Skin to calcaneus distance in the neonate

Background: Current recommendations for obtaining blood from neonates advise avoidance of the midline area of the heel and are based on postmortem studies. Objective: Because of the potential pain and tissue damage from repeated heel pricking in the same area, to investigate using ultrasonography whether the distance from skin to calcaneus is less at the midline than at the borders. Methods: One hundred consecutive healthy preterm and 105 consecutive healthy term neonates were studied 48-72 hours after delivery. The skin to perichondrium distance (SPD) was measured on two occasions by ultrasound at the external, midline, and internal areas of the heel. Findings: Mean SPD was 0.2 mm less at the midline than at the other sites. The proportion of measurements < 3 mm at any of the three sites was the same. Depth was < 3 mm in less than 3% of the term and similar to 20% of the preterm infants. The SPD correlated only with gestational age. Of children < 33 weeks gestational age, 38% had an SPD < 3 mm compared with 8% of older preterm infants. The proportions of preterm infants of >= 33 weeks gestation and term infants with an SPD < 3 mm were similar (8% v 3%). Interpretation: With the use of automated lancets of 2.2 mm length or less, the whole heel plantar surface is safe for obtaining blood in term and preterm infants of >= 33 weeks gestation. This means that soft tissue damage and pain from repeated pricking in the same area can be reduced.