European Experts Issue New Guidance on Caring for Catheter Exit Sites in Newborns

A team of European neonatal and vascular access specialists has published a detailed recommendation on how clinicians should manage the exit sites of catheters in newborn infants, a seemingly small patch of skin that can determine whether a life-saving device stays safe or becomes a pathway for deadly infection. The guidance, published in the journal Pediatric Research as the seventh installment in a series of ten recommendations on neonatal vascular access, is the product of a structured multidisciplinary consensus process led by the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research together with the Neonatal European Vascular Access Team, known as NEVAT. The document distills current evidence and expert deliberation into practical strategies for assessing, cleaning, securing, and monitoring the point where a catheter crosses the skin of some of the most vulnerable patients in medicine.

The problem the authors set out to address is rooted in the peculiar biology of newborn skin. In preterm infants, the stratum corneum, the outermost barrier layer of the epidermis, is thin and poorly keratinized, which means the skin offers far less resistance to microorganisms and loses water far more rapidly than adult skin. This immaturity drives increased transepidermal water loss and leaves the skin fragile and prone to injury. At the same time, neonates who need intravenous nutrition, medications, or hemodynamic support often carry catheters for weeks, and every dressing change or manipulation of the device creates another opportunity for contamination, skin stripping, or accidental dislodgement. The combination of immature skin, prolonged catheter dwell times, and repeated handling makes the exit site a critical bottleneck in neonatal intensive care, where failures translate directly into catheter-related bloodstream infections, medical adhesive-related skin injury, dressing failure, and loss of vascular access that may be difficult or impossible to replace.

The recommendation covers the full range of devices used in neonatal units, including peripheral venous access devices, central venous access devices such as peripherally inserted central catheters, epicutaneo-caval catheters, femorally and centrally inserted central catheters, umbilical venous and arterial catheters, and intra-arterial lines. Each device type presents a slightly different exit site anatomy and risk profile, but the authors argue that the underlying principles of assessment, antisepsis, securement, and monitoring should be standardized across all of them. Standardization, they contend, is what allows a unit to detect deterioration early, compare outcomes over time, and reduce the unexplained variation in practice that has long characterized neonatal care from one center to another.

Central to the recommendation is the systematic assessment of both the exit site and the surrounding skin. Clinicians are advised to inspect the site at defined intervals, documenting the appearance of the skin, the presence of redness, swelling, or exudate, the integrity of the dressing, and the external catheter length, since a change in the length of catheter protruding from the skin is a classic early sign of migration. The authors emphasize the use of validated neonatal skin assessment tools, drawing on instruments such as the Neonatal Skin Condition Score, to make observations reproducible rather than subjective. Because adhesive-related injury is a well-recognized hazard in very preterm infants, the guidance also stresses careful technique when applying and removing dressings and adhesives, including the use of adhesive removers and gentle peel techniques to avoid stripping the fragile epidermis.

On the question of asepsis, the recommendation endorses the Aseptic Non Touch Technique framework, known as ANTT, distinguishing between Standard-ANTT for procedures involving small key sites and key parts, such as routine exit site care and dressing changes, and Surgical-ANTT for procedures that require a larger sterile field, such as catheter insertion. The ANTT approach, which originated in the United Kingdom and has been adopted widely across Europe, rests on the principle of identifying the key parts of the equipment and the insertion site that must remain free of microorganisms and protecting them from contact with non-sterile surfaces throughout the procedure. The authors point to quality improvement studies showing that standardizing and improving compliance with aseptic non-touch technique can reduce healthcare-associated infections in neonatal units, and they argue that a shared, teachable framework is more reliable than idiosyncratic local habits.

Skin antisepsis before and around catheter care is addressed with specific attention to gestational age, a nuance that distinguishes neonatal practice from adult guidelines. Chlorhexidine-based solutions are recommended as the agents of choice, consistent with their broad-spectrum activity and residual effect, but the concentration and formulation must be adapted to the maturity of the infant’s skin. Recent randomized feasibility work in preterm neonates, including the Arctic trial comparing 2% chlorhexidine gluconate in aqueous solution with 2% chlorhexidine gluconate in 70% isopropyl alcohol, illustrates the ongoing effort to balance antimicrobial efficacy against the risk of chemical burns and skin irritation in extremely immature skin. Alcohol-based preparations act faster and leave less residue, but they carry a higher risk of skin injury in preterm infants and must be allowed to dry fully; aqueous formulations may be preferred for the most fragile patients. The recommendation instructs clinicians to remove antiseptic residue after the procedure to limit cumulative exposure of the developing skin.

Perhaps the most technically distinctive elements of the guidance concern securement. Traditional suture fixation is problematic in neonates because sutures create additional skin breaks and infection risks, so the authors advocate sutureless securement strategies. One approach uses subcutaneously anchored sutureless devices that stabilize the catheter hub without penetrating the skin. The other, increasingly popular in European centers, is cyanoacrylate tissue adhesive, specifically octyl-butyl-cyanoacrylate glue, applied at the exit site to fix the catheter in place and simultaneously form a microbial barrier. Clinical studies in neonates, including randomized trials of cyanoacrylate securement for umbilical venous catheters and observational series in peripherally inserted central catheters and epicutaneo-caval catheters, have reported reductions in accidental dislodgement and promising trends in complication rates. The glue works by polymerizing on contact with tissue moisture, creating a flexible film that anchors the catheter and can be peeled away or sloughs off naturally as the skin exfoliates.

Dressing selection receives equally detailed treatment. The recommendation favors semipermeable transparent films with a high moisture vapor transmission rate, a property usually abbreviated as MVTR. This parameter, typically measured in grams of water vapor passing through a square meter of material per day, determines how well a dressing allows the skin underneath to breathe while still blocking external contaminants and maintaining a sterile field. In neonates, whose skin loses water at high rates and whose catheters may remain in place for weeks, a dressing with inadequate vapor permeability can trap moisture, causing maceration that weakens the skin barrier and promotes microbial growth, whereas an excessively permeable dressing may lose adhesion prematurely. The authors also describe dressing configurations tailored to specific devices, including setups for umbilical catheters, and provide guidance on when and how dressings should be changed, favoring change on indication, such as soiling, loosening, or visible deterioration, rather than on a fixed routine schedule that multiplies manipulation of fragile skin.

The document closes the loop with recommendations on complication monitoring and catheter removal, underscoring that exit site care does not end until the device is out and the site has healed. Clinicians are urged to maintain vigilance for local signs of infection, phlebitis, infiltration, and skin breakdown, and to remove catheters as soon as they are no longer clinically necessary, since dwell time is one of the strongest modifiable risk factors for catheter-related bloodstream infection. The authors acknowledge that the evidence base in neonates remains thinner than in adult vascular access, and that many elements of the recommendation rest on expert consensus informed by studies in related populations, a limitation they address by making the reasoning behind each element explicit.

The significance of the work lies less in any single novel technique than in its ambition to make excellent exit site care universal rather than accidental. By codifying assessment schedules, antisepsis protocols, securement technologies, and dressing standards into a single recommendation, the European group aims to give every neonatal unit, regardless of size or resources, a coherent playbook for protecting the skin-catheter interface. If widely implemented, the authors argue, standardized exit site management could reduce catheter-related infections, medical adhesive-related skin injuries, dressing failures, and device dislodgements, sparing fragile newborns painful reinsertions, prolonged antibiotic courses, and the serious systemic complications that begin, all too often, at a few square centimeters of immature skin.

Subject of Research: Evidence-based management of catheter exit sites in neonatal vascular access

Article Title: Exit site management: neonatal european vascular access team – ESPR recommendation 7

Article References: Piersigilli, F., Romitti, M. G., Van Eenoo, S., van der Lee, R., Hugill, K., van Rens, M., Iacona, G., Barone, G., Rodriguez-Perez, C., on behalf of the Pediatric and Neonatal Vascular Access SIG of the ESPR and NEVAT, Van Eenoo, S., van der Lee, R., van Rens, M., Debuf, M.-J., Milan, A., Yousef, N., Schwaberger, B., Pittiruti, M., Werther, T., … Tuna, M. L. (2026). Exit site management: neonatal european vascular access team – ESPR recommendation 7. Pediatric Research. https://doi.org/10.1038/s41390-026-05471-w

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05471-w

Keywords: neonatology, vascular access, catheter exit site, ANTT, chlorhexidine, cyanoacrylate glue, sutureless securement, transparent dressings, MVTR, catheter-related infection, medical adhesive-related skin injury, ESPR recommendations