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Heel blood sampling in European neonatal intensive care units: compliance with pain management guidelines
  1. Valentina Losacco1,
  2. Marina Cuttini1,
  3. Gorm Greisen2,
  4. Dominique Haumont3,
  5. Carmen R Pallás-Alonso4,
  6. Veronique Pierrat5,
  7. Inga Warren6,
  8. Bert J Smit7,
  9. Björn Westrup8,
  10. Jacques Sizun for the ESF Network9
  1. 1Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Rome, Italy
  2. 2Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
  3. 3Department of Neonatology, Saint-Pierre University Hospital, Free University of Brussels, Brussels, Belgium
  4. 4Department of Neonatology-SAMID, 12 de Octubre University Hospital, Madrid, Spain
  5. 5Service de Médecine Néonatale, Hôpital Jeanne de Flandre, Lille Cedex, France
  6. 6Winnicott Baby Unit, Imperial College Health Care, National Health Service Trust, London, UK
  7. 7Department of Neonatology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
  8. 8Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
  9. 9Woman, Mother and Child Department, Centre Hospitalier Universitaire, Brest, France
  1. Correspondence to Marina Cuttini, Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, 00156 Roma, Italy; marina.cuttini{at}


Objective To describe the use of heel blood sampling and non-pharmacological analgesia in a large representative sample of neonatal intensive care units (NICUs) in eight European countries, and compare their self-reported practices with evidence-based recommendations.

Methods Information on use of heel blood sampling and associated procedures (oral sweet solutions, non-nutritive sucking, swaddling or positioning, topical anaesthetics and heel warming) were collected through a structured mail questionnaire. 284 NICUs (78% response rate) participated, but only 175 with ≥50 very low birth weight admissions per year were included in this analysis.

Results Use of heel blood sampling appeared widespread. Most units in the Netherlands, UK, Denmark, Sweden and France predominantly adopted mechanical devices, while manual lance was still in use in the other countries. The two Scandinavian countries and France were the most likely, and Belgium and Spain the least likely to employ recommended combinations of evidence-based pain management measures.

Conclusions Heel puncture is a common procedure in preterm neonates, but pain appears inadequately treated in many units and countries. Better compliance with published guidelines is needed for clinical and ethical reasons.

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  • ESF Network C Amiel-Tison, France; JV Browne, USA; M Cuttini, Italy; G Greisen, Denmark; D Haumont, Belgium; PS Hűppi, Switzerland; H Lagercrantz, Sweden; K Stjernqvist, Sweden; Warren, UK. ESF Officers: C Moquin-Pattey, M Minkowsky and B Schaller.

  • Funding This study was funded by the European Science Foundation Network on Research on Early Developmental Care for Extremely Premature Babies in neonatal intensive care units ( and by the Ospedale Pediatrico Bambino Gesù of Roma, Italy (Grant no. OPBG 200580X001247).

  • Competing interests None.

  • Ethics approval As this study was carried out on units' policies, and not on human subjects, requirements for informed consent and Ethics Committee approval do not apply.

  • Provenance and peer review Not commissioned; externally peer reviewed.