Venepuncture versus heel lance for blood sampling in term neonates

Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice.

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.

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.

We included randomized controlled trials (RCTs) and quasi-RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet-tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non-specific arousal.

Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture.

We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs.

We conducted a meta-analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome.

We included eight studies with 826 neonates. The studies were performed in six high-, upper-middle, or low-income countries.

We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet-tasting solution) Pain scores Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet-tasting solution is administered (SMD -1.34, 95% CI -1.55 to -1.14; I² = 94%; 6 studies, 488 participants; moderate-certainty evidence). Need for more than one skin puncture Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate-certainty evidence) Venepuncture compared to heel lance (with sweet-tasting solution) Pain scores Venepuncture may reduce pain compared to heel lance during the procedure when a sweet-tasting solution is administered (SMD -0.38, 95% CI -0.69 to -0.07; I² = 79%; 3 studies, 170 participants; low-certainty evidence). Need for more than one skin puncture The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet-tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low-certainty evidence). This is due to the small number of participants in each group.

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.

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.

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.