2.4 Pediatric & Geriatric Special Populations

Pediatric & Geriatric Special Populations

Phlebotomy Technicians must adapt their technical execution, equipment selection, and interpersonal communication when collecting blood specimens from pediatric and geriatric patients. Both populations present distinct physiological, anatomical, and psychological challenges. Children have smaller blood volumes, higher anxiety levels, and delicate tissue structures, while elderly individuals often present with fragile skin, sclerosed veins, sensory deficits, and altered vascular compliance.

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Section 1: Pediatric Phlebotomy Protocols

Pediatric phlebotomy spans neonates, infants, toddlers, children, and adolescents. Minimizing trauma and ensuring physical safety during the collection procedure requires psychological preparation and secure positioning.

Psychological Preparation & Communication

• Build Trust: Address both the child and parent upon entering. Use age-appropriate language (e.g., explain that you are going to "take a tiny picture of your blood").
• Honesty: Never tell a child that the puncture will not hurt. Explain that they will feel a quick "pinch" or "bug bite," and encourage them to count to three or focus on a distraction.
• Distraction Techniques: Use bubbles, light-up toys, videos, or virtual reality headsets to divert attention away from the equipment.

Safe Immobilization Techniques

Movement during needle insertion is the leading cause of accidental needle sticks and pediatric tissue trauma. Always secure assistance from a second healthcare provider or trained parent.

• Parent Lap Hold (Supine / Vertical Position): The child sits on the parent's lap. The parent wraps their legs around the child's legs and uses one arm to hug the child's torso while extending and securing the target arm firmly at the elbow joint.
• Cradle Hold: Used for infants and young toddlers lying supine on an exam table. An assistant stands on the opposite side of the table, leaning gently over the child's torso to restrain the shoulders and non-target arm.

Blood Volume Limits & Iatrogenic Anemia Risk

Infants and pediatric patients have significantly lower total blood volume (TBV) than adults (an infant's TBV is approximately 80 to 85 mL per kilogram of body weight). Removing large or repeated blood volumes can induce iatrogenic anemia—anemia caused by medical blood sampling.

CLSI Pediatric Volume Limit Rule: Removing > 10% of a pediatric patient's total blood volume within a 30-day period (or > 1% to 5% within 24 hours) is potentially life-threatening. Phlebotomists must log all drawn blood volumes in the patient's record.

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Section 2: Newborn Screening (NBS) & Guthrie Card Protocols

State-mandated Newborn Screening (NBS) tests detect congenital metabolic, endocrine, and hematologic disorders—such as Phenylketonuria (PKU), Congenital Hypothyroidism, Galactosemia, and Sickle Cell Disease—before symptoms cause irreversible brain damage or mortality.

Equipment & Filter Paper Cards

Newborn screening specimens are collected on special absorbent filter paper cards (historically known as Guthrie Cards).

[Infant Heel Stick] ===> [Wipe First Drop] ===> [Touch Large Drop to ONE side of Filter Paper Circle]
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[Air-Dry Horizontally for 3 Hours] <=== [Ensure Blood Soaks Fully to Back]

Step-by-Step NBS Collection Technique

1. Perform a standard heel stick on the medial or lateral plantar surface of the heel (depth < 2.0 mm).
2. Wipe away the first drop of blood thoroughly.
3. Allow a single, large, elevated drop of blood to form at the puncture site.
4. Apply Blood to Filter Paper: Touch the printed circle on the front side of the filter paper card directly to the blood drop. Allow the paper to absorb the blood until the printed circle is completely filled.
5. Check Full Saturation: Turn the card over to confirm the blood has soaked completely through to the back side of the paper.
6. Repeat for all required printed circles on the specimen card.

Critical Quality Rules for NBS Cards

• Single Drop Application: Apply only one large drop per circle. Never reapply blood to an already spotted circle (double-spotting creates uneven blood concentration, leading to inaccurate laboratory quantification and false results).
• No Direct Skin Contact: Do not press the filter paper directly against the infant's heel skin. Skin contact transfers skin oils and compresses the filter paper matrix.
• Drying Protocol: Allow NBS cards to air-dry in a horizontal position on a flat, non-absorbent surface at room temperature (18°C to 22°C) for at least 3 hours.
• Environmental Warnings: Keep drying cards away from direct sunlight, artificial heat sources, moisture, or chemical fumes.

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Section 3: Geriatric Phlebotomy Protocols

Geriatric patients (individuals aged 65 and older) undergo physiological vascular and integumentary changes that require modified phlebotomy execution.

Anatomical & Physiological Aging Changes

• Loss of Skin Elasticity & Subcutaneous Fat: Skin becomes thin, papery, and prone to tearing. Veins lose surrounding connective tissue support, causing them to roll easily.
• Sclerosed & Arthritic Vessels: Blood vessels become narrowed, hardened (sclerosed), and easily prone to collapse under standard vacuum pressure.
• Fragile Capillaries: Increased susceptibility to petechiae (small purple hemorrhagic spots) and hematoma formation.

Technical Modifications for Geriatric Draws

Communication & Sensory Adjustments

• Hearing Loss: Speak in a clear, resonant, medium-pitched voice facing the patient directly. Do not shout, as high-pitched shouting distorts sound for hearing-impaired adults.
• Visual Deficits: Ensure room lighting is adequate and hand documents directly to the patient.
• Cognitive Decline / Dementia: Maintain a calm, unhurried demeanor. Reassure the patient continuously, even if they become disoriented or resistant.