Buy this Article for $7.95

Have a coupon or promotional code? Enter it here:

When you buy this you'll get access to the ePub version, a downloadable PDF, and the ability to print the full article.


Analgesia/methods, Heel, Neonate, Pain, Punctures.



  1. Morrow, Carla DNP, CNM, RN
  2. Hidinger, Andrea MSN, RNC, IBCLC
  3. Wilkinson-Faulk, Debbie PhD, RN, CPNP


Purpose: To measure the difference in pain scores for newborns who were held and swaddled while undergoing routine heel lance procedures compared to newborns who were lying on their backs and not swaddled during heel lance. Additionally, we sought to compare the total amount of time it took to collect the specimens in each group.


Design and Methods: A total of 42 neonates recruited from a large tertiary hospital were enrolled in a randomized controlled trial. Infants in the experimental group (n = 22) were swaddled and held in an upright position during routine heel lance procedures while neonates in the control group (n = 20) remained in a standard care position. Pain was measured with the Neonatal Inventory Pain Scale (NIPS) at two points in time for each group (just before the heel lance procedure and at the completion of the heel lance). Total collection time was measured using a stopwatch accurate to 1/100th of a second. Specimen quality was measured based on the number of rejected specimens for each group. Descriptive statistics and t tests were used to analyze the data.


Results: The mean NIPS score for neonates who were swaddled and held during the procedure (experimental group) was significantly lower (M = 1.3, SD = .9) than the score for infants in the standard position (control group) (M = 2.7, SD = 1.3), t (40) = -4.48, p < .001. Although the total collection time was lower for infants who were swaddled (2 minutes and 17 seconds, SD = 59) versus (2 minutes and 47 seconds, SD = 85) for controls, this was not a statistically significant difference (p = .45).


Clinical Implications: Swaddling combined with positioning neonates upright during routine heel lance procedures offers nurses a nonpharmacologic method of neonatal pain reduction for heel sticks. This technique can be easily implemented on any unit independent of facility protocols. Furthermore, the technique is not associated with any cost or policy development, making it more likely that nurses can use it in practice.


Article Content

Healthy term neonates undergo multiple routine painful procedures including heel lancing shortly after birth and during the initial hospital admission (American Academy of Pediatrics [AAP], 2006). The heel lancing procedure is a reasonably straightforward practice, yet problems for the neonate still occur such as pain and bruising, varying specimen quality, and extended collection time for nurses (AAP, 2006; Shepherd, Glenesk, Niven, & Mackenzie, 2006). Nurses may squeeze the heel to obtain an adequate amount of blood sampling, thus causing hemolysis and contamination of the blood sample, which sometimes increases the need for repeat testing (Kazmierczak, Robertson, & Briley, 2002). Bruising caused by heel squeezing during heel lancing has also been associated with increased pain for neonates during subsequent heel lancing, and has been reported to be equally painful or even more painful than the actual heel lance itself (Vertanen, Fellman, Brommels, & Viinikka, 2001). Grunau, Oberlander, Holsti, and Whitfield (1998) evaluated 40 preterm infants during routine heel lancing, documenting that the most prominent behavioral response to pain occurred during heel squeezing rather than during the initial heel prick (p < .003). Shepherd et al. enrolled 340 infants seeking to compare two heel lancing devices (Tenderfoot and Genie Lancet). Outcome measures included total collection time, amount of time squeezing, presence of bruising, and pain. Results indicated a significant increased pain response for the group of infants experiencing increased total collection time, squeezing, and bruising.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Furthermore, some disease conditions result in infants being subjected to additional blood sampling; this happens frequently in infants born to mothers with gestational diabetes (up to 10% of all pregnancies) and late preterm neonates who develop significant hyperbilirubinemia (9% of newborns) (Bhutani et al., 2004; Reece, Leguizamon, & Wiznitzer, 2009).


It is important to evaluate and address pain issues experienced by neonates during routine heel lancing, not only to increase the infants' comfort but also to decrease the negative consequences of excessive pain. One such consequence is an altered pain response known as hyperalgesia; this condition was studied by Taddio, Shah, Atenafu, and Katz (2009), who demonstrated that infants who were exposed to repeated (more than 5) painful needle punctures on the first day of life showed a greater pain response during later needle punctures when compared with neonates who had been exposed to a fewer number of needle punctures. It also appears that altered pain perception has long-term consequences in some vulnerable neonates, which may include cognitive and behavioral deficiencies, as described by Klein, Gaspardo, Martinez, Grunau, and Linhares (2009), who examined whether pain and stress experienced by premature infants predicted temperament in later toddlerhood. They prospectively recruited 56 infants from the neonatal intensive care unit (NICU); 26 were followed up as toddlers. Researchers carefully documented both behavioral and physiologic pain responses for each infant while in the NICU, and temperament at toddlerhood was assessed using the mother's responses to the Early Childhood Behavior Questionnaire (ECBQ). Infants who experienced greater reactivity to pain during their NICU admission also scored higher on the ECBQ. The researchers concluded that toddlers exposed to repeated painful stimuli as premature newborns had behavioral responses indicating more stressful reactions to early childhood experiences.


Grunau et al. (2009) looked at the relationship between multiple painful (skin breaking) procedures among term and preterm infants, comparing later cognitive, behavior, and motor abilities. This longitudinal study recruited 211 newborns (137 preterm and 74 full-term) for evaluation at 8 and 18 months. During both the 8- and 18-month evaluation, infants and toddlers were given standardized tests to evaluate cognitive, language, psychomotor, and gross motor development. Results established that both preterm and term infants who experienced higher number of skin breaking procedures during the neonatal period also exhibited lower levels of cognitive and motor development as toddlers.


Guidelines and Standards

The Joint Commission requires pain assessment and management of pain for all patients, including neonates (Phillips, 2000). Thus, neonatal pain guidelines and organizational standards have been created to promote both the assessment and management of acute neonatal pain. The AAP (2006) has issued recommendations regarding neonatal pain assessment and management, which clearly advocate for the implementation of special care protocols for neonates undergoing acute painful procedures. These care protocols include the active use of nonpharmacologic approaches to prevent neonatal pain through methods such as nonnutritive suckling (NNS), kangaroo care (KC), oral sucrose administration, and swaddling.


Literature on Nonpharmacologic Pain Relief

Numerous studies have documented effective nonpharmacologic methods of pain prevention for neonates undergoing routine procedures, and summarized here according to the method. Despite the plethora of studies, nonpharmacologic pain reduction remedies such as these proven methods have not been effectively used for routine heel lancing in clinical practice (Simons et al., 2003). Sharek, Powers, Koehn, and Anand (2006) reported that very few (16%) of the 211 newborns in their study at 12 hospitals received any form of nonpharmacologic analgesia during routine heel lancing. Researchers offered multiple explanations for this finding, including a lack of knowledge among staff regarding evidence-based neonatal pain protocols as well as difficulty in getting staff to "buy in" to a new policy.


In a follow-up study subsequent to implementing a large-scale neonatal pain management protocol (oral sucrose administration), Dunbar et al. (2006) reported improvements in nonpharmacologic acute pain management. Specifically 65% of the newborns in whom the new protocols were implemented received sucrose analgesia before heel lancing. Improvements were attributed to intensive local implementation efforts. Compliance was best in units with larger and diverse support teams, when staff were involved early in the planning for change, and when strategies such as preprinted routine sucrose orders were used (Dunbar et al., 2006).


Nonnutritive Sucking and Pain Relief

NNS has been reported as a valuable analgesic for acute painful procedures in neonates in several studies. Bo and Callaghan (2000) studied 27 preterm neonates experiencing multiple heel lance procedures. Each infant received one of four interventions for pain relief: NNS, music therapy, combined NNS and music therapy, or no intervention during subsequent heel lance procedures. NNS combined with music therapy had the most convincing analgesic effects (p < .001). However, infants in the NNS alone group did exhibit significantly decreased pain responses compared to no intervention (p < .001).


Carbajal, Chauvet, Couderc, and Olivier-Martin (1999) studied 150 term neonates experiencing venipuncture. Each infant was randomly assigned to one of six groups: no treatment (n = 25), placebo (n = 25), pacifier (n = 25), 2 mL 30% glucose (n = 25), 2 mL 30% sucrose (n = 25), and 2 mL sucrose combined with sucking on a pacifier (n = 25). Infants in the NNS alone group had significant reduction in pain (p < .001). However, combining NNS with oral sucrose had a synergistic effect as this group demonstrated the lowest pain response (p < .0001). Im, Kim, Park, Sung, and Oh (2008) studied 99 term neonates comparing NNS (n = 33), maternal touch (n = 33), and no intervention (n = 33). Although infants in both the NNS and maternal touch groups had significantly lower NIPS scores (p < .001), NNS proved to be more beneficial at relieving acute pain in neonates than maternal touch alone (p < .009).


Oral Sucrose and Pain Relief

Oral sucrose administration has been extensively studied in both preterm and term neonates and has been found to be an effective means of acute pain control for infants experiencing heel lancing (Stevens, Yamada, & Ohlsson., 2010). A Cochrane review on the topic (Stevens et al., 2010) included 44 randomized controlled trials and 3,496 infants, and found that oral sucrose administration for pain associated with heel lancing significantly reduced neonatal pain responses to routine procedural pain. Greenberg (2002) studied 84 full-term infants (>17 hours of age) who received a routine heel lance procedure. These infants were randomized into four groups: water-moistened pacifier, sugarcoated pacifier, oral sucrose solution, and no intervention. Oral sucrose demonstrated significant pain reduction for these infants; however, the group receiving the sugarcoated pacifier did experience the least amount of pain. Mathai, Natrajan, and Rajalakshmi (2006) studied 104 term neonates at 24 hours of life who were undergoing routine heel lance procedures and randomly assigned them to receive one of six interventions: expressed breast milk (n = 18), sucrose (n = 17), distilled water (n = 15), NNS (n = 18), massaging (n = 17), and rocking (n = 17). Again infants receiving oral sucrose and NNS experienced significantly reduced pain (p < .001). Some researchers have looked at whether sucrose as a single intervention is beneficial. Carbajal et al. (1999) reported that sucrose alone administered with a sterile syringe reduced pain among term infants experiencing venipuncture procedures when compared with placebo.


In contrast to previous reports, Taddio et al. (2008) found that oral sucrose administration was ineffective at treating acute pain in term neonates undergoing routine heel lance procedures. By design this study limited painful procedures to term neonates less than 12 hours of age. The researchers attributed their findings to a young postnatal age, concluding that oral sucrose administration may be more effective in older neonates than in younger neonates.


Breastfeeding and Pain Relief

Breastfeeding also seems to be an effective method of pain reduction for term neonates. Leite et al. (2009) studied full-term neonates who were breastfed during metabolic screening and found that breastfeeding significantly reduced neonatal pain across all outcome measures. When breastfeeding was compared with oral sucrose administration, breastfeeding was found to be a superior analgesic for term neonates undergoing heel lance procedures (Codipietro, Ceccarelli, & Ponzone, 2008). In a Cochrane review, Shah, Aliwalas, and Shah (2006) included 11 studies examining the effects of breastfeeding or breast milk on acute procedural pain; breastfeeding was also found to be a significant analgesic for this type of pain.


Carbajal, Veerapen, Courdec, Jugie, and Ville (2003) studied 180 full-term neonates during a routine venipuncture procedure. Infants were randomly assigned one of four groups: breastfeeding (n = 44), held by their mother (n = 45), 1 mL of sterile water orally (n = 45), or 30% sucrose followed by NNS (n = 45). Both breastfeeding and oral sucrose combined followed by NNS proved to significantly reduce infant pain responses (p < .0001).


Gray, Miller, Phillip, and Blass (2002) examined 30 infants comparing breastfeeding (n = 15) versus swaddling (n = 15) during a routine heel lance procedure. Infants assigned to the breastfeeding group experienced significantly decreased crying and grimacing (p = .001) and 11 of the 15 breastfed infants did not cry at all during the procedure. Uga et al. (2008) studied 200 full-term infants to determine the analgesic effect of breastfeeding during a routine heel lance procedure. Infants in the experimental group (n = 100) breastfed during the procedure, and caressing and/or NNS was used to manage pain in the control group (n = 100). This study concluded that infants who breastfeed during the heel lance procedure experienced significantly less pain compared to caressing and/or NNS (p < .001).


Kangaroo Care and Pain Relief

Likewise, KC has been shown to be an effective analgesic; it has been studied more extensively in stable preterm neonates than in full-term neonates. Kashaninia, Sajedi, Rahgozar, and Noghabi (2008) studied 100 full-term infant pain responses while receiving a vitamin K injection. Infants were randomized to either receive KC for 10 minutes (n = 50) or remain in a quiet room (n = 50) in the nursery during the procedure. NIPS scores were significantly reduced among the infants receiving KC (p < .001). Gray, Watt, and Blass (2000) studied 30 full-term infants undergoing routine heel lance procedures who had been randomized to receive either KC or swaddling during the procedure. KC significantly reduced crying by 82% and grimacing by 65%.


However, other studies have had different results. Castral et al. (2009) performed a meta-analysis to determine the effect of KC as an analgesic for both preterm and term infants undergoing acute painful procedures. Six of the 12 studies included compared KC to open crib, two studies compared KC to swaddling, and one study compared oral glucose to KC. None of the studies compared breastfeeding or NNS to KC. All 12 studies reported a significant reduction in pain, although these results were based mainly on behavioral responses to pain such as grimacing and crying. The increases in heart rate variations often associated with infant pain responses varied a great deal across all studies. Although more studies are needed to determine the magnitude of KC as an analgesic, KC does seem to be an effective analgesic for acute painful procedures among infants, and it is a readily available intervention that is easy to initiate on any nursing unit.


Swaddling and Pain Relief

Swaddling alone has also been shown to decrease pain perception in preterm neonates; however, there are few studies evaluating swaddling in term neonates (Yamada et al., 2008). Huang, Tung, Kuo, and Ying-Ju (2004) studied 32 preterm infants in which each subject was randomly assigned to receive either swaddling or facilitated tucking as an intervention to pain from a routine heel lance procedure. Infant heart rates recovered significantly sooner following the heel lance procedure in the swaddling group (p < .05). Prasopkittikun and Tilokskulchai (2003) included four studies comprising 108 infants for a meta-analysis of swaddling. Swaddling both term and preterm infants was found to be moderate to highly effective at reducing pain infants experienced from heel lance procedures.


Why Is Pain Relief Not Offered Routinely for Heel Lancing?

Why are proven nonpharmacologic methods of neonatal pain control in term neonates (such as breastfeeding and sucrose administration) not always used in clinical practice? One reason is that some of the methods are not always practical because of feeding preferences or facility protocols. For example, a substantial number of infants are not breastfed (Gartner et al., 2005). In addition, in many institutions, nurses are required to obtain an order for sucrose administration, which then makes that intervention a timely and cumbersome one to administer (Lefrak et al., 2006). KC, although shown to be effective, requires that the infant and mother be together during the heel lance, a situation that is not always possible.


Resistance to change has also been cited as a potential barrier to implementing nonpharmacologic pain protocols. Byrd, Gonzales, and Parsons (2009) surveyed 102 NICU nurses to determine perceived barriers to pain management. Nearly 40% of the nurses surveyed indicated that it was generally difficult to initiate change on their unit. The majority of respondents stated that more registered nurses resisted change as compared to physicians. Other barriers identified in this survey included a lack of knowledge regarding evidence-based nonpharmacologic practices among both nurses and physicians. In addition, organizational barriers to sucrose administration exist in the literature (Lefrak et al., 2006). These issues include a lack of an agreed-upon oral sucrose protocol as well as which hospital division will control the dispensing of and charges for the mixture. These barriers can be overcome, however, as shown by Thompson (2005) who demonstrated that after one large tertiary (348 bed) NICU implemented an evidence-based protocol, usage of oral sucrose as an analgesic increased four-fold. We also know that convenient access to oral sucrose significantly influences successful implementation. In Dunbar et al's study (2006) of 12 hospitals participating to improve the management of pain in newborns, several successful interventions were described. One successful model involved hospital pharmacies being responsible for dispensing sucrose along with a physician order being required to obtain it. In one hospital, oral sucrose was made more available by having the dietary department dispense the mixture. Each of the 12 participating facilities also included sucrose on the preprinted admission orders increasing the use of oral sucrose as an analgesic for routine laboratory draws from 8% to 65% (p < .001) (Dunbar et al., 2006).


This Study

It is important that nurses do their best to reduce pain for neonates experiencing heel lancing. Because the evidence for nonpharmacologic pain relief during heel lancing has been varied, nurses need to not only review the literature on the topic but also conduct scholarly studies at their institutions. Evaluating alternative methods of nonpharmacologic neonatal pain control supports the identification of practical and accessible techniques that nurses can incorporate into their practice. Although a number of studies have described promising nonpharmacologic acute pain control in neonates, we do not know whether every technique works for every neonate. In addition, it is essential that nurses study interventions that are easy to implement and that do not require much from the institution in terms of financial charges or additional physician orders. Comparatively little research has been done about the effectiveness of swaddling term neonates who are undergoing painful procedures, and thus this method was chosen as the subject of our nursing research.


As cited in some literature, the pain related with heel lancing is closely associated with squeezing of the heel rather than breaking of the skin via the heel prick (Grunau et al., 1998; Shepherd et al., 2006). In addition, although we found no studies specifically about the effects of holding the infant in an upright position during heel lancing, we hypothesized that such upright holding may facilitate blood flow by gravity, thus decreasing the amount of squeezing required to obtain the sample. We also predicted that containment by swaddling the infant would provide a comfort measure during the procedure. Therefore, we were interested in finding out whether upright positioning would decrease the amount of time that the infant's heel would need to be squeezed to obtain the appropriate amount of blood for the specimen, and whether this plus swaddling could reduce pain during routine heel lance procedures.


Study Design and Methods


We calculated that a sample size of 40 subjects would achieve 80% power to detect two-tailed significance level of 0.05. Following approval from the institutional review board, 42 newborn term infants who were >=37 weeks gestational age, clinically stable and who qualified for a total serum bilirubin (TSB) procedure were recruited from the normal newborn nursery. All of the 42 recruited infants completed the study that took place at a large tertiary hospital serving a major metropolitan area between February and April 2008. The obstetrical unit handles approximately 6,300 births per year. All infants in this facility undergo an objective measurement for hyperbilirubinemia as recommended by national guidelines (AAP, 2004). Initially each infant is assessed with a noninvasive instrument also known as a transcutaneous bili (TcB) meter. Because TSB evaluation is currently considered the gold standard for diagnosing hyperbilirubinemia in neonates, infants scoring in the high-intermediate or high-risk zone by TcB measurement subsequently receive a TSB evaluation (AAP, 2004). Consequently, TSB testing is a standard procedure for study participants. For this reason the researchers chose neonates who were undergoing TSB testing because these neonates were going to have the procedure regardless of pain reduction interventions and nurses routinely obtain these samples. This study excluded infants who were admitted to the NICU, neonates born to diabetic mothers, those previously diagnosed with hyperbilirubinemia, as well as infants with other medical complications.



Pain was measured using the Neonatal Inventory Pain Scale (NIPS) at two points in time for each group (just before the heel lance and at the completion of the heel lance). The researchers chose NIPS because it was the standardized instrument already being used by the nursing staff, and both reliability and validity had been previously established. The original NIPS research was done on both term and preterm infants, and the scale is composed of six behavioral groupings intended to assess infant pain (Lawrence et al., 1993). Behavioral groupings include facial expression, cry, breathing patterns, arms, legs, and state of arousal. Each behavioral response (e.g., breathing patterns) is given an operational definition provided on the backside of the scoring instrument as a reference. Each behavior (except cry) has descriptors for the two possible scores of 0 and 1. Cry has three descriptors for a possible maximum score of 2 (0 = no cry, 1 = whimper, 2 = vigorous cry). The instrument lists time periods and allows scoring at 1-minute intervals before, during, and after a procedure with a total possible score of 0 to 7, with lower scores indicating more relaxation and less pain. Concurrent validity ranged from 0.53 to 0.84 between NIPS scores at each interval. Interrater reliability ranged from 0.92 to 0.97 and was statistically significant, p < .05 using a Pearson correlation (Lawrence et al., 1993). According to Lawrence et al., a NIPS of 4.8 +/- 2.5 can be expected during painful procedures. A decrease of 2 points was anticipated for the experimental group in this study.



Neonates were randomly assigned to either the experimental (n = 22) or the control groups (n = 20) by the last digit of their medical record number. The purpose of the study was explained to parents, and informed consent was obtained from the mother by the researcher. Testing was done in the newborn nursery when infants were subjected to heel lancing for the TSB procedure. Six registered nurses working in the nursery were the only nurses who performed the heel sticks and assessed pain levels. Each of these nurses was trained on infant positioning, swaddling, holding, and NIPS scoring. Infants in the control group were placed in a standard position (supine while lying inside a crib) during sample collection. The crib was elevated 30[degrees] angle and one leg was elevated during the heel lance procedure (Figure 1). Infants assigned to the experimental group were swaddled and held in an upright position leaving one leg exposed. Swaddled infants were held upright at a 90[degrees] angle during the procedure allowing the nursing staff to maneuver the exposed heel with the nondominant hand during sample collection (Figure 2). All six nurses individually evaluated the NIPS score while performing the procedure. NIPS scores were done both just before the procedure and at the completion of the procedure.

Figure 1 - Click to enlarge in new windowFigure 1. Heel lancing with baby in crib (control group).
Figure 2 - Click to enlarge in new windowFigure 2. Heel lancing with baby held upright and swaddled (experimental group).

Total collection time was measured at the beginning of heel squeezing for each group using a stopwatch accurate to 1/100th of a second. Specimen quality was also measured based on the number of rejected specimens for each group. SPSS 16.0 for windows was used for all data analysis. Differences between the groups were analyzed with independent t test (continuous variables). Descriptive statistics were used to analyze group characteristics.



Demographic and clinical characteristics of each group were similar (Table 1). No significant differences in behavior were found before the procedure between the groups. The overall mean NIPS score for neonates who were swaddled and held during the procedure (experimental group) was significantly lower (M = 1.3, SD = .9) than the score for infants in the standard position (control group) (M = 2.7, SD = 1.3), t (40) = -4.48, p < .001). These results suggest that infants who were swaddled and held upright really did experience less pain. Although the total collection time (heel squeezing) was lower for infants who were swaddled, it was not statistically significantly shorter. Mean collection time for swaddled infants was 2 minutes and 17 seconds (SD = 59) compared to a mean of 2 minutes and 47 seconds (SD = 85) p = .45 for the control group. None of the specimens in either group were rejected for poor specimen quality.

Table 1 - Click to enlarge in new windowTable 1. Characteristics of Each Group

Clinical Implications

Nurses can use the results of this study done with normal term infants to add to their knowledge of pain relief for heel lancing in full-term neonates, and to examine their own clinical practice. The evidence from this randomized controlled trial reported here showed that the technique of swaddling infants while holding them in an upright position was superior for pain relief during heel lance procedures when compared with a standard position technique.


Using the swaddling technique, nurses can implement the procedures in this study independent of either facility protocols or maternal feeding preferences. Because this technique can be easily implemented on any unit without associated cost or policy development, nurses may be more likely to put it into practice.


Evaluating nursing practice is essential in the development of evidence-based nursing interventions. This study is strengthened by its prospective randomized controlled design. There is much more that needs to be learned about how to reduce pain in newborns who undergo heel lancing for blood work. It would be important to study the value of swaddling for other painful procedures such as venipunctures or intramuscular injections. We also need to know more about pain relief in preterm infants, and this requires additional research. It would also be helpful to have a larger study that compares all the nonpharmacologic pain relief methods discussed in this article to see whether some work better than others in a given sample of newborns. Because this study evaluated simultaneous upright position and swaddling, it is unclear whether positioning or swaddling used would influence pain perception. This study also found that the upright position of the neonate seemed to decrease collection time (heel squeezing) by 30 seconds. It is also unclear how this finding will influence nursing practice in terms of productivity and cost, and this should be studied. Future studies with larger sample sizes may aid in determining the overall significance of this finding to nursing practice.


It has been our clinical observation that frequently serum specimens obtained by heel lancing are rejected from the laboratory because the sample is inadequate. These occurrences are not only frustrating to nurses, they may also hinder care by delaying results. Although the laboratory rejected none of the specimens from this study, it is recognized that other tests such as the complete blood count are more commonly rejected than the TSB sample. Therefore, replicating this study with a larger sample size and alternate specimens may be needed to evaluate this further.



Special thanks to Connie Harper, BSN, RNC, for coordinating training sessions and assisting with data collection.


Suggested Clinical Implications

Nurses who care for newborns should:


Collaboratively develop neonatal pain care protocols as recommended by the American Academy of Pediatrics


Routinely use nonpharmacologic methods of pain control for infants undergoing heel stick procedures


Develop specific standing orders for the use of nonpharmacologic methods of pain control (such as swaddling) for infants undergoing routine painful procedures


Consider using the following techniques for reducing neonatal pain during routine heel sticks


* Swaddling the infant while holding upright


* Do heel sticks during breastfeeding when possible


* Investigate institutional procedures for oral sucrose administration


* Kangaroo care



Become educated about current research evidence on relieving neonatal pain during routine procedures such as heel sticks.



American Academy of Pediatrics

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


Free access to neonatal pain journal articles and clinical practice guidelines for the assessment and management of neonatal pain.


National Guideline Clearinghouse


Summarizes current evidence and provides evidence-based clinical practice guidelines, including guidelines for the assessment and management of neonatal pain.


Phillips Children's Medical Ventures


Sweat-ease is manufactured by Children's Medical Ventures. Scientific information is provided about the drug, and guidelines for administration are included.




American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatrics Section on Surgery, Canadian Paediatric Society Fetus and Newborn Committee, Batton, D. G., Barrington, K. J., & Wallman, C. (2006). Prevention and management of pain in the neonate. Pediatrics, 118(5), 2231-2241. doi:10.1542/peds.2006-2277 [Context Link]


American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316. [Context Link]


Bhutani, V. K., Johnson, L. H., Jeffrey Maisels, M., Newman, T. B., Phibbs, C., Stark, A. R., & Yeargin-Allsopp, M. (2004). Kernicterus: Epidemiological strategies for its prevention through systems-based approaches. Journal of Perinatology, 24(10), 650-662. doi:10.1038/ [Context Link]


Bo, L. K., & Callaghan, P. (2000). Soothing pain-elicited distress in Chinese neonates. Pediatrics, 105(4), E49. [Context Link]


Byrd, P. J., Gonzales, I., & Parsons, V. (2009). Exploring barriers to pain management in newborn intensive care units: A pilot survey of NICU nurses. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses, 9(6), 299-306. doi:10.1097/ANC.0b013e3181c1ff9c [Context Link]


Carbajal, R., Chauvet, X., Couderc, S., & Olivier-Martin, M. (1999). Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates. BMJ (Clinical Research Ed.), 319(7222), 1393-1397. [Context Link]


Carbajal, R., Veerapen, S., Couderc, S., Jugie, M., & Ville, Y. (2003). Analgesic effect of breast feeding in term neonates: Randomised controlled trial. BMJ (Clinical Research Ed.), 326(7379), 13. [Context Link]


Castral, T. C., Warnock, F., Leite, A. M., Haas, V. J., & Scochi, C. G. (2008). The effects of skin-to-skin contact during acute pain in preterm newborns. European Journal of Pain (London, England), 12(4), 464-471. doi:10.1016/j.ejpain.2007.07.012


Codipietro, L., Ceccarelli, M., & Ponzone, A. (2008). Breastfeeding or oral sucrose solution in term neonates receiving heel lance: A randomized, controlled trial. Pediatrics, 122(3), 716-21. doi:10.1542/peds.2008-0221 [Context Link]


Dunbar, A. E., 3rd, Sharek, P. J., Mickas, N. A., Coker, K. L., Duncan, J., McLendon, D., ... Johnston, C. C. (2006). Implementation and case study results of potentially better practices to improve pain management of neonates. Pediatrics, 118(Suppl. 2), S87-94. doi:10.1542/peds.2006-0913E [Context Link]


Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., Eidelman, A. I., & American Academy of Pediatrics Section on Breastfeeding. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506. doi:10.1542/peds.2004-2491 [Context Link]


Gray, L., Miller, L. W., Philipp, B. L., & Blass, E. M. (2002). Breastfeeding is analgesic in healthy newborns. Pediatrics, 109(4), 590-593. [Context Link]


Gray, L., Watt, L., & Blass, E. M. (2000). Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 105(1), e14. [Context Link]


Greenberg, C. S. (2002). A sugar-coated pacifier reduced procedureal pain in newborns. Pediatric Nursing, 28(3), 271-277. [Context Link]


Grunau, R. E., Oberlander, T., Holsti, L., & Whitfield, M. F. (1998). Bedside application of the neonatal facial coding system in pain assessment of premature neonates. Pain, 76(3), 277-286. [Context Link]


Grunau, R. E., Whitfield, M. F., Petrie-Thomas, J., Synnes, A. R., Cepeda, I. L., Keidar, A., ... Johannesen, D. (2009). Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain, 143(1-2), 138-146. doi:10.1016/j.pain.2009.02.014 [Context Link]


Huang, C. M., Tung, W. S., Kuo, L. L., & Ying-Ju, C. (2004). Comparison of pain responses of premature infants to the heelstick between containment and swaddling. The Journal of Nursing Research: JNR, 12(1), 31-40. [Context Link]


Im, H., Kim, E., Park, E., Sung, K., & Oh, W. (2008). Pain reduction of heel stick in neonates: Yakson compared to non-nutritive sucking. Journal of Tropical Pediatrics, 54(1), 31-35. doi:10.1093/tropej/fmm083 [Context Link]


Kazmierczak, S. C., Robertson, A. F., & Briley, K. P. (2002). Comparison of hemolysis in blood samples collected using an automatic incision device and a manual lance. Archives of Pediatrics & Adolescent Medicine, 156(11), 1072-1074. [Context Link]


Kashaninia, Z., Sajedi, F., Rahgozar, M., & Noghabi, F. A. (2008). The effect of kangaroo care on behavioral responses to pain of an intramuscular injection in neonates. Journal for Specialists in Pediatric Nursing: JSPN, 13(4), 275-280. [Context Link]


Klein, V. C., Gaspardo, C. M., Martinez, F. E., Grunau, R. E., & Linhares, M. B. (2009). Pain and distress reactivity and recovery as early predictors of temperament in toddlers born preterm. Early Human Development, 85(9), 569-576. doi:10.1016/j.earlhumdev.2009.06.001 [Context Link]


Lawrence, J., Alcock, D., McGrath, P., Kay, J., MacMurray, S. B., & Dulberg, C. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 59-66. [Context Link]


Leite, A. M., Linhares, M. B., Lander, J., Castral, T. C., dos Santos, C. B., & Silvan Scochi, C. G. (2009). Effects of breastfeeding on pain relief in full-term newborns. The Clinical Journal of Pain, 25(9), 827-832. doi:10.1097/AJP.0b013e3181b51191 [Context Link]


Lefrak, L., Burch, K., Caravantes, R., Knoerlein, K., DeNolf, N., Duncan, J., ... Toczylowski, K. (2006). Sucrose analgesia: Identifying potentially better practices. Pediatrics, 118(2), S197-202. doi:10.1542/peds.2006-0913R [Context Link]


Mathai, S., Natrajan, N., & Rajalakshmi, N. R. (2006). A comparative study of nonpharmacological methods to reduce pain in neonates. Indian Pediatrics, 43(12), 1070-1075. [Context Link]


Prasopkittikun, T., & Tilokskulchai, F. (2003). Management of pain from heel stick in neonates: an analysis of research conducted in Thailand. Journal of Perinatal and Neonatal Nursing, 17(4), 304-312. [Context Link]


Phillips, D. M. (2000). JCAHO pain management standards are unveiled. Journal of the American Medical Association, 284(4), 428-429. [Context Link]


Reece, E. A., Leguizamon, G., & Wiznitzer, A. (2009). Gestational diabetes: The need for a common ground. Lancet, 373(9677), 1789-1797. doi:10.1016/S0140-6736(09)60515-8 [Context Link]


Shah, P. S., Aliwalas, L. I., & Shah, V. (2006). Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews (Online), 3, CD004950. doi:10.1002/14651858.CD004950.pub2 [Context Link]


Sharek, P. J., Powers, R., Koehn, A., & Anand, K. J. (2006). Evaluation and development of potentially better practices to improve pain management of neonates. Pediatrics, 118(Suppl. 2), S78-S86. doi:10.1542/peds.2006-0913D [Context Link]


Shepherd, A. J., Glenesk, A., Niven, C. A., & Mackenzie, J. (2006). A Scottish study of heel-prick blood sampling in newborn babies. Midwifery, 22(2), 158-168. doi:10.1016/j.midw.2005.07.002 [Context Link]


Simons, S. H., van Dijk, M., Anand, K. S., Roofthooft, D., van Lingen, R. A., & Tibboel, D. (2003). Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Archives of Pediatrics & Adolescent Medicine, 157(11), 1058-1064. doi:10.1001/archpedi.157.11.1058 [Context Link]


Stevens, B., Yamada, J., & Ohlsson, A. (2010). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews (Online), (1), CD001069. doi:10.1002/14651858.CD001069.pub3 [Context Link]


Taddio, A., Shah, V., Hancock, R., Smith, R. W., Stephens, D., Atenafu, E., Beyene, J., Koren, G., Stevens, B., & Katz, J. (2008). Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures. Canadian Medical Association Journal, 179(1), 37-43. doi:10.1503/cmaj.071734 [Context Link]


Taddio, A., Shah, V., Atenafu, E., & Katz, J. (2009). Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants. PAIN, 144(1-2), 43-48. doi:10.1503/cmaj.071734 [Context Link]


Thompson, D. G. (2005). Utilizing an oral sucrose solution to minimize neonatal pain. Journal for Specialists in Pediatric Nursing: JSPN, 10(1), 3-10. doi:10.1111/j.1539-0136.2005.00002.x [Context Link]


Uga, E., Candriella, M., Perino, A., Alloni, V., Angilella, G., Trada, M., ... Provera, S. (2008). Heel lance in newborn during breastfeeding: An evaluation of analgesic effect of this procedure. Italian Journal of Pediatrics, 34(1), 3. doi:10.1186/1824-7288-34-3 [Context Link]


Vertanen, H., Fellman, V., Brommels, M., & Viinikka, L. (2001). An automatic incision device for obtaining blood samples from the heels of preterm infants causes less damage than a conventional manual lancet. Archives of Disease in Childhood.Fetal and Neonatal Edition, 84(1), F53-5. [Context Link]


Yamada, J., Stinson, J., Lamba, J., Dickson, A., McGrath, P. J., & Stevens, B. (2008). A review of systematic reviews on pain interventions in hospitalized infants. Pain Research & Management, 13(5), 413-420. [Context Link]