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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 155-161

Comparison of pain response to vein puncture versus heel lance among preterm infants undergoing blood sampling


Department of Pediatric Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Submission04-Mar-2020
Date of Decision12-Mar-2020
Date of Acceptance17-Mar-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Sanaa G.Y Mohamed
Pediatric Nursing Department, Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_6_20

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  Abstract 


Background Pain in neonates is largely underestimated and neglected. Accurate pain assessment is the first step toward effective pain management. Skin-breaking procedures such as heel lances, vein punctures, and arterial punctures are the most frequently performed painful procedures in neonatal ICUs. Few studies have been done to compare preterm infants’ pain response to heel lance vs venipuncture.
Aim The aim was to compare pain response to venipuncture vs heel lance among preterm infants undergoing blood sampling.
Materials and methods A comparative descriptive research design was used on a convenient sample of 60 preterm infants less than 37 weeks of gestation who were undergoing blood sampling for complete blood count, blood chemistry, or glucose estimation. Neonatal assessment sheet, blood sampling assessment sheet, and premature infant pain profile scale were used to collect data from two neonatal ICUs of both Cairo University Children Hospital (El Monira) and El Manial University Hospital (Kaser El Aini). After a written consent from parents, the same preterm infant pain response was continuously monitored 30 s before procedure and up to 6 min during the procedure over 2 days (one for venipuncture and one for heel lance).
Results The total mean premature infant pain profile score significantly increased during venipuncture than heel lance. Behavioral state was significantly more unstable during vein puncture than heel lance. Venipuncture procedure significantly increased heart rate and decreased oxygen saturation more than heel lance.
Conclusion Preterm infants perceive pain as demonstrated by premature infant pain profile scale and vein puncture is the more painful procedure than heel lancing for blood sampling in preterm infants.
Recommendations Premature infant pain profile scale should be included in the routine assessment for preterm infants.

Keywords: Keywords, heel lance, pain, preterm infants, venipuncture


How to cite this article:
Mohamed SG, Elhamid Dabash SA, Mohamed Rashad H, Moselhi EA. Comparison of pain response to vein puncture versus heel lance among preterm infants undergoing blood sampling. Egypt Nurs J 2019;16:155-61

How to cite this URL:
Mohamed SG, Elhamid Dabash SA, Mohamed Rashad H, Moselhi EA. Comparison of pain response to vein puncture versus heel lance among preterm infants undergoing blood sampling. Egypt Nurs J [serial online] 2019 [cited 2020 Sep 30];16:155-61. Available from: http://www.enj.eg.net/text.asp?2019/16/3/155/292496




  Introduction Top


Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Although pain is a subjective phenomenon, the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment (William and Neil, 2003; International Association for the Study of Pain, 2017).

Numerous newborns routinely undergo blood-letting procedures in nurseries/neonatal intensive care unit (NICU) for diagnostic and therapeutic purposes, but usually these procedures are done without pain preventing or relieving measures. The misconception that the infant does not perceive pain owing to various reasons (incomplete myelination, immature central nervous system, etc.) has been dispelled, and it has been emphasized that even extremely preterm babies also perceive pain and suffer from more serious consequences than older children and adults (Alberto et al., 2009; American Academy of Pediatrics, 2016).

Unrelieved pain in neonates may result in increased morbidity and length of stay in nurseries/NICU, altered immune function, exaggerated pain in later life, and altered psychosocial development (Oliveira et al., 2017). As neonates cannot self-report pain, assessment of pain in neonates has to be relied on behavioral and physiologic reactions to pain. Physiologic markers usually include changes in heart rate, respiratory rate, blood pressure, and oxygen saturation (Sweet and McGrath, 1998; Weissman et al., 2009).

Behavioral reactions include changes in facial expressions, body movements, and crying; however, these may be absent in some early preterm, neurologically impaired, pharmacologically treated, or intubated neonates (Grunau et al., 1990; Mari and Riikka, 2016). The objective pain assessment requires a multidimensional tool that encompasses these parameters. Various pain assessment scales have been developed and validated for this purpose. These are based on either behavioral changes or physiological variations or a combination of both. The latter provides a better estimate of infant pain (Kenner and Lott, 2014).

Heel lancing and venipuncture are the common procedures for blood sampling. The former is the conventional method in neonates for measurement of bilirubin, glucose, and screening for metabolic disorders (Shah and Ohlsson, 2012). The procedure of heel lancing raises concerns apart from pain, which include chances of collecting hemolyzed sample, inadequate sample from single prick, and chances of puncturing calcaneus bone, leading to osteochondritis (Shah and Ohlsson, 2012). Venipuncture, on the contrary, a common procedure in older children and adults, has a reduced risk of a hemolyzed or clotted sample, increased sample volume, and possibly less pain. However, a skilled phlebotomist is needed to perform the procedure (Björn et al., 1998). Usually no efforts are made to assess or mitigate pain during these procedures. This study is an attempt in that direction.

Preterm infants are repeatedly exposed to painful procedures because of routine care (Ayse et al., 2017). Surmounting evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes (Witt et al., 2016).

To improve preterm infants’ neurodevelopmental outcomes, it is essential to adopt proper interventions to alleviate their pain during NICU procedures. Evidence shows that procedural pain is often poorly managed in neonatal period, and many painful procedures are performed without any pain relief (Ghoneim, 2016). The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences (American Academy of Pediatrics, 2016).

It is now a well-known fact that procedural pain remains a challenge in the NICU setting, and pain in neonates has detrimental effect. Some research studies were done about the assessment and management of pain, but despite being aware of this fact, neonates are still being subjected to repeated painful stimuli as a routine practice in NICUs (Gurmeet et al., 2017).


  Materials and methods Top


Aim

The aim was to compare pain response to venipuncture vs heel lance among preterm infants undergoing blood sampling.

Research design

A comparative descriptive research design was conducted.

Setting

This study was conducted from November 2018 to April 2019 at two NICUs of Cairo University Children Hospital (El Monira) and El Manial University Hospital (Kaser El Aini).

Sample

A convenient sample of 60 preterm infants were assigned according to the following inclusion criteria: preterm infants (from 28 weeks to <37 weeks of gestation, undergoing blood sampling (heel lance and vein puncture) for complete blood count, blood chemistry, or glucose estimation, in the first 2 days of life, and they were attached to monitor and pulse oximeter. Preterm infants with significant morbidity like birth asphyxia, major congenital malformations or any illness were excluded. Preterm infants whose mother had a history of receiving epidural analgesia for delivery or any form of opioids during pregnancy or labor and whose parents refused consent were also excluded.

Instruments

The following instruments were used:
  1. (Neonatal assessment sheet: it was developed by the research investigator to collect data about preterm infant, such as sex, diagnosis on admission and present diagnosis, duration of hospitalization, Apgar score, residence, and mode of delivery.
  2. Blood sampling assessment sheet: it was be developed by the research investigator to collect data about the type of blood sample technique (heel lance or vein puncture), site of insertion, complication, time of procedure, etc.
  3. Premature infant pain profile (PIPP) scale: it was developed and validated by Stevenset al.(1996). It includes seven indicators for assessment of pain in preterm infants: three behavioral responses (brow bulge, eye squeeze, and nasolabial furrow), two physiologic responses (heart rate and oxygen saturation), and two contextual responses (gestational age and behavioral state). Each indicator is scored on a four-point scale (0–3) to give a maximum total score of 21. Score 0–6 indicates minimal or no pain, score 7–12 indicates slight to moderate pain, and scores greater than 12 indicate severe pain.


Tool validity and reliability

Tool I and tool II were submitted to a panel of five experts in the field of high-risk neonates and pediatric nursing to examine the content validity. Reliability test was done using Cronbach’s α; it was 0.75%.

Tool III PIPP) is a standardized and valid tool developed by Stevens et al. (1996), and its reliability is 0.96%.

Pilot study

The pilot study was conducted on 10% of the total sample (six preterm infants) to test the feasibility and applicability of tools and estimate the time required for filling the tools. Preterm infants who shared in the pilot study were included in the study sample.

Data collection procedures

An official permission was obtained from the director of El Manial University Hospital (Kaser El Aini) and Cairo University Children Hospital (El Monira); another permission was obtained from the head of the NICUs. The blood-drawing procedure was carried out by the nurses on duty. Before the procedure, the test area was warmed for 1 min by gently placing it between the warm hands of the nurse; thereafter, the skin was cleansed with disinfectant (spirit swab) and waited for 2 s. Heel lancing and venipuncture were performed by a microlance 3 mm and 21 G needle, respectively. Behavioral state and physiological responses were continuously monitored 30 s before the procedure and up to 6 min during the procedure over 2 days (one for venipuncture and one for heel lance) in the same preterm infant. After that preterm infants’ response to pain was rated on PIPP.

Ethical considerations

A primary approval was obtained from the Research Ethics Committee of the Faculty of Nursing, Cairo University. A written informed consent was obtained by the research investigators from the parents, and they were informed that they have the right to withdraw from the study at any time without reason. Confidentiality was secured for each preterm infant.

Data analysis

Data were statistically described in terms of mean±SD, or frequencies (number of cases) and percentages when appropriate. Comparison of quantitative variables between heel and venipuncture was done using paired t-test, whereas qualitative variables were compared using McNemar test. Comparison according to diagnosis and site of venipuncture was done using Kruskal–Wallis test. Correlation between various variables was done using Spearman rank correlation equation. Two-sided P values less than 0.05 was considered statistically significant. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Sciences; IBM Corp., Armonk, New York, USA) release 22 for Microsoft Windows.


  Results Top


[Table 1] shows that more than half of preterm infants (56.7%) were males and 43.3% of them were females. Most preterm infants (81.7%) were delivered by cesarean section and the minority (18.3%) vaginal. The mean gestational age of preterm infants was 33.07±2.537 weeks and 1.823.95±559.013 g for their birth weight. Respiratory distress syndrome was the most common diagnosis, which represented 70%.
Table 1 Preterm infants characteristics in percentage distribution (n=60)

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[Table 2] delineates that there was a statistically significance difference between heel lance and venipuncture regarding the time duration of sampling (P=0.000 and 0.00, respectively).
Table 2 Characteristics of blood sampling in heel lance and venipuncture in percentage distribution (n=60)

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[Table 3] illustrates that there were no statistically significant differences between the total mean scores of heel lance and venipuncture before blood sampling procedures, whereas it increased significantly during the procedures (P=0.209 and 0.000, respectively). Venipuncture procedure significantly increased preterm infants’ heart rate and decreased oxygen saturation more than heel lance (P=0.000 and 0.020, respectively).
Table 3 Comparison of premature infant pain profile total mean score before and during heel lance and vein puncture

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[Table 4] reveals that there was no correlation between total mean PIPP scores of heel lance and venipuncture during blood sampling and gestational age, sex, mode of delivery, time of sampling, insertion site, and duration of insertion (P=0.39, 0.96, 0.29, 0.63, 0.91, 0.36, 0.87, 0.50 and 0.32, and 0.45, 0.72, 0.66, 0.40, 0.10, 0.00, 0.84, 0.97, and 0.75, respectively).
Table 4 Correlation between premature infant pain profile total score and characteristics of preterm infant and blood sampling

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  Discussion Top


Awareness that neonates can perceive pain and it needs to be mitigated did not exist among the health professionals till recently. Pain in neonates had largely been underestimated, but the recent studies have conclusively shown that neonates exhibit pain response which should be mitigated by any means (Weissman et al., 2009).

The results of the current study revealed that there was a statistically significant difference between heel lance and venipuncture regarding the characteristics of blood sampling. Approximately half of the preterm infants had heel lance in afternoon in comparison with majority of them have venipuncture in the morning. This result is supported by Humphrey et al. (1992) who found that routine venipuncture for blood sample was done in the morning. Moreover, the routine venipuncture blood sampling time in the current study setting is the early morning, whereas heel lance is more common at the afternoon time.

Considering the duration of insertion, the results of the current study showed significant increase in the mean insertion duration of venipuncture than heel lance (2.65±1.684 and 0.600±0.2017, respectively). This goes in line with Moselhi (2010), who found that more than half of preterm infants’ needle insertion duration was within 2–5 min. On the contrary, the WHO (2010) reported that venipuncture is a skill that takes time and practice to master.

Regarding insertion frequency, this study results represented that nearly all preterm infant’s blood sampling via heel lance and more than three-quarters in venipuncture was taken from the first trial. This goes in line with Moselhi (2010), who summarized that half of the preterm infant’s blood sampling via venipuncture was taken from the first trial.

Gibbins (2013) concluded that prolonged painful procedures increase physiological and behavioral pain response. Regarding physiological response to pain, this study results revealed that there was significant increment in the mean heart rate during heel lance and venipuncture; however, the increment was significantly more in venipuncture than in heel lance. In congruent with the previous results, Shrestha and Adhikari (2012), who studied pain response to venipuncture vs heel lance blood sampling in term neonates, found that there was significant increment in heart rate during procedure in both groups; however, the increment was significantly more in heel lance group than in venipuncture group, which contradicts this study results.

In relation to oxygen saturation, the results of this study documented that there was significant decrease in oxygen saturation during heel lance and venipuncture; however, the fall in oxygen saturation was significantly more in venipuncture than in heel lance. This goes in the same direction with Shrestha and Adhikari (2012), who found that there was a significant decrease in oxygen saturation in both groups during the procedure; however, the fall in oxygen saturation was significantly more in heel lance group than in venipuncture group, which contradicts this study results.

On the contrary, Moselhi et al. (2019), Alemdar and Özdemir (2017), and Bauer et al. (2004) found a significant increase in heart rate and decrease in oxygen saturation, which are consistent with the present study. In response to heel lancing, Weissman et al. (2009) and Lindh et al. (1999) found a significant increase in the heart rate. Ibrahim et al. (2016) summarized that a significant increase in heart rate and decrease in oxygen saturation to heel lancing. All of these findings are consistent with the findings of the current study.

Preterm infants’ responses to pain from painful procedures such as heel sticks both anatomically as a change in facial expressions. Preterm infants’ responses to pain from painful procedures such as heel sticks include changes in facial expressions. These changes in facial expression to watch for include tightly squeezed eyes, bulging brows, an open stretched mouth, deepened nasolabial furrow, a taut cupped tongue, and a quivering chin (Stevens and Johnston, 2011).

Regarding behavioral responses and facial expression, this study results revealed that there were statistically significant differences during heel lance and venipuncture regarding behavioral characteristics (Brow bulge, eye squeeze, and nasolabial furrow); however, behavioral response and facial expression were markedly maximum and tense during venipuncture than heel lance. This goes in line with Moselhi (2010), who concluded that facial expression become markedly constant (a continuous grimace with tight facial muscles, furrowed brown, eyes squeezed tightly shut, and deepened nasolabial furrow) during venipuncture in the control group. Moreover, Ibrahim et al. (2016) summarized that behavioral response and facial expression were markedly maximum and tense during heel lance.

The results of this study showed that no correlation between PIPP score during heel lance and venipuncture and preterm infants’ characteristics (gestational age, sex, and birth weight). These findings are supported by Ibrahim et al. (2016), who studied the effect of foot massage on pain responses to heel stick and found that there were no correlation between pain score and the preterm infants’ characteristics, including gestational age, sex, and birth weight. Moselhi (2010) also found that were no correlations between pain score and the preterm infants’ characteristics such as gestational age and birth weight.

Considering other variables (duration and site of insertion), the results of this study showed no correlation was detected between PIPP score and these variables. Ibrahim et al. (2016) concluded that there was no correlation between PIPP score and duration of insertion. On the contrary, Moselhi (2010) contradicted these findings, as he reported that there was a significant correlation between total pain score and duration of insertion during procedure.

In relation to the total mean PIPP scores during heel lance and venipuncture, the results of this study showed that the total mean PIPP score significantly increased during venipuncture than heel lance. These results contradict Shrestha and Adhikari (2012) and Shah and Ohlsson (2012), who concluded that venipuncture was less painful and more effective than heel lance when performed by a trained phlebotomist. From the research investigators point of view, the differences may be related to needle size that was used in venipuncture. The American Academy of Pediatrics and Canadian Pediatric Society (2006) stated that pain responses of neonates are influenced by the timing of painful procedures, the technique used, and the degree of professional expertise.

Limitation

Interpretation of the results should acknowledge some limitations such as lack of blinding in the studies and small sample size. Future studies should try to ensure that the research be performed in a facility that will offer an adequate sample size to validate the findings.


  Conclusion Top


This study concluded that venipuncture is more painful than heel lance in preterm infants.

Recommendations

Based on the study results, the following recommendations are proposed:

PIPPs should be included in the routine assessment for preterm infants, and a small needle size of 23 G (Butterfly needle) should be used according to WHO (2010) guidelines.[29]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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