Nursing care
Newborn heel stick: safe puncture zones, comfort measures and sample errors
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
Puncture the medial or lateral edge of the plantar heel, never the back of the heel, where bone lies closest to the skin. Warm the foot, clean with alcohol and let it dry, use an appropriately short lancet in one quick stroke, and avoid heavy squeezing. Breastfeeding, skin-to-skin contact, swaddling or prescribed sucrose reduce pain.
Why the heel and which parts are safe
Capillary heel sampling is used from birth to about six months for small-volume tests such as glucose, bilirubin and newborn screening. The safe zones are the medial and lateral edges of the plantar surface. In a term baby the distance from skin to bone is shortest at the back of the heel, so that area is avoided to prevent striking the calcaneus. For older, heavier infants, a finger-prick or venepuncture is usually more appropriate.
Use a neonatal heel lancet with the depth limit set by policy, and shorter devices for preterm infants. Too much pressure on the lancet makes the puncture deeper than intended. Complications of poor technique include osteomyelitis of the calcaneus, nerve or vessel injury, bruising, scarring and skin breakdown.
Preparation and the critical steps
Confirm identity, the test ordered and any timing requirement. Warm the heel and keep the baby warm, for example swaddled with only the foot exposed, because warmth improves blood flow. Clean the site with alcohol and allow it to dry fully; povidone iodine is not recommended for neonatal skin punctures and can interfere with results. Check whether the test has timing rules, such as feeding status for glucose or a minimum age for screening, because a mistimed sample may need repeating.
Hold the foot firmly and puncture with one quick, continuous stroke. Wipe away the first drop, which may contain tissue fluid. Let drops form and collect them without strong squeezing, because squeezing dilutes the sample with tissue fluid and causes haemolysis. Apply pressure afterward until bleeding stops, and never reuse a lancet or puncture the same spot twice.
Comfort measures that reduce pain
Heel sticks hurt, and newborns respond with crying, grimacing and heart rate changes. Breastfeeding during the procedure has been shown to reduce pain scores and crying time, and skin-to-skin contact and swaddling with holding also help. Small amounts of oral sucrose are another option when prescribed or covered by protocol.
Involve parents where possible. A parent can hold the baby skin to skin or breastfeed while the nurse samples. Limit attempts: if two attempts fail, seek another opinion rather than continuing to puncture, and consider whether venepuncture would be a better route for the volume required. Explain the procedure to parents beforehand so they know what to expect and how they can help.
Errors that ruin newborn screening cards
Screening cards need each printed circle filled by a single large drop soaking through to the back. Common reasons for rejection include dabbing blood repeatedly onto one circle, which forms serum rings, spots that do not soak through, insufficient spots, diluted samples from squeezing, and contamination from touching the filter paper. Incomplete or illegible card details are also a frequent cause of rejection.
Consider a hypothetical student collecting a screening sample who squeezes the heel hard and touches the card to the heel several times on one circle. The best correction is to start a fresh circle with a single free-flowing drop. Pressing harder, layering more blood or rubbing the spot all make the sample less accurate.
Labelling, order of collection and aftercare
When several capillary samples are needed, collect the haematology specimen first, then chemistry and blood bank samples, which is the reverse of venous order and reduces errors from platelet clumping. If several tubes are needed, venepuncture may give more accurate results. Label at the bedside with the date, time, patient identity, location, test and method of collection.
After collection, apply pressure until bleeding stops and check the site later, because repeated adhesive strips can damage fragile newborn skin. Remove every lancet, wipe and wrapper from the cot so nothing is left behind. Record the number of attempts, the comfort measure used and how the baby tolerated the procedure, so repeat sampling can be planned with less distress.
Sources and further reading
WHO guidelines on drawing blood: best practices in phlebotomy. Heel-prick for birth to about six months, medial and lateral plantar sites, avoiding the posterior heel, maximum depth, warming, alcohol not povidone iodine, wiping the first drop, avoiding squeezing, complications, sucrose and limiting attempts.
Italian Journal of Pediatrics: Methods for reducing pain during a heel lance in newborns. Breastfeeding most effective, followed by skin-to-skin contact and swaddling with holding, for heel lance pain.
BMC Pediatrics: Dried blood spot quality in newborn screening. Causes of unsatisfactory screening samples including serum rings from repeated dipping, contamination, incomplete penetration, insufficient spots, dilution and incomplete information.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our maternity and newborn practice questions are the closest set to what this page covers.
Common questions
Which part of the heel should be avoided?
The back of the heel, where the calcaneus lies closest to the skin. Use the medial or lateral edges of the plantar surface.
Why should the nurse avoid squeezing the heel hard?
Heavy squeezing dilutes the blood with tissue fluid and causes haemolysis, which can make results inaccurate or the sample unusable.
What comfort measures help during a heel stick?
Breastfeeding, skin-to-skin contact, swaddling with holding and, when prescribed or allowed by protocol, oral sucrose.