European Experts Issue New Standards for Managing Tiny Veins in Newborns

Every day in neonatal intensive care units across Europe, clinicians thread slender plastic catheters into the veins of the smallest and most fragile patients on Earth. These peripheral venous access devices, or PVADs, are the workhorses of newborn medicine, delivering antibiotics, fluids, nutrition, and lifesaving medications through veins that may be thinner than a strand of spaghetti. Yet despite how universal the procedure is, the way these devices are inserted, secured, monitored, and removed has long been governed more by local habit than by hard evidence. A new recommendation published in the journal Pediatric Research aims to change that, offering the fifth in a series of ten structured, evidence-based statements from the Neonatal European Vascular Access Team, known as NEVAT, together with the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Pediatric Research.

The document, led by Matheus van Rens and Robin van der Lee of Radboud University Medical Center in Nijmegen, together with an international consortium spanning the Netherlands, Italy, Belgium, Germany, Austria, Spain, Portugal, France, Bulgaria, the United Kingdom, and beyond, tackles a problem that is deceptively simple to state and notoriously difficult to solve: peripheral intravenous lines in newborns fail, and they fail often. Multicenter observational work cited by the group has documented substantial complication rates in neonatal peripheral cannulation, including infiltration, extravasation, phlebitis, and dislodgement. When a line fails, a baby endures another painful needle stick, clinicians lose precious time, and the delivery of critical therapy is interrupted. In an era when neonatal intensive care has become extraordinarily sophisticated, the humble peripheral cannula has remained a stubbornly weak link.

What makes the new recommendation distinctive is its insistence that vascular access should be planned, not improvised. The authors argue that decisions about which device to place in which baby should shift from habit-driven choices to individualized vascular access planning, in which the intended therapy, its expected duration, and the anatomy of the infant’s veins are assessed before the first needle is inserted. This philosophy builds on the group’s earlier research, including the ABBA project, whose name stands for assess better before access, a retrospective cohort study of neonatal intravascular device outcomes that underscored how much of the variability in device success traces back to decisions made at the very start of therapy. It also aligns with the neonatal DAV-expert algorithm, a consensus framework developed with the Italian vascular access groups GAVeCeLT and GAVePed for choosing the most appropriate venous access in newborns.

A central technical pillar of the recommendation is standardized vein assessment before cannulation. The document endorses the Rapid Superficial Vein Assessment protocol, known as RaSuVA, a pre-procedural systematic evaluation of the superficial veins designed to optimize venous catheterization in neonates. Rather than palpating blindly for a promising-looking vessel, clinicians using RaSuVA systematically survey candidate veins, often with the aid of visualization technology, and select the best available target before puncturing the skin. The logic is straightforward: the quality of the vein chosen at minute zero largely determines whether the catheter will still be functioning days later. Assessment protocols of this kind convert an art into a repeatable procedure, and they give vascular access teams a common language for documenting why a particular vein and device were chosen.

Visualization technology itself features prominently in the recommendation. Near-infrared light devices, which project an image of subcutaneous veins onto the skin by detecting the differential absorption of infrared light by hemoglobin, have been studied in neonatal units as aids to peripheral cannulation. A cross-sectional study in a level III neonatal intensive care unit examined the efficiency of such systems, and a 2024 meta-analysis of randomized controlled trials assessed their effectiveness for peripheral intravenous cannulation in children and adolescents. The recommendation’s authors position these tools within a broader assessment strategy rather than as magic bullets, emphasizing that technology works best when combined with a structured protocol and trained hands. For premature infants whose veins are nearly invisible to the naked eye, even modest improvements in first-attempt success can spare significant distress.

Once a catheter is in place, keeping it there becomes the next battle, and here the recommendation embraces a material that might surprise readers outside the field: medical-grade cyanoacrylate glue. The same class of chemistry found in household superglue, formulated for tissue contact, has emerged as a sutureless securement method for vascular catheters. The group cites retrospective observational work on octyl-butyl-cyanoacrylate glue for securing peripheral intravenous catheters in neonates, as well as a decade of clinical experience with cyanoacrylate securement in a large university hospital and studies of its use for epicutaneo-caval catheters in newborns. Glue-based securement anchors the catheter, seals the puncture site, and may reduce the micro-motion at the catheter tip that contributes to vein irritation. The consortium has even published a dedicated protocol for the safe and effective removal of the adhesive from fragile neonatal skin, acknowledging that a securement method is only as good as its removal strategy.

Securement, however, is a balancing act. The skin of a premature infant is structurally immature, and adhesive dressings can cause medical adhesive-related skin injuries, a problem documented in neonatology departments. The recommendation therefore engages with the properties of transparent semipermeable membranes, including their moisture-vapor transmission characteristics, and with modern infusion therapy standards that govern dressing changes and site inspection. The goal is a securement system that holds the catheter firmly, allows the skin to breathe, permits visual inspection of the insertion site, and peels away without tearing the epidermis. These may sound like small engineering details, but in a two-kilogram infant, they are the difference between a line that lasts a week and one that fails within hours.

Perhaps the most forward-looking element of the recommendation is its attention to detecting failure early. Infiltration and extravasation, in which infused fluid leaks out of the vein into surrounding tissue, are among the most common and feared complications of peripheral therapy in neonates, and severe extravasation injuries can cause lasting tissue damage. The authors highlight research into novel sensor technology for earlier notification of such events in the neonatal population, as well as work on optical detection of infiltration during peripheral intravenous infusion in newborns. The premise is compelling: rather than waiting for a nurse to notice swelling or for an alarm to sound after tissue has already been harmed, continuous monitoring could flag the leak at its onset, allowing the infusion to be stopped before injury occurs. Combined with retrospective analyses of the modifiable and unmodifiable factors that drive device-related complications, this surveillance-oriented approach reframes catheter failure not as bad luck but as a preventable event with detectable precursors.

The recommendation also situates peripheral devices within the full spectrum of neonatal vascular access, including long peripheral catheters, which occupy the gap between short peripheral cannulas and centrally placed epicutaneous-caval catheters, and the prevention of catheter-related bloodstream infections, a field with its own established evidence base. Antiseptic skin preparation before catheter insertion, including the use of chlorhexidine gluconate in isopropyl alcohol in premature neonates, is addressed in light of Cochrane evidence on antiseptic solutions for neonatal central catheter insertion. Even the experience of the baby and family is not neglected: the consortium has published work on maintaining parent-infant skin-to-skin contact during catheter insertion, reflecting a growing conviction that technical excellence and developmental care are not competing priorities but complementary ones.

What emerges from the document is less a single technique than a system: standardized nomenclature, consistent with the NAVIGATE project’s position statement on vascular access device terminology; structured pre-procedural assessment; evidence-informed device selection; modern securement; vigilant surveillance; and gentle removal. The authors acknowledge that some long-standing practices in neonatal vascular access lack supporting evidence, and their recommendation is explicitly an effort to close that gap with structured, evidence-based guidance. For a field in which the difference between success and failure is measured in millimeters of vein and hours of dwell time, the arrival of a unified European standard for peripheral venous access marks a quiet but consequential shift. If the recommendation achieves its aims, the smallest patients in intensive care will spend less time being stuck with needles and more time simply being babies.

Subject of Research: Evidence-based management of peripheral venous access devices in neonatal care

Article Title: Management of peripheral venous access devices (PVADs): Neonatal European Vascular Access Team – ESPR Recommendation 5

Article References: Management of peripheral venous access devices (PVADs): Neonatal European Vascular Access Team – ESPR Recommendation 5. (n.d.). https://doi.org/10.1038/s41390-026-05515-1

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05515-1

Keywords: neonatology, vascular access, peripheral venous access devices, ESPR recommendations, NEVAT, RaSuVA, cyanoacrylate glue, near-infrared vein visualization, extravasation, neonatal intensive care, catheter securement, Pediatric Research