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J Perinat Neonat Nurs
rVolume 31 Number 2, 160–165 rCopyright C2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/JPN.0000000000000254
Blood Sampling in Newborns
A Systematic Review of YouTube Videos
Mariana Bueno, PhD, RN; ´
Erika Tihemi Nishi, RN; Taine Costa, RN, MScN; La´
ıs Machado Freire;
Denise Harrison, PhD, RN
ABSTRACT
Objective of this study was to conduct a systematic review
of YouTube videos showing neonatal blood sampling, and
to evaluate pain management and comforting interventions
used. Selected videos were consumer- or professional-
produced videos showing human newborns undergoing
heel lancing or venipuncture for blood sampling, videos
showing the entire blood sampling procedure (from the first
attempt or puncture to the time of application of a cotton
ball or bandage), publication date prior to October 2014,
Portuguese titles, available audio. Search terms included
“neonate,” “newborn,” “neonatal screening,” and “blood
collection.” Two reviewers independently screened the
videos and extracted the following data. A total of 13 140
videos were retrieved, of which 1354 were further evalu-
ated, and 68 were included. Videos were mostly consumer
produced (97%). Heel lancing was performed in 62 (91%).
Forty-nine infants (72%) were held by an adult during the
procedure. Median pain score immediately after puncture
was 4 (interquartile range [IQR] =0-5), and median length
of cry throughout the procedure was 61 seconds (IQR =
88). Breastfeeding (3%) and swaddling (1.5%) were rarely
implemented. Posted YouTube videos in Portuguese of
Author Affiliations: School of Nursing of the University of S ˜
ao Paulo,
S˜
ao Paulo, Brazil (Dr Bueno and Mss Nishi and Costa); Waldemar
Monastier Children’s Hospital, Campo Largo, Brazil (Ms Costa); and
University of Ottawa and Children’s Hospital of Eastern Ontario,
Ottawa, Canada (Dr Harrison). Ms Freire is a nursing undergraduate
student at the School of Nursing of the Federal University of Minas
Gerais, Belo Horizonte, Brazil.
Disclosure: The authors have disclosed that they have no significant
relationships with, or financial interest in, any commercial companies
pertaining to this article.
Corresponding Author: Mariana Bueno, PhD, RN, Av Dr En ´
eas Car-
valho de Aguiar, 419, Cerqueira C ´
esar, S˜
ao Paulo/SP, CEP 05403-000,
Brazil (mariana.bueno@usp.br).
Submitted for publication: September 26, 2016; accepted for publication:
February 11, 2017.
newborns undergoing blood collection demonstrate min-
imal use of pain treatment, and maximal distress during
procedures. Knowledge translation strategies are needed
to implement effective measures for neonatal pain relief
and comfort.
Key Words: infant, neonatal nursing, newborn, pain
All newborn infants undergo blood sampling
for newborn screening, and sick hospitalized
infants require repeated blood sampling and
other painful procedures over the course of their
hospitalization.1–6 High-quality synthesized evidence
is available on effective, simple-to-use, and low-cost
interventions for neonatal procedural pain treatment.
Effective interventions include breastfeeding before
and during painful procedures such as heel lancing
and venipuncture,7skin-to-skin contact, or kangaroo
care before and throughout the procedure8and small
amounts of sweet solutions such as glucose and
sucrose.9,10
These interventions are recommended in interna-
tionally published guidelines11–13; however, studies
conducted over many years across different continents
continue to demonstrate that newborn infants undergo
numerous painful procedures in which analgesic strate-
gies are not consistently and effectively implemented.1–6
Results of a recently published systematic review in-
dicate a strong association between pain-related stress
in preterm infants to poor developmental outcomes
such as limited growth and weight gain, changes
on the development of subcortical structures, and
gray matter, and cognitive and motor developmental
changes.14
Therefore, developing, evaluating, and implement-
ing knowledge translation strategies on neonatal pain
relief are essential to improve outcomes for infants
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
160 www.jpnnjournal.com April/June 2017
in neonatal units. Knowledge translation is defined
as a dynamic and interactive process, including syn-
thesis, dissemination, exchange, and application of
knowledge to improve health of individuals, to im-
prove effectiveness of health services and products,
and finally to strengthen the healthcare system.15 In
the last few years, the Internet has provided addi-
tional means by which health information can be
disseminated.
The Internet provides unprecedented opportunities
for patients and general public to retrieve health infor-
mation at a global level.16 Specifically, YouTube is a
popular tool that has over a billion users and allows
people to watch and share originally created videos,17
and potentially provides a new way to communicate
evidence-based health information to a large number of
people.18 Harrison et al18 conducted a systematic review
of YouTube videos showing infant immunizations, and
reported minimal use of recommended pain treatment
strategies. Since then, they posted their own YouTube
video showing infants receiving effective pain treat-
ment (breastfeeding and sucrose) during immunization
(https://www.youtube.com/watch?v=8Wzjxvrl91U)for
widespread dissemination of knowledge to parents and
healthcare providers.19
The purpose of this study was to conduct a similar
systematic review of YouTube videos showing neonatal
blood sampling, to assess infants’ pain during the pro-
cedures, and to ascertain the use of effective procedural
pain management strategies.
METHODS
Type of study
A systematic review of YouTube videos of newborn
infants undergoing blood sampling.
Search methods
Videos were considered as eligible if they met the
following criteria: consumer- or professional-produced
videos showing human newborns undergoing heel
lancing or venipuncture for blood sampling, videos
showing the entire blood sampling procedure (from the
first attempt or puncture to the time of application of a
cotton ball or bandage), publication date before Octo-
ber 2014, Portuguese titles, available audio.
Search terms included “neonate,” “newborn,”
“neonatal screening,” and “blood collection.” Terms
were selected according to the highest proportion of
web searches on Google Trends.20 Therefore, 4 differ-
ent search strategies were organized combining 2 terms
per search.
Search methods were based in a prior systematic re-
view of YouTube videos.18 A new YouTube account
was created to eliminate the chance of search history
influencing search rankings. The end point was deter-
mined through a discontinuation rule of 70 videos. It
means that when 70 consecutive videos did not meet
the eligibility criteria and were excluded, no future
videos were screened. After viewing a video that met
the inclusion criteria, the first 5 related suggested videos
that appeared were screened.18
Data extraction
Two reviewers performed the screening independently
and assessed videos for eligibility (EN and LF). In
case of conflicts not solved through a consensus be-
tween the 2 reviewers, a third reviewer (MB) was
consulted.
Data were independently extracted by 2 authors (EN
and TC) and included video name and URL, date of
upload, length of the videos, number of views, num-
ber of likes, number of dislikes, number of comments,
type of the video, type of painful procedure, number
of punctures, total length of the procedure (from the
first attempt or puncture to the time of application of a
cotton ball or bandage), positioning of the infant during
the procedure, use of observable analgesic strategy(ies)
before, during, and or after puncture(s), and type of
observable analgesic strategy(ies) implemented. Infants’
pain was assessed using a commonly used subset of the
Neonatal Facial Coding System (NFCS)21 (brow bulge,
eye squeeze, nasolabial furrow, stretch open mouth) at
15 seconds after the first and last puncture, as well as
prevalence of crying before, during, and after the pro-
cedure, and total length of crying (from the first attempt
or puncture to the time of application of a cotton ball
or bandage).
Data analysis
Data were stored in a pretested Microsoft Excel for
Windows spreadsheet and logistic checks were per-
formed by a third reviewer (MB). Data were analyzed
using the software SPSS version 20. Descriptive data
are presented as mean and standard deviation in case
of normal distribution, and are presented as median and
interquartile ranges (IQR) if data did not follow normal
distribution. Pain scores were calculated only if all 4 fa-
cial actions were able to be observed by both coders
(EN and TC), and agreement between 2 coders was as-
sessing by using κstatistics. All data were analyzed for
κstatistics, including videos in which grimacing was
not considered observable by the coders. Agreement
between the coders in regard to length of crying was
evaluated by the intraclass correlation coefficient.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 161
RESULTS
Searches were conducted during March 2015. Of the
13 140 videos retrieved, 1354 were evaluated; 68 videos
of neonates undergoing blood sampling were included
(see Figure 1).
The oldest included video was posted in October
2006. Median length of the videos was 214.5 seconds
(IQR =204.25, range 33-638 seconds) and median num-
ber of views was 416 (IQR =4527.49, range 45-28 285).
Number of likes per video varied between 1 and 18,
and number of dislikes ranged from 1 to 15. There
were comments in 21 videos (range 1-19).
Included videos were mostly produced by families
(66 videos, 97%). One video showed twins receiving
one procedure each; therefore, data of 69 infants who
underwent blood sampling were evaluated.
Heel lancing was performed in 62 (91%) infants and
venipuncture in 7 infants. Number of attempts for blood
Figure 1. Study selection process for systematic review
(PRISMA diagram).
sampling ranged from 1 (53 infants, 77%) to 6 (1 infant)
punctures (median 1, IQR =0). Length of the proce-
dure (from the first attempt or puncture to the time of
application of a cotton ball or bandage) ranged from
9.5 to 348 seconds, median of 96 seconds (IQR =92).
The majority of the newborns were held by an adult
before and during the procedure (49 infants, 72%).
Comforting/analgesic strategies included breastfeeding
(2 infants) and swaddling (1 infant).
It was possible to score the NFCS at 15 seconds im-
mediately after the first puncture or attempt in 23 (33%)
infants. Median pain score was 4 (IQR =0.5, range 0-4),
and the majority (74%) of the assessed infants presented
the highest pain score possible as displayed at Figure 2.
Five infants who received more than one puncture were
assessed after the last puncture for the same facial ac-
tions. Results were median pain score 4 (IQR =0, range
0-4): 4 infants scored 4, and 1 infant scored 0.
Crying before the procedure was observed in 29
(46%) infants, and crying during and after blood sam-
pling was observed in 62 (91%). Median time spent
crying during the entire procedure (from the first punc-
ture or attempt until the application of a cotton ball or
bandage) was 61 seconds (IQR =88, range from 0 to
300 seconds).
Interrater agreement of the NFCS and total time spent
crying of all included videos was established by 2
trained observers (EN and TC). Data extracted from
videos were included on the analyses (see Table 1).
DISCUSSION
Systematic review of YouTube videos is an innovative
method for measuring knowledge translation. Although
search and screening processes are not standardized
yet for this type of research, systematic review meth-
ods are evolving. Our method was based on a prior
systematic review of YouTube videos showing infant
immunization.18 This new area of research includes
a limited number of studies of pediatric pain-related
videos published on the Internet to date.18,22
A large variability on the characteristics of the in-
cluded videos, such as length, number of views, num-
ber of likes and dislikes, was observed. This might be
explained by the nature of the videos, which were
mainly produced by families. The reasons for which
parents post such videos of their infants undergoing
blood sampling are not known, and similarly to what
was performed in a prior review, we did not seek to
uncover reasons for these posts.18
This systematic review of 68 YouTube videos with
Portuguese titles showing newborn infants undergo-
ing blood sampling clearly showed that most in-
fants were highly distressed during the procedures.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
162 www.jpnnjournal.com April/June 2017
Figure 2. Pain scores at 15 seconds immediately after the first puncture or
attempt. S˜
ao Paulo, 2015.
Recommended pain treatment strategies such as breast-
feeding, skin-to-skin care, or sucrose were almost never
used despite internationally published consensus and
guidelines recommending the pain prevention and
treatment for newborns during blood sampling and
other painful procedures.11–13,23 ,24 Placing the infants on
their parents’ lap was observed in 72% of the videos
although this is insufficient to effectively reduce pain.25
Effective analgesic strategies for single neonatal proce-
dures such as breastfeeding, skin-to-skin contact, and
sweet solutions were rarely implemented as highlighted
by the included videos.
The heterogeneity of the included videos precludes
an assessment of reasons for the lack of implement-
ing analgesic strategies during neonatal blood sampling.
Barriers for using breastfeeding and/or skin-to-skin con-
tact described in the literature may include profes-
sional’s preference to perform blood sampling with-
out the parents, parents’ preference not to be involved
during painful procedures, units’ cultures and/or poli-
Table 1. Interrater reliability for grimacing
and total time spent crying
Grimacing κ(CI 95%)
Brow bulge 0.77 (0.69-0.84)
Eye squeeze 0.84 (0.77-0.9)
Nasolabial furrow 0.87 (0.81-0.92)
Open mouth 0.88 (0.82-0.93)
Crying ICC (CI 95%)
Time spent crying 0.983 (0.972-0.989)
Abbreviations: CI, confidence interval; ICC, intraclass correlation coefficient.
cies, out-of-date policies, insufficient time, knowledge,
and education of the healthcare professionals, staff be-
ing uncomfortable performing blood sampling, with in-
fants being breastfed or positioned on skin to skin.26,27
Sweet solutions may not be readily available for admin-
istration in clinical settings.28 Parental refusal has also
been identified as a barrier for administration of sweet
solutions.28,29 Further exploring these barriers is nec-
essary as an attempt to contribute on the development
and implementation of knowledge translation strategies
tailored to contribute to better neonatal pain outcomes.
Improving neonatal pain treatment by consistently
using effective internationally recommended pain treat-
ment strategies is important. Traditionally, education
has targeted healthcare providers; however, supporting
parents to advocate for effective pain treatment for their
infants may contribute to improved neonatal pain man-
agement practices. Knowledge translation interventions
targeted at parents are rarely described in the literature.
In a randomized controlled trial, parents received (i)
a pain information booklet and information on how to
provide comfort to their infants, in addition to a generic
booklet on neonatal care, or (ii) a generic booklet on
neonatal care alone.30 Parents who received specific in-
formation on neonatal pain management and comfort
were more satisfied with the information and more in-
volved with their infants during painful procedures.30
Regardless the presence of one or more family mem-
bers, the included videos did not highlight parental
involvement on infants’ comforting and pain manage-
ment. However, studies indicate that parents consider
their participation on neonatal pain control as vital and
they want to be involved on their infant’s care during
painful procedures although barriers such as emotional
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 163
difficulties in being present or participating and staff
attitudes and behaviors are described.30–32 Some nurses
consider parents’ presence for observing and comfort-
ing their infants important; however, some nurses feel
this is inappropriate and not in the best interests of
the infant or family.33 In addition to this, our results
conflict with findings of a Canadian prospective ob-
servational study that indicates parental presence as a
consistent predictor on the use of analgesic interven-
tions during tissue-damaging procedures in hospitalized
neonates (ie, infants received analgesia more frequently
if their parents were present).4
Informing parents on the risks of untreated neonatal
pain and on effective and safe strategies available for
pain prevention and management may empower them
on advocating for better pain care for their infants. Sev-
eral strategies can be implemented, as per the booklet
investigated in a recently published study.30 Following
current trends, consumers wish to search for and create
content online and interact with like-minded others.34
Therefore, the Internet and social media are power-
ful ways of dissemination of information and interac-
tion. Video-based demonstrations have been increas-
ingly used to teach consumers about health topics and
also to promote wellness.22 The YouTube, particularly,
can be utilized as a platform to communicate impor-
tant health information.35 However, the effects of the
Internet, and social media on health outcomes such as
satisfaction, feasibility, clinical utility, clinical practices,
are still poorly investigated to date.
Therefore, this review will serve as a baseline to eval-
uate the impact of the “Seja doce com os bebˆ
es” video
on neonatal pain relief practices captured by videos
prospectively posted on YouTube. This is a publicly
accessible video that was produced and originally pub-
lished on YouTube on July 2014, in English and French,
and is named “Be Sweet to Babies” with an updated
version on January 2016 (https://www.youtube.com/
watch?v=HmJGQJ8ayL8).36 The Portuguese version, the
“Seja doce com os bebˆ
es” video, was published on
YouTube on October 2014, with an updated version
on January 2016 (https://www.youtube.com/watch?v=
ZGLSNdYtppo).37 It has reached more than 7500 views
and 50 likes after being available for 24 months. The
video clearly shows the effectiveness of 3 interventions
on neonatal pain relief in which parents can be in-
volved: breastfeeding, skin-to-skin contact, and sweet
solution.
Interestingly, coders reported extremely poor blood
sampling technique in a large number of included
videos. Analyzing the procedures’ technique was be-
yond the scope of the present study although this might
have influenced neonatal pain responses during blood
collection. Further analyses of the included videos fo-
cusing on the procedures’ technique may indicate the
need of educational strategies for healthcare profession-
als focusing on blood sampling procedures in neonate
infants.
Limitations to the study include that most videos
were produced by families, which resulted in a large
variability on these videos’ characteristics and quality,
precluding data extraction and analyses for some of the
videos, especially for grimacing.
CONCLUSION
This systematic review included 68 videos publicly
posted on YouTube showing newborn infants under-
going blood sampling. Procedures caused pain and
distress on infants and analgesic and comforting inter-
ventions were rarely implemented. Knowledge transla-
tion strategies targeted at healthcare professionals and
parents are needed as an attempt of implementing
evidence-based, effective, and safe strategies for neona-
tal pain relief in clinical settings. Finally, this review will
serve as a baseline to evaluate the impact of a knowl-
edge translation tool using YouTube.
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The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 165
