The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
VERY IMPORTANT! - This web page is not to be taken as dispensing medical information. If you have questions about the newborn screen, you should talk with your baby's healthcare provider or representatives of your state's Newborn Screening Program.
Reading further in this page constitutes your agreement to indemnify and hold harmless the author, editor, and host website for any claim resulting from information you read here.
In particular, representatives of a group calling themselves "Save Babies Through Screening Foundation, Inc." have told me that the current guidelines for newborn screening in the state of California could result in the deaths of babies because the screening is too late to save the lives of babies with the most severe form of galactosemia and too early to detect hypothyroidism, which could cause brain damage and death. If you are concerned about this, I encourage you to call them Toll Free: 1-888-454-3383. Be sure to ask them whether it makes sense for you to have your baby's first newborn screen be done from cord blood, so that galactosemia may be detected as early as possible. Later testing would then detect the conditions which are not reliably detectable from cord blood.
This page remains here as a historical record and as a basis for further
discussion among healthcare providers.
Here is the California booklet, Important
Information for Parents about the Newborn Screening Test.
If this brutal heelstick were truly necessary, our society could justify the short-term trauma with long-term health benefits. However, it doesn't take much thinking to realize that the primitive heelstick hasn't changed in some thirty-odd years, and there's got to be a better way. Scientists can clone farm animals and send humans into space, but we're still slicing and dicing newborns' heels to test their blood for various very rare metabolic problems. Medicine has already developed tests to assess the newborn's blood for glucose levels and signs of infection with a much smaller amount of blood. Why are we still having to slice a baby's heel open and milk the baby's leg to fill five one-inch circles with baby's blood? [The alternative to milking the leg is to use a scalpel to create such a long incision that it bleeds freely. This incision is relatively painless, and the technician doesn't need to milk the baby's leg in a painful way, but the incision is the equivalent of a two-inch long incision on an adult's heel. After seeing this technique performed, I was wondering when they were going to suture the cut. This has got to be painful in healing. Other practitioners use the scalpel to create a deep puncture wound that can actually cause longterm bone or nerve damage.]
I'm not sure, but I suspect that much of the reason we're still using primitive technology is that the Newborn Screen Programs are generally state run and so lack funds for research and development of more humane techniques. Some soft-hearted doctors have invented heel-slicing devices that are somewhat more humane - they use a small spring-loaded scalpel to slice the surface rather than a lancet to puncture the tissue; this is less painful and causes less physical and emotional trauma.
But the basic question is why our technology can't perform the newborn screen with a much smaller amount of blood. We can send vicious criminals to the gas chamber on a single drop of blood - why can't we do better than this for the most fragile and precious members of our society?
I include this opinion piece here to try to start some intelligent dialogue among parents and care providers. Let's find a better way for our babies!
[As an interesting aside, you'll hear many healthcare professionals
downplay the pain to the baby of having a heelstick done - these are often
people who don't actually perform the procedure themselves, but that's
beside the point. However, once transcutaneous methods become available,
suddenly everyone proclaims that heelsticks are actually painful for the
baby. See the BiliCheck
or breast milk for procedural pain in neonates.
Shah PS, Aliwalas LI, Shah V.
Cochrane Database Syst Rev. 2006 Jul 19;3:CD004950.
AUTHORS' CONCLUSIONS: If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure compared to placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for repeated painful procedures is not established and further research is needed. These studies should include various control interventions including glucose/ sucrose and should target preterm neonates.
NOTE - I find that having the baby suck on a pinkie in a STERILE glove
does a good job of calming the baby. There's an acupressure point
in the roof of the mouth that generates endorphins.
for newborn screening: developing a national framework.
Pediatrics. 2005 Oct;116(4):862-71.
"Despite the scope of these programs, the evidence base for a number
of NBS applications remains relatively weak."
Faithful challenge newborn
blood test laws - Parents argue state-mandated screenings violate religious
competencies essential for health care professionals in primary care.
Engstrom JL, Sefton MG, Matheson JK, Healy KM.
J Midwifery Womens Health. 2005 May-Jun;50(3):177-83.
This article reviews newborn screening tests for genetic and metabolic
disorders, explores the impact of the tests on the family, and discusses
implications for clinicians.
NEWBORN SCREENING REPORT ADDRESSES INCONSISTENCIES AND CONTROVERSIES (from the AAP) - This report addresses inconsistencies across state screening programs; tests are available for about 30 inherited diseases, but few states require newborn screening for them all. This report also addresses issues of outdated technology and informed consent.
Newborn Screen Table - a list of the different tests done in each state
Discussion of the Newborn Screen for California Please note that
the state of California states that blood collected in capillary tubes
or from IV lines may yield unreliable newborn screen results.
ACADEMY OF PEDIATRICS - Newborn Screening Fact Sheets (RE9632), including
a chart of which states
test for which diseases.
Screening for Metabolic Disorders from Neonatology
on the Web
Recessive diseases may hide in families for generations, never exhibited until the "right" (wrong) partner comes along. A negative family history and several healthy children is not a guarantee of protection. Add the fact that genetic mutations can crop up and a family with no history of disease suddenly can find itself with a sick member.
Some families will look at the raw numbers and decide the odds are steep enough to forego screening. But I would hate to see them rely on their number of previous healthy children.
Science 10 April 2009:
Vol. 324. no. 5924, pp. 166 - 168
Prev | Table of Contents | Next
NEWBORN BLOOD COLLECTIONS:
Science Gold Mine, Ethical Minefield
Health agencies launched a system 40 years ago to identify babies at risk. Now there are millions of blood samples in files that researchers want to access, raising public concern.
NEWBORN BLOOD COLLECTIONS: Science Gold Mine, Ethical Minefield by Jennifer Couzin-Frankel [You can purchase the article or listen to the free podcast.]
Science 10 April 2009:
Vol. 324. no. 5924, pp. 166 - 168
Health agencies launched a system 40 years ago to identify babies at
risk. Now there are millions of blood samples in files that researchers
want to access, raising public concern.
lancing in term new-born infants: an evaluation of pain by frequency domain
analysis of heart rate variability.
Lindh V, Wiklund U, Hakansson S.
Pain. 1999 Mar;80(1-2):143-8.
In conclusion, the squeezing of the heel is the most stressful event
during the heel prick procedure.
Contact Reduces Pain And Anxiety In Newborns - full text "
Expands Program to Screen Newborns for Additional Disorders - On July
11, 2005 the Genetic Disease Branch (GDB) expanded the newborn screening
program to include congenital adrenal hyperplasia, and disorders detectable
via Tandem Mass Spectrometry (MS/MS).
Expanded Screening/Supplemental Testing
Private Sources for newborn MS/MS screening:
1-800-533-1710 (URL isn't working?)
Expands Program to Screen Newborns for Additional Disorders - On July
11, 2005 the Genetic Disease Branch (GDB) expanded the newborn screening
program to include congenital adrenal hyperplasia, and disorders detectable
via Tandem Mass Spectrometry (MS/MS).
New technologies allow for the screening of more disorders and/or the
screening of the basic set from a smaller blood sample. Here's some
information from PerkinElmer
Genetics (formerly Pediatrix Screening, Inc. and Neo Gen Screening).
Their StepOne® can identify a child's risk for more than 50 disorders
of body chemistry.
attitudes toward expanding newborn screening.
Acharya K, Ackerman PD, Ross LF.
Pediatrics. 2005 Oct;116(4):e476-84.
"For each condition, 8% to 41% of physicians would personally choose to test their own infant."
CONCLUSIONS: Most physicians support diagnostic genetic testing of high-risk
children but are less supportive of expanding newborn screening, particularly
for conditions that do not meet the Wilson and Jungner criteria.
STUDY ASSESSES EFFECTS OF EXPANDED NEWBORN SCREENING
"Despite expanded newborn screening's apparent positive impact on the health and well-being of infants with metabolic disorders and their families, questions remain," state the authors of an article published in the November 19, 2003, issue of JAMA, The Journal of the American Medical Association. Many states are now using tandem mass spectrometry, a new procedure that screens for many disorders with a single evaluation, to expand mandated newborn screening. The study described in this article was designed to assess the effects of expanded screening for biochemical genetic disorders on child outcomes and parental stress. The study compared newborn identification by expanded screening with clinical identification. The study also assessed the impact on parents of a false-positive screening result (compared with a normal result) in the expanded newborn screening program.
The study drew from a cohort of children who were identified as having any of 20 biochemical genetic disorders between February 1999 and June 2002, and who were evaluated by December 2002. The sample included 50 affected children identified by the New England Newborn Screening Program in Massachusetts and Maine or by a private screening lab in Pennsylvania and 33 affected children identified clinically from any New England state. In addition, 94 children who had a false-positive result in the expanded newborn screening program and 81 unaffected children who had normal newborn screening results were enrolled. The children received a standard medical examination. Their medical records were obtained, and measures of child functioning were assessed. A total of 254 mothers and 153 fathers were interviewed and completed the Parenting Stress Index (PSI).
The authors found that
* Twenty-eight percent of children identified by newborn screening required
hospitalization at least once within the first 6 months of life, vs. 55%
* One child identified by newborn screening functioned in the range of mental retardation, vs. 8 children identified clinically.
* Mothers of children identified by newborn screening reported significantly lower overall stress on the PSI than mothers of children identified clinically; however, fathers of children identified by newborn screening and fathers of children identified clinically reported similar overall stress levels.
* Twenty-one percent of children in the false-positive group were hospitalized, vs. 10% in the comparison group.
* The PSI scores of mothers in the false-positive group were significantly higher than those of mothers in the comparison group; mothers in the false-positive group also scored higher on the parent-child dysfunction subscale than mothers in the comparison group.
"This study highlights some of the challenges to current newborn screening practices," the authors conclude. The findings demonstrate the need to educate parents about newborn screening before the birth of their child and the need to educate primary care and other health professionals about metabolic disorders.
Waisbren S, Albers S, Amata S, et al. 2003. Effect of expanded newborn
screening for biochemical genetic disorders on child outcomes and parental
stress. JAMA, The Journal of the American Medical Association 290(19):2564-2572.
Some Progress!!! "MS/MS can reliably analyze approximately 20 metabolites in one short-duration run (i.e., ~2 minutes) and provide a comprehensive assessment from a single blood-spot specimen."
Using Tandem Mass Spectrometry for Metabolic Disease Screening Among Newborns A Report of a Work Group
Synopses of Selected Papers Presented at the Tandem Mass Spectrometry for
Metabolic Disease Screening Among Newborns Workshop, San Antonio, Texas,
We took the opportunity to send some of the blood for typing, so we
already know her group if ever she needs a transfusion. [Ed.: Blood typing
can be done very easily at the birth by drawing blood from the umbilical
cord and/or placenta, even after the placenta is separated from the baby.]
Absolutely everything that happens to a newborn is putting something into its emotional system that will indeed last a lifetime. The studies done on circumcision pain show that severe pain in a baby's first days does have long-term consequences, and they're bad. This is important to remember when you're trying to assess the balance of risks and benefits of any procedure done to the newborn. Fortunately, babies cry to let us know clearly when they're in pain.
In the U.S., the hospital routine is to do the NBS just before the baby is discharged. This tends to be at around 36 hours, and this timing is pessimal - the baby tends to be very dehydrated, so it can take quite a long time of stabbing the baby (up to a half hour) in order to get the necessary blood samples. Nursing often isn't yet well established, so it can't always comfort the baby, and the trauma of a half-hour of torture can disrupt the beginnings of a good breastfeeding relationship.
In addition, when done at 36 hours, there's still a fairly high false negative rate for congenital hypothyroidism (6-12%).
All of this is to say that the timing of the NBS is critical.
Having done and seen too many traumatic heelsticks at 36 hours, it's clear to me that the very small benenfit isn't worth the certain trauma to the baby's psyche and the breastfeeding relationship. In addition, the false sense of security from a negative result may cause the parents and the midwife to discount early signs of hypothyroidism that was missed by the test.
And . . . this balance shifts dramatically when the NBS is done at 6 days . . . the optimal time in terms of accuracy. Many midwives do offer good evidence-based care in this regard, and they wait until the baby is about a week old.
But sometimes homeborn babies are transported to the hospital or taken to see the pediatrician before 6 days, and there can be a lot of pressure from the state to get a newborn screen done before the baby leaves their clutches.
I agree that there is value in doing the newborn screen when the trauma can be minimized and the accuracy maximized.
It's great to have the baby's blood type, and this can also be gotten
from cord blood. Actually, cord blood will also detect the most severe
cases of PKU, but it will miss the milder cases. Then again, breasted babies
receive such low levels of phenylalanine in the breastmilk that milder
cases of PKU may not be detected if the baby is already getting mature
breastmilk. The issues are complicated.
I would say the info from the hospital is wrong. Most of the new tests
are accurate after 24 hours, they are testing the marker differently now.
But the test is now independent of feeds. I would ask the actual lab doing
the tests what they are using etc. as it probably differs somewhat from
state to state etc. Information like that will just convince people they
should formula supplement in the early days.
If this is so, why does my state require two tests? The state officials told me it is because the first test done at the hospital at 24 hours is not accurate and that a second test is very important. The guidelines for the home birth babies is a first test at a week and a second test at 4-6 weeks old. The state actually seems happy that we wait a week for the first test and never give any of the parents who refuse the second test a problem....unlike the hospital babies who they follow through with until the second test is done.
The lab that does our testing is in Oregon, and I believe it is the
western regional testing site....and all they do is metabolic screening
Ok, so now I feel like I'm really off the mark. We have always told
moms that the reason for waiting to do a PKU was because the milk had to
be in and the baby on protein >24h. Now I read the following. I read this
post (below) on the perinatal nursing list. So what is the right answer?
concerning a discussion on PKU testing:
Actually, I don't do them at all right now since I'm not working yet
since the move. [GRIN] But at my last facility, we were told by the CA
Dept. of Health, whichever bureau was responsible for the newborn screening,
that they can be accurate as soon as 6 hrs. after delivery, as long as
the baby has had a breast or bottle feed to receive protein. (And yes,
colostrum is highly concentrated protein, despite the fact that a lot of
our staff did not think it sufficient.) Our neonatologists and pediatricians
struggled with that one, though, even after a good lit search was done
that seemed to back up the health dept. guidelines. So we compromised and
did them just prior to discharge-- anywhere between 12 and 24 hrs. I don't
have the citations now, since moving, but I was convinced.
The book I have "The Wisconsin Health Care Professionals' Guide to Newborn Screening" says that the following tests may be affected by timing:
It was a while back but i found myself one morning facing a whole board
of medical "experts" who had gathered to examine the state newborn screening
program. I thought i had been invited to talk to a woman Carol Walters
who was director of genetic screening and the program coordinator for Newborn
Screening Program(she liked homebirth and me). I walked in the room-had
been called to take the place of another midwife who was at a birth and
there i was at round table of 15 to 20 medical practitioners/pediatricians/neonatologist
etc. all meeting concerning the re-organization of the newborn screening
of the state!!!
I spoke with the director of medical genetics and the newborn screening laboratory for Childrens Hospital of the University of Pittsburgh Medical center. Dr Jan Bruck. I spoke at length with her about newborn screen and performing PKUs. So the good news is that was correct that PKU's can be done on cord blood!!!!!! Now let me qualify that. PKUs done on cord blood will miss a very rare PKU baby/the more mild case. So The Newborn screen dept suggests that for parents who do not want to do a heel stick on the babe that a safe and non-traumatic way to screen adequately is to use cord blood directly onto the card. A severely affected infant will show positive for PKU with cord blood, the cord blood PKU card should then be followed by a PKU urine test at 4 to 6 weeks. Dr. Burke assured me that then you would catch the otherwise milder case of PKU that may not be picked up by cord blood. Now another possible scenario she mentioned is that the mothers blood could also be drawn at birth and fill a separate card with. You would then need to ask the lab for numerical values for the assay on the PKU. Should the babies numerical value exceed the mothers even if they are within normal limits this would be suspicious. And another PKU test should be done. This would not seem to be the choice of practice since Dr. Burke seemed to think that the cord blood test combined with PKU urine test at 4 to 6 weeks was as accurate.
Perhaps if you were concerned about loosing track of the parents for some reason this could be requested. Most of the other 35 (yes she said 35) tests they now do should be fine on cord blood, but I would like to call her on Monday to verify that again, she did say so but I was not as specific as I would like to have been. I am also going to have her fax me information and studies.
A couple of other interesting things that she mentioned: she in 25 years has never seen a positive African American PKU babe.
PKU is far more common than the one post I read earlier- and of course it is race reference related but it for general numbers runs more on the line more like one in 10,000. Though we can not make a decision base on skin pigment but truly the baby must be lighter" than both parents to suspect PKU, but that is a hard judgement to make.
So I hope some of you find this helpful, it is my experience that the
newborn screen folks are genuinely concerned about the lack of "compliance"
(ohh how I hate that word-and no I do not think it should be a law) with
the out of hospital birth parents. But I also do think there is a misunderstanding
about the "PKU" aspect of the test. This is not their greatest concern
but they are highly concerned with catching a rapid deadly diseases early
like galactosemia or severe cases of congenital hypothyroidism. All of
which the cord blood would be accurate for. PKU does tend to have other
symptoms and most home birth parents do see a pediatrician or family doc
at some point who may suspect/or you yourself as a midwife may suspect
the baby is in trouble with phenylalanine disorder. So the NBS should be
represented as a screen for numerous metabolic and other disorders-all
of them rare but some very dangerous.
The devices listed here cannot cause nerve damage because they can only
penetrate a pre-measured depth to the level of the capillaries only.
It is not only the nerves that you have to worry about. Because the old-fashioned
lancets are used "free-hand" so to speak, the risk of inadvertently penetrating
too deeply and hitting a tendon/nerve is great as is the risk of a needle-stick
accident to the person drawing the lab and/or the baby, baby's sibling,
etc. . Believe me, there have been several law suits won against
the use of lancets (though I admit they were hospital based cases as homebirth
families are not prone to sue,...Thank God.) These devices cost more than
freehand lancets, but they are safer and cause far less pain to the baby
so for the extra $2.50, it is a small price to pay.
from Hawaii Medical - Sweeping-Action Heel Lancet
Tenderfoot - New Technology Makes Heelstick Bearable to Baby and Midwife As Well
Here's their Skin Incision
Products Catalog with the technical specifications for the different
BD Genie™ Safety Lancet - this works great for me! I choose the size depending on the baby's weight.
QuikHeel™ Safety Lancet.
& Little Nicky® Infant Heel Incision Devices - lowers cost
versions of the Tenderfoot.
Heel Puncture from Alliance Laboratory Services
Capillary Blood Collection Methods Using the BD Microtainer® Quikheel™
The baby I did a NBS test on last week slept through it - honestly!!
I've never had one sleep through before, but this one did. I'm now
using the Tenderfoot and it bleeds really well, esp. if the foot is warm.
I use a wet disposable diaper, heated VERY briefly in the microwave (be
sure and check temps before you wrap the baby's foot!) around the foot
for at least 5 minutes (usually while I'm filling out the form).
Then mom holds the baby upright over her shoulder to let capillary blood
flow downwards while I do the "blood-letting." Usually, babies object
briefly to the poke, but then settle down quickly. I don't have to
squeeze or milk or anything using this technique.
I do not know why I had so much trouble with them, I bought them from Moonflower (years ago) and they are available from Cascade, I do believe, BUT... I could not get enough blood with them, and you only get one shot . [Editor: It seems very likely that the author is confusing the Tenderfoot with a Microtainer or Accucheck style spring-loaded pointed lancet. The Tenderfoot wasn't around "years ago".] if you need to repeat, the one you used cannot be reset, you must use a new one . That gets kind of expensive ( I do almost all of my own "pku" tests) . I never had good luck with the pointed spring-loaded lancets (like the ones for checking blood sugars) . They only go straight in and straight out and you kind of have to get lucky to hit a capillary in order to get blood. When I was using either of these methods, I had to do repeats (costly and caused more pain to the baby and parents and me).
I have developed my own technique for using the good cheap old
flat lancet . I simply make a very deliberate cut straight into the
heel and as I am pulling the lancet out, I shift it slightly to the side
so to make certain that I get a 1/16th or so long slice cut . I never
have to repeat, I get plenty of blood, and many of the babies have only
a very slight reaction to the pain of it . (what a relief) . I always
talk to the baby and tell them what I am going to do (they always listen
to me - I can tell) and why we are doing it . I always use a very
warm wet cloth around the foot to prepare it, and I always ask the mom
or dad to hold the baby like they are going to burp the baby so that the
leg is dangling below the heart .
I have tried the tenderfoot, and did not have good luck with it. I know
another practice nearby that uses them, and the student I had last year,
who had also had a placement there, felt that their method was much harder
on the baby too. I usually do a good poke with my lancet, and rarely have
to repoke. I find that it is not just the poke, but I seem to have a way
of milking the leg to encourage blood flow that makes it fast a therefore
less traumatic. Seem to have taught it to the 2 students I've had so far,
but I don't know exactly what I do.
For what it's worth, my technique for doing heelsticks (with the Microtainer
- which is not a pointed lancet, but a knife like the tenderfoot, except
that it can be reused): soak a disposable diaper in very warm water, squeeze
it out enough to stop dripping
Swaddle the baby snugly with one foot out, and wrap that foot in the diaper, using the tapes to fasten it around the ankle.
Have mom or whoever is up for it hold baby upright while you fill out the forms.
Explain it to the baby.
Have baby held upright facing you, and (VERY important) don't let the holder flex that leg at the thigh. (cuts way down on blood flow)
After preparing the foot, dorsiflex the foot, place the device firmly against the foot and push the plunger and rock it through about a 30 degree arc before withdrawing it.
Hold the baby's calf and milk it to increase blood flow, try a little firm pressure above and/or below the site if you need to. Never squeeze the heel - causes bruising and may mess up the test (according to our State Lab).
If blood flow slows before all the circles are filled, rub up the puncture site with an alcohol wipe to break up the clot -just be sure to wipe it with a plain gauze before you attempt to get any more blood for the test.
If all else fails, remember it's more humane to do another stick if the first is not flowing well than to keep mashing away at a "dry hole" .
I think these comments are good, esp. holding the baby upright .
We also use the yellow microtainers . But to warm the foot have found
something better . I buy a box of the handwarmers from Costco .
These are little packs that are to be used in your gloves . Keep
the foot warmer . Found that wet heat evaporates faster . The
hand warmers are a dry, chemical heat .
I have to agree . I have settled on the "nasty" steel lancet pokers.
Have *never* hurt a baby, but I learned from a master who worked in a nursery
for several years, and considered it a failure if I had to poke more than
once :) I heat the foot, poke and twist as I'm doing the stab, and the
babies, by and large, bleed beautifully . Very rarely do I have to
do it more than once . However, the other secret is a well-hydrated
baby . Beware the day three baby in a primip . They just *won't*
I too use the tenderfoot devices . I love them!!! They are MINIMALLY
painful and get excellent results as they are designed to cut to, and only
to, the level of the capillary bed.
The Tenderfoots are SAFER for the baby as well . There have been
several cases of permanent nerve damage to babies who had to undergo repeated
sticks for bili levels where the old lancets were used . Lancets,
no matter what the shape, size, etc. should no longer be used . They
are a legal liability even if they are a fraction of the cost . Because
the Tenderfoots have a guaranteed level of penetration, and a protective
case that prevents accidental needle sticks, they are the only way to go
. Most of our Chicago area hospitals have changed over to using them
We use the tenderfoot, and there is a trick to it . You have to
hold the device firmly to the heel, and then depress the button, but don't
pull the device away immediately like you do a regular stabbing lancet
. This produces the best results for me . I also had trouble
with this until someone told me the trick.
I agree...there is a trick to the Tenderfoot . When used properly, it works great, most of the time in one stick . You DO have to press very firmly and HOLD it there for a second after popping the button . When I first used them, I crabbed about them, and I had to sometimes use 3 of them each time until I got the hang of it . I think I wasn't pressing it firmly enough against the heel to get the poke it is capable of . But as I do think they are safer and I had heard about the studies citing nerve damage to babies from lancets, I persevered . You also have to get the right spot on the foot . Since the casing is rather large compared to a lancet, it can be difficult at first to see that one is poking at the right site . If used properly, I do think they work great, but I still get an occasional baby that just doesn't bleed . My method is to first warm the heel with a latex glove filled with water while filling out the paperwork . A warmed heel definitely increases blood flow . I never milk the leg . When I was in training, I observed a couple of midwives who milked the legs, and sometimes, these babies ended up with bruised legs.
With a Tenderfoot, I have noticed that some babies don't even notice
they've been poked and don't cry at all (although sometimes it's the crying
that makes the blood flow so well!).
Yes! The Tenderfoot has to be used following the guidelines .
Additionally, the device has to be held so that the "slice" is vertical
(up and down) on the sole of the foot. It bleeds better that way .
If you hold it so the "slice" is across the heel, it hurts more and bleeds
less! At any rate, you will not have to "milk" the baby's leg/foot and
it will not cause scarring or nerve damage as the lancets have been known
How to do the Almost Perfect NBS heelstick
When I do heelsticks, we warm the baby's heel for five minutes with
a warm washcloth wrapped in a disposable diaper. I use the yellow Microtainer
Safety flow Lancets available from Cascade. Before I stick, the baby either
Mom or Dad holds the baby upright so that the foot is completely down.
I press the Microtainer Lancet against the foot hard before depressing
the blade. When the blade is depressed, I hold it in position for a second
or two. As soon as I remove it the foot starts bleeding like crazy, and
I just drip it onto the circles. I never have to squeeze as long as the
baby is upright.
Since I started doing heelsticks this way 8 out of 10 babies slept though the whole thing, one would whimper and then go back to sleep and the last would start to cry and we put him to breast and he then nursed through the test.
One birth I did was for a home health care nurse who had to treat neonatal
jaundice at home. She did heel sticks for many situations and when I did
the heel stick for her daughter without a whimper she was amazed. She asked
all the nurses in her home health care squad to come one evening and learn
the technique from me. Well I hope someone/or some little baby benefits
from all this long winded stuff.
Everyone has a slightly different technique when it comes to doing it, and that you will work out, in the end, what's best for you. Personally, I don't like to do heelsticks while baby nurses, in part because I don't like to hurt babies while they're nursing, and in part because I'm getting older and I need to protect my back, so don't like to do contortionist acts if possible.
I get the baby nicely padded on a table (kitchen table or change table) with blankets and a receiving blanket, and welcome mom or dad to participate. I tell them that the baby will cry a bit, but that they can give the baby their finger to suck while I'm working, which will make the baby feel better. I warm the foot well (hot cloth, covered with a plastic bag to keep the heat in), while I'm getting stuff ready to go. I use plain lancets, not the spring-loaded kind.
Really important points are to do the heelstick when the baby is well-hydrated. I won't do it unless the baby is demonstrating that it's doing okay this way (peeing and stooling well, starting to gain), unless, of course, we're getting to that day 5 point. Also, be very careful about the location of the heel puncture. Although the diagram suggests that there is a wide range of possible locations, I find that if you flex the baby's foot, and pick the outer border about a cm above the point of the heel (nice fat pad there), they bleed very nicely, and don't seem to mind the poke too much. The puncture should be done firmly (hard to do the first few times), but not, of course, with real aggression. I also twist the lancet almost a quarter turn as I'm poking, which seems to help further with bleeding. Be very careful not to hang onto the baby's ankle so firmly that you're cutting off circulation....a common beginner's mistake. Just sort of dangle the foot in your hand.
The baby does cry, of course, but this is where I tell parents to give them a finger to suck, if they want. I talk to the baby while I'm doing it, too, sympathetically, but not in such a manner as to have the parents think that this is the worst thing that could ever happen.
It takes some experience, of course, but I practically never have to do a heel puncture more than once, and I've often had the whole thing done in well under a minute. The longer and more drawn out the process, the more tense for the parents (and baby). I do point out that some babies get royally ticked about having their foot restrained by my hand and that's what's making them cry.
The babies I have done have squawked a little, but settle right down once it's over. Usually they'll nurse then (which is an excellent opportunity to see how *that's* going). I always give the baby a nice cuddle after I've poked them and apologize. Only seems like the right thing to do :-) I also usually mention at some point that we're being mean to be kind, in the long run.
I just want to thank everyone for their great advice. I've just come
home from a delightedly successful heelstick After warming baby's foot
with a heated up oat bag, I decided to get the mom to hold the baby over
her shoulder, and held that microtainer pressed down for a few seconds
before pulling it away. Baby just let out a little squawk and then went
to sleep, and this baby has been so fussy I was sure she'd really complain!
She bled beautifully (how morbid that sounds!), I didn't even need to massage
her calf at all, just waited for the drops to form and drop down in the
circles. Minimal fuss and stress, wonderful! Of course, it could all just
be a fluke, but I'll stick with this technique for now and see if that's
what works best for me.
The National Coalition
for PKU and Allied Disorders
hypothyroid screening using cord blood TSH.
Wu LL, Sazali BS, Adeeb N, Khalid BA.
Singapore Med J. 1999 Jan;40(1):23-6.
screening for congenital hypothyroidism].
Moslinger D, Frisch H, Strobl W, Stockler-Ipsiroglu S
[Article in German]
As TSH is physiologically high during the first 2 days of life, the trend to early hospital discharge will result in a significant increase of the recall rate in future.Epidemiology of congenital hypothyroidism.
Neonatal screening in early discharged neonates mostly is not recommended before day 4.
It is possible to screen newborns for galactosemia from cord blood. Delaying the diagnosis by even a few days could result in the baby's death.
Do you consider it the standard of care to encourage your clients
to have the baby screened for galactosemia using cord blood and then to
do the heelstick for a followup newborn screen at the usual time (within
NO, NO, NO, a 1,000 time NO!
The standard of care is state law which does require that we inform parents about the normal state heel-stick screening and either provide the service or provide information about how they can arrange such screening.
It is a conflict of interest for an organization that either directly profits (sells the service) or is funded by money from those who profit from its use to promote this service, made even more egregious by threats and attempts at intimidation.
Any electronically transmitted material regarding such threats should
be sent to the Midwifery Advisory Council.
Yes, we've had two false positives, and each time the Health Dept. recommends
bringing the baby to the hospital immediately. They draw more blood,
and results are back in about five days. They are required to recommend
that the babies take a special formula and avoid breastmilk all together.
When I ask, they agree that the baby would really look sicker at this point
if it were truly galactosemia. They have a legal obligation to recommend
that the mom stop breastfeeding, but moms can really do whatever feels
right for their baby. However, it is important that they appear compliant
and carry the special formula out the door with them so they don't get
reported for noncompliance. What an awful thing if a false positive
resulted in the child being removed from the home because the mom continued
In general, cord blood is not suitable to provide the blood sample for the newborn screen because it is taken before the baby has taken breastmilk (or alternative) into the digestive tract. Phenylketonuria is a difficulty in digesting the protein, phenylalanine, and galactosemia is a difficulty in digesting the milk sugar, galactose. The toxic metabolic byproducts cannot be detected until at least 12 hours after the baby has taken in a good feed.
Although the mother's thyroid hormones and TSH do not cross the placenta, the mother's thyroid-stimulating immunoglobulins may cross the placenta and affect the baby's thyroid levels. This may lead to a false negative on the test for hypothyroidism done on cord blood. This test actually is not very reliable before Day 4, even though it's routinely done at Day 2 for most hospital births.
Cord blood does provide accurate test results for blood levels that are not affected by feeding. For example, the baby's blood type can be accurately assessed from cord blood, as well as sickle cell disease and other hemoglobinopathies.
Screening for Sickle Cell Disease and Other Hemoglobinopathies - National
Institutes of Health Consensus Development Conference Statement - April
6-8, 1987 - " . . . cord blood samples can be used for neonatal screening
[ed. - for sickle cell disease]. The hemoglobin components within these
samples (especially Hb Barts) are more stable . . . "
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