Blood Collection:
Babies and Children

PRC-PALM-SPC-5.51-pro1-prs1: OBTAINING BLOOD FROM BABIES AND CHILDREN PROCESS

PRC-PALM-SPC-5.51-pro1-prs1-stw1: OBTAINING CONSENT FOR MINORS STANDARD WORK

Infant Blood Volume Determination

Must be determined prior to heel stick/arm draw as removal of more than 10% of an infant’s blood volume in a short period of time can lead to serious consequences, such as iatrogenic anemia or cardiac arrest.

When requested to collect blood specimens from infants, phlebotomists must be able to quickly estimate blood volume to avoid harming the patient. The parent should be asked how much baby weighs. If parent unsure, check Epic or call physician’s office for approximate weight in kilograms/ pounds. See table below:

If a request for blood collection exceeds this protocol the phlebotomist must, see below:

Call the physician.

1. Determine which tests should be drawn at this time.
2. Collect only those tests, following the protocol above. 
3. Cancel tests not collected in Sunquest lab use cancel code EXCEED-; (Dr. or nurse full name and credentials) and (date and time) and BY (tech code and initials)

Determining site of draw on infants – newborn to 1 year

Collection of blood from Neonates ages 0 through 3 months, this must be done by an     experienced phlebotomist or a pediatric nurse. Heel stick is the only acceptable manner of collection for laboratory personnel in this age group unless infant weight is 21 pounds or greater than an arm draw can be performed. (Do not obtain the blood from a finger on an infant under 1 year of age).

• Heel stick ONLY if neonate under 20 pounds (9kg)
• Heel stick or Arm draw if neonate 21 pounds or greater- arm draw can be performed if need, follow steps below for arm draw: 

Do not draw from heel if: Feet are edematous, injured or infected, bruised, injured by multiple previous heel sticks or if testing requires more than 1 mL of blood, refer the patient’s family to the pediatric service.

Do not obtain the blood from a finger on an infant under 1 year of age

Do not perform heel sticks on infants less than or equal to 5.0 pounds or 2.3kg refer to pediatric unit.

Cleansing site:  Alcohol wipes, 70% solution, 2% tincture of iodine, Chlorohexidine (CHG) swab or one step.

2% tincture of iodine

• Prepping of area, allow iodine to completely dry, if not allowed to dry may falsely increase levels of potassium, phosphorus or uric acid in laboratory testing

Ethanol Testing / blood cultures on children <6months old draws

• Use 2% tincture of iodine

Blood cultures

• Chlorohexidine (CHG) swabs or one step (Do not use on children  <=2  months)
• 2% tincture of iodine
• Gauze or cotton balls

Children <= 2 months

• Do not use Chlorohexidine (CHG) swabs or one step

(0-3 months) blood collection:

• Heel stick only if neonate weighs under 20 pounds (9kg)
• If neonate weighs 21 pounds or greater can perform arm draw but use caution when using tourniquet to avoid injury and or nerve damage to site.
• Do not obtain the blood from a finger on an infant under 1 year of age

Steps:

1. Patient identification: Ask the parents for the baby’s name and date of birth. Some babies may not have been named for religious reasons. In this case; verify the last name, sex and date of birth of the baby.
2. Parent’s ability to assist: Assess the parent’s ability to assist you.  If the parent appears to be apprehensive or unable to assist standing by the infant, a second phlebotomist must be present. Do not leave the baby on the table alone to wash your hands. Whenever you have a difficult or uncooperative patient a second phlebotomist must be present to assist.  See the policy regarding: SPECIMEN COLLECTION FROM POTENTALLY UNCOOPERATIVE PATIENTS.
3. Baby Weight: Ask the parent how much the baby weighs, if weight in pounds use conversion above. If parent unsure, check Epic or call Physician’s office for approximate weight in kilograms to determine allowable maximum collection volume.
4. Ask the parents if there have been any other blood collections in the last 24 hours.
5. Place a moisture barrier pad or sheet on the exam table.
6. Have the parent place the baby on the table and remain with child, never leave child unattended.
7. Pre-warm the infant’s foot with a heel warmer. If needed, place a heel warmer around baby heel and one around the calf. Wrap in diaper or blanket for 5-10 minutes, if necessary. Have parent hold child during this time. Reassure the parents that you will be as gentle as possible.
8. Wash your hands
9. Hold the foot to avoid sudden movements clean the foot with an alcohol pad and allow the area to dry before obtaining the specimen, do not touch, blow or dry the area after cleaning as this will contaminate the foot. Do not rush this step.
10. Place your lancet on the lateral or medial portion of the plantar surface the heel (see picture for correct puncture sites); never puncture the center of the foot. When the lancet is properly positioned, depress the trigger. Never twist the lancet to make a larger hole. To avoid infection, do not puncture the foot in the same place as previous heel stick

11. Newborns do not bleed immediately do not squeeze excessively as this will dilute blood. Wipe away the first drop of blood then begin the collection.
12. Heel stick order of draw is different from a venipuncture collection:
    1. Collect the lavender top tube first. Next, draw the chemistry and blood bank tubes.
    2. It is best if you mix the lavender top tube as you receive each drop to prevent clotting or clumping. If any clotting occurs you must start over. (No scooping-this will cause blood to clot.)
    3. Label the specimens before leaving the room. Dispose of the lancet in the sharps container. Have the parents comfort the infant.
    4. No more than 2 attempts should be made to collect the specimen; call the physician if the second collection is unsuccessful.  Suggest the baby’s family be referred to the pediatric service.
    5. Label all tubes at chair in presence of parents.

(4 months to 1 year old) blood collection (Heel stick or Arm draw):

Conditions that may influence the choice of heel or arm draw include:

• Weight of infant: less than 9kg (21lbs. or greater) heel stick
• Greater than 9kg (21 lbs. or greater) arm draw (Use caution when using tourniquet to avoid injury and/or nerve damage to site)
• Do not obtain the blood from a finger on an infant under 1 year of age

Steps:

1. Patient identification: Ask the parents for the baby’s name and date of birth. Some babies may not have been named for religious reasons. In this case; verify the last name, sex and date of birth of the baby.
2. Parent’s ability to assist: Assess the parent’s ability to assist you.  If the parent appears to be apprehensive or unable to assist standing by the infant, a second phlebotomist must be present. Do not leave the baby on the table alone to wash your hands. Whenever you have a difficult or uncooperative patient a second phlebotomist must be present to assist.  See the policy regarding: SPECIMEN COLLECTION FROM POTENTALLY UNCOOPERATIVE PATIENTS.
3. Baby Weight: Ask the parent how much the baby weighs, if weight in pounds use conversion above. If parent unsure, check Epic or call Physician’s office for approximate weight in kilograms to determine allowable maximum collection volume.
4. Ask the parents if there have been any other blood collections in the last 24 hours.
5. Place a moisture barrier pad or sheet on the exam table.
6. Wash your hands
7. A heel stick or Arm venipuncture (Use caution when using tourniquet to avoid injury and/or nerve damage to site) may be used according to the infant’s size. (Do not obtain the blood from a finger on an infant under 1 year of age)
8. Check the arm for a vein. Many infants will have palpable veins and a heel stick will not be necessary. See above for steps to draw from an arm. If no vein is present, follow procedure for neonates and perform a heel stick.
9. Always have a second lab assistant available to hold the child still, if needed. Parents may assist in holding the child still. The second phlebotomist should hold the elbow and wrist of the baby in case of sudden movements.
10. No more than 2 attempts should be made, call the physician if you are unsuccessful at obtaining the specimen.
11. Label all tubes at chair in presence of parents.

(1-4 years old) blood collection (Arm, Hand or Finger draw)

1. Ask the parent for name and date of birth
2. Ask the parent to watch the child; do not leave the child unattended
3. Wash hands
4. Sudden movements are likely to take place.
5. The parent may hold the child on their lap
6. Phlebotomist with assistance from a parent and/or second phlebotomist will assist with holding the child. (Use caution when using tourniquet to avoid injury and/or nerve damage to site)
7. When finished, wrap the arm with a Band-Aid or Co flex if necessary and instruct the parent to remove the bandage in 20 minutes.
8. Do not apply the Co flex too tight, this can cut off circulation.
9. No more than 2 attempts should be made, call the physician if you are unsuccessful at obtaining the specimen.
10. Label all tubes at chair in presence of parents.

(5-9 year old) blood collection (Arm or Hand or Finger draw):

1. Same as 1-4 year olds
2. At this age the child may attempt to run away
3. The parents must bring the child to the chair, not the phlebotomist, injury can occur to the phlebotomist or child if attempts are made to bring the uncooperative child to the chair.
4. The child may be placed in the phlebotomists/parent lap.
5. Some children in this age group are very cooperative and will sit without the parent.  Assess the child very carefully if they are going to sit alone. Introduce yourself to the child; explain that there will be a pinch. Show them the tourniquet explains every step you are going to do. (Use caution when using tourniquet to avoid injury and/or nerve damage to site)
6. Do not force the child into the chair; it is the parent’s responsibility to place the child in the phlebotomy chair. If the child is completely uncooperative the procedure may not be able to be performed on that day and the physician must be called. Refer to the policy: SPECIMEN COLLECTION FROM POTENTIALLY UNCOOPERATIVE PATIENTS
7. No more than 2 attempts should be made, call the physician if you are unsuccessful at obtaining the specimen.
8. Label all tubes at chair in presence of parents.

(14-17 years old) blood collection (Arm or Hand or Finger draw):

1. Parental permission must be obtained to draw a minor except in the following circumstances: Exception includes:

Minor is between the ages of 14 and 17 and the test(s) requested are any of the following:

• Test for pregnancy
• Test for sexually transmitted disease
• Tests for Substance abuse

2. Refer to: PRC-PALM-SPC-5.51-pro1-prs1-stw1: OBTAINING CONSENT FOR MINORS STANDARD WORK

(18 years old and above) blood collection (Arm or Hand or Finger draw):

      Patient will be treated as an adult