Key messages
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Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief.
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We don’t know which procedure, venepuncture or heel lance, is more painful for newborn babies when sugar is used for pain relief.
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We need better designed and larger studies that fully report their results to show which method is better for babies.
Why do we take blood samples from newborn babies?
In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain.
How are blood samples taken?
Venepuncture
Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well-trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance.
Heel lance
Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain.
What did we want to find out?
We wanted to find out:
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whether venepuncture is less painful than heel lance for newborn babies; and
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which procedure works best first time, so a second skin puncture is not needed.
What did we do?
We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We included eight studies involving 826 full-term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK.
When no sweet-tasting solution was given:
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venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and
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venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies).
When a sweet-tasting solution was given:
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venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and
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we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies).
What are the limitations of the evidence?
Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain.
How up to date is this evidence?
This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.
Baca abstrak penuh
Heel lance has been the conventional method of blood sampling in neonates for screening tests. Neonates undergoing heel lance experience pain which cannot be completely alleviated.
Matlamat
To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates.
Kaedah Pencarian
We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025.
Kriteria Pemilihan
Trials comparing pain response to venepuncture versus heel lance with or with out the use of a sweet tasting solution as a co-intervention in term neonates.
Pengumpulan Data dan Analisis
Outcomes included pain response to venepuncture versus heel lance with or without the use of a sweet tasting solution using validated pain measures, the need of repeat sampling and cry characteristics. Analyses included typical relative risk (RR), risk difference (RD), number needed to treat (NNT), weighted mean difference (WMD) and standardized mean difference (SMD) with their 95% confidence intervals (CI). Between study heterogeneity was reported including the I squared (I2) test.
Keputusan Utama
Six studies (n = 478) of variable quality were included. 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. Meta-analysis showed a significant reduction in the venepuncture versus the heel lance group (SMD -0.76, 95% CI -1.00 to -0.52; I2 = 0%). When a sweet tasting solution was provided the SMD remained significant favouring the venepuncture group (SMD - 0.38, 95% CI -0.69 to -0.07). 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; I2 = 97%). The NNT to avoid one repeat skin puncture was 3 (95% CI 2 to 4). Cry characteristics favoured the venepuncture group but the differences were reduced by the provision of sweet tasting solutions prior to either procedure.
Kesimpulan Pengarang
Based on moderate-certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet-tasting solution is used. When sweet-tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low-certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet-tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions.
Further high-quality studies are needed, particularly in settings where sweet-tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling.
Pembiayaan
Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way.
Pendaftaran
Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4
