient of 0.99 was obtained for both automatic and manual lancets. NIPS is actively used in the clinic where we collect data. It was also preferred because the sampling group matched the age range. Statistical tests: The data were coded and entered into the computer. NCSS (Number Cruncher Statistical System) 2007 & PASS (Power Analysis and Sample Size) 2008 Statistical Software (Utah, USA) were used for statistical analyses. When evaluating the study data, descriptive statistical methods (mean, standard deviation, median, frequency, ratio) as well as Student’s t-test in two-group comparisons of parameters showing normal distribution in comparisons of quantitative data and the Mann–Whitney U test for two-group comparisons of parameters not showing normal distribution were used. The Wilcoxon signed-rank test was used in intragroup comparisons of parameters not showing normal distribution. During comparison of qualitative data, Yates’s continuity correction test (Yates’s corrected chi-square) was used. Significance was evaluated at levels of p < 0.01. Ethics: Before conducting the study, written permission was obtained from the administration department of the hospital as well as ethical permission from the local ethics committee. Informed consent forms were used to inform the parents of all participating neonates about the purpose, plan and period of the study, and how data of the study would be used. RESULTS Participants The distribution of the data on the birth weight, gestation week, postnatal age and type of delivery of the newborns in the study, and a comparison of these characteristics has been provided in Table 1. There was no statistically significant difference between the groups (p > 0.01) (Table 1). Table 1 Distribution of descriptive characteristics of neonates Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) a Mann-Whitney U test (Z). b Student’s t-test (t). c Yates’s Continuity Correction Test (χ2). Table 1 Distribution of descriptive characteristics of neonates Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) Automatic lancet (n = 35) Manual lancet (n = 35) Test value p Mean ± SD Mean ± SD Postnatal age (days) 1.29 ± 1.32 1.09 ± 1.12 Z = 0.570 0.569a Birth weight (g) 3449.71 ± 315.50 3460.29 ± 392.98 t = 0.124 0.902b Birth length (cm) 49.83 ± 1.67 49.83 ± 1.74 t = 0.000 0.999b Head Circumference (cm) 34.46 ± 1.42 34.31 ± 1.18 t = 0.457 0.649b n (%) n (%) Sex Female 16 (45.7) 19 (54.3) χ2 = 0.229 0.633c Male 19 (54.3) 16 (45.7) Delivery method Cesarean section 18 (51.4) 17 (48.6) χ2 = 0.000 0.999c Normal 17 (48.6) 18 (51.4) Gestational Week 38th week 27 (77.1) 26 (74.3) χ2 = 0.000 0.999c 39th week 8 (22.9) 9 (25.7) a Mann-Whitney U test (Z). b Student’s t-test (t). c Yates’s Continuity Correction Test (χ2). Comparsion of pain scores according to groups When the procedures were compared between the groups, a highly significant difference was found in favor of the automatic lancet group between the mean pain scores during and after the procedure (p < 0.01) (Table 2). Table 2 Comparison of pain scores of neonates during and after the procedure according to lancet type Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** a Mann–Whitney U test (Z). b Wilcoxon signed-rank test. ** p < 0.01. Table 2 Comparison of pain scores of neonates during and after the procedure according to lancet type Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Pain score during procedure 3.74 ± 1.44 0.00–6.00 5.74 ± 1.20 1.00–7.00 Z = 5.549 0.001** Pain score after procedure 0.80 ± 1.39 0.00–4.00 2.23 ± 1.55 0.00–5.00 Z = 3.878 0.001** Test value Z = 4.869 Z = 5.190 pb 0.001** 0.001** a Mann–Whitney U test (Z). b Wilcoxon signed-rank test. ** p < 0.01. Comprasion of crying and procedure time according to groups When the distribution of duration of crying after the procedure according to lancet used was examined, the duration of crying after the procedure was 6.34 ± 12.16 s for the automatic lancet group and 19.40 ± 21.91 for the manual lancet group, around a 66% difference in post-procedural crying time. A highly significant difference was found in favor of the automatic lancet group between the mean durations of crying after the procedure (p < 0.01) (Table 3). Table 3 Comparison of crying times during and after procedure in neonates by the lancet type used (N = 70) Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** a Mann-Whitney U test (Z). ** p < .01. Table 3 Comparison of crying times during and after procedure in neonates by the lancet type used (N = 70) Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** Automatic lancet (n = 35) Manual lancet (n = 35) Test value pa Mean ± SD Min–max Mean ± SD Min–max Crying time during procedure (s) 12.80 ± 9.77 0.00–32.00 41.29 ± 23.93 0.00–94.00 Z = 5.712 0.001** Crying time after procedure (s) 6.34 ± 12.16 0.00–45.00 19.40 ± 21.91 0.00–72.00 Z = 3.577 0.001** a Mann-Whitney U test (Z). ** p < .01. When the procedure time was compared between the groups, a highly statistically significant difference was found in favor of the automatic lancet group (p < 0.01) (Table 4). Table 4 Comparison of processing time by the lancet type used (N = 70) Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Mann-Whitney U test (Z). ** p < 0.01. Table 4 Comparison of processing time by the lancet type used (N = 70) Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Procedure time (s) Test value p Mean ± SD Median Automatic lancet (n = 35) 19.11 ± 6.59 18.0 Z = 5.678 0.001** Manual lancet (n = 35) 42.77 ± 22.47 32.0 Mann-Whitney U test (Z). ** p < 0.01. DISCUSSION Manual lancets or needle tips are usually used during heel lance procedures [17]. Automatic lancets used during heel lancing procedures allow manual lancet incision depth [18, 19]. As such, automatic lancets decrease pain levels [13]. Hyo et al. found that pain scores of 50 preterm babies in whom manual lancets were used for capillary blood gas or bilirubin were higher compared with automatic lancets [13]. Hwang and Seol found that premature infant pain profile scores during and after puncture were significantly lower in the automatic group than in the manual lancet group [20]. Britto et al. used 26-gauge needles and manual lancets during blood drawing from the heel in their work with 40 preterm babies. The pain score of the experimental group using manual lancets was not significantly different [17]. The results of the present study and previous studies [13, 17, 20] showed that the use of automatic lancets was more effective in reducing pain compared with manual lancets. Automatic lancets may reduce the pressure to the heel by increasing the volume of flowing blood, and concordantly, contribute to a reduced pain score. Automatic lancets have been suggested to cause less tissue damage, prevent multiple heel punctures [7], reduce pressure applied to the heel and result in reduced pain and shorter duration crying [12, 15]. Britto et al. reported that heel prick with a manual lancet caused less crying than a 26-gauge needle [17]. Shepherd et al. compared two different types of lancets and demonstrated that neonates who underwent lancing with automatic lancets remained calmer and the difference between their durations of crying was highly significant. In line with that study, the results of the present study were in favor of automatic lancet in terms of reduced duration of crying [12]. In the present study, it was found that the procedure time was significantly reduced in babies for whom automatic lancets were used, as compared with manual lancets (p < 0.01). Automatic lancets used during heel lancing procedures allow a greater amount of blood flow from the puncture site, as compared with manual lancets [21]. The increased blood flow shortens the procedure time by preventing multiple heel punctures [7, 13]. In a randomized manual lancet study conducted on 40 healthy term babies, Paes et al. identified that automatic lancets significantly reduced the duration of the procedure as compared with manual lancets [15]. Similarly, Hyo et al. and Kellam et al. also demonstrated that automatic lancets used in preterm neonates reduced procedure time, as compared with manual lancets [7, 13]. In contrast, Kazmierczak et al. reported that although procedure time was reduced in the use of automatic lancet as compared with manual lancets, there was no significant difference between procedure times in either method [9]. This was ascribed to the increased blood flow due to larger incision width in the heel created by automatic lancets (2.4 mm) compared with those of manual lancets (1.75 mm). Hwang and Seol used manual and automatic lancets to take heel blood in their study performed with 24 preterm babies. Measures of effectiveness were significantly better with automatic lances than with manual lancing, including shorter duration of heel blood sampling [20]. The results of the current study and previous studies [7, 12, 13, 18] show that the use of automatic lancets was more effective in reducing procedure time as compared with manual lancets. CONCLUSION Heel prick is one of the most used and painful procedures in neonates. Of particular importance is the puncture site chosen, and the equipment used in heel lancing. The use of automatic lancet helps to reduce pain scores, shorten the procedure time and significantly shortens post-procedural crying time compared with manual lancets. Therefore, the results of this study show that it is effective both in preventing time loss and reducing pain in neonates undergoing heel prick procedures. LIMITATIONS OF THE STUDY The data obtained and the information in the information forms in the study are limited to the questions posed concerning the 70 neonates in the NICU of a training and research hospital in Istanbul and are not generalizable. ACKNOWLEDGMENTS We thank the parents of the infants who participated in the study and nurses employed in the NICU. FUNDING This study was funded by the researchers. References 1 Jeong IS , Park MS , Lee JM , et al. Perceptions on pain management among Korean nurses in neonatal intensive care units . 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To reduce the pain of heel prick in the newborn: comparison of six types of lancets . Pediatr Med Chir 2012 ; 34 : 182 – 5 . http://dx.doi.org/10.4081/pmc.2012.71 Google Scholar CrossRef Search ADS PubMed 11 Galas M , Lam JM. Clinical images heel-stick calcinosis cutis . CMAJ 2016 ; 188 : 900. http://dx.doi.org/10.1503/cmaj.151084 Google Scholar CrossRef Search ADS PubMed 12 Shepherd AJ , Glenesk A , Niven CA , et al. A Scottish study of heel-prick blood sampling in newborn babies . Midwifery 2006 ; 22 : 158 – 68 . http://dx.doi.org/10.1016/j.midw.2005.07.002 Google Scholar CrossRef Search ADS PubMed 13 Hyo BL , Mi JR , Ji Mi J , et al. A comparative study of two different heel lancet devices for blood collection in preterm infants . J Korean Soc Neonatal 2010 ; 17 : 239 – 44 . http://dx.doi.org/10.5385/jksn.2010.17.2.239 Google Scholar CrossRef Search ADS 14 Vertanen H , Fellman V , Brommels M , et al. 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Evaulation of new lancet device (bd quickheel) on pain response and success of procedure in term neonates . Arch Pediatr Adolesc Med 2003 ; 157 : 1075 – 8 . http://dx.doi.org/10.1001/archpedi.157.11.1075 Google Scholar CrossRef Search ADS PubMed 19 Barker DP , Latty BW , Rutter N. Heel blood sampling in preterm infants: which technique? Arch Dis Child Fetal Neonatal Ed 1994 ; 71 : 206 – 8 . Google Scholar CrossRef Search ADS 20 Hwang MJ , Seol GH. Cerebral oxygenation and pain of heel blood sampling using manual and automatic lancets in premature infants . J Perinat Neonatal Nurs 2015 ; 29 : 356 – 62 . http://dx.doi.org/10.1097/JPN.0000000000000138 Google Scholar CrossRef Search ADS PubMed 21 Janes M , Pinelli J , Landry S , et al. Comprasion of capillary blood sampling using an automated incision device with and without warming the heel . J Perinatol 2002 ; 22 : 154 – 8 . Google Scholar CrossRef Search ADS PubMed © The Author(s) [2017]. Published by Oxford University Press. 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Journal of Tropical PediatricsOxford University Press

Published: Dec 14, 2017

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