European Experts Issue New Standards for Umbilical Catheter Care in Newborns

Every year, hundreds of thousands of critically ill newborns across Europe and beyond receive life-sustaining fluids, medications, and nutrition through thin tubes threaded into the blood vessels of the umbilical cord. These umbilical venous and arterial catheters are among the most common and most consequential devices in neonatal intensive care, yet the way they are inserted, positioned, secured, and monitored varies dramatically from one hospital to the next. A new recommendation published in Pediatric Research by the Neonatal European Vascular Access Team, or NEVAT, working with the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research, aims to close that gap. The document, the second in a series of ten planned recommendations, lays out a standardized approach to the management of umbilical catheters that its authors say will improve patient safety and reduce harmful practice variation across neonatal units.

The clinical stakes are considerable. Umbilical catheters provide direct access to the central circulation of a newborn in the first days of life, a period when peripheral veins are tiny, fragile, and often inadequate for the concentrated nutrition and vasoactive drugs that preterm and critically ill infants require. The umbilical vein offers a route to the inferior vena cava and the right atrium, while the umbilical arteries allow monitoring of blood gases and blood pressure and continuous infusion of medications. But the same anatomical shortcuts that make these devices so useful also make them dangerous when they are misplaced. A venous catheter that stops short of the inferior vena cava can deliver hypertonic fluid directly into the portal circulation of the liver, causing tissue damage, thrombosis, or even hepatic necrosis. An arterial catheter positioned too high or too low can compromise blood flow to the spinal cord, the intestines, or the lower limbs.

The new recommendation emphasizes that the risks are not hypothetical. Recent systematic reviews and meta-analysis cited by the working group document a substantial burden of adverse events associated with umbilical vascular catheters, including bloodstream infections, thrombosis of the portal venous system, hepatic injury from inadvertent infusion of parenteral nutrition into liver parenchyma, and catheter malposition. One retrospective study published in 2025 specifically examined the pursuit of zero central line-associated bloodstream infections in umbilical catheterization, underscoring that these infections are largely preventable with rigorous insertion and maintenance bundles. A risk prediction model developed by Australian researchers further highlights that adverse events are frequent enough, and predictable enough, to warrant systematic prevention strategies rather than case-by-case vigilance.

At the heart of the recommendation is a call for standardized protocols covering three distinct phases of catheter management: assessment before insertion, the insertion procedure itself, and post-insertion evaluation of catheter tip position. The authors argue that each phase contains critical decision points where deviation from best practice compounds risk. Before insertion, clinicians must assess whether an umbilical catheter is truly the most appropriate vascular access device for the infant’s expected needs and duration of therapy, drawing on structured decision-making tools such as the neonatal device-expert algorithm previously developed by members of the same group. The recommendation aligns with the nomenclature established by the Navigate project, a global position statement that created a common vocabulary for vascular access devices, in part because inconsistent terminology has historically made it difficult to compare evidence and practices across centers.

The insertion phase receives particularly detailed attention. The recommendation describes a technique in which the catheter is advanced under controlled conditions with attention to asepsis, pain management, and securement. Procedural pain in neonates is a recognized concern, and the authors point to established guidelines for procedural pain management in newborns as an integral component of any catheterization. Skin antisepsis is another technical focus. The document reviews the evidence comparing aqueous 2 percent chlorhexidine gluconate with 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol, noting recent studies in moderate and extremely preterm infants suggesting that the alcohol-based preparation is safe after the first week of life and may be associated with a reduced incidence of catheter-related bloodstream infections. A randomized feasibility trial known as the Arctic trial, together with a Cochrane review of antiseptic solutions for central catheter insertion in neonates, informs this guidance, and national surveys of neonatal practice in Italy reveal how rapidly adoption of alcohol-based chlorhexidine has been spreading.

Perhaps the most consequential technical shift endorsed by the recommendation concerns how clinicians confirm that the catheter tip has reached its intended destination. For decades, the default method has been a plain chest and abdominal radiograph obtained after insertion, with the clinician estimating tip position relative to vertebral bodies and cardiac silhouette. The recommendation now champions ultrasound-based tip navigation and tip location, performed in real time during insertion. Structured protocols such as Neo-Echotip, developed for central venous access devices in neonates, allow the operator to watch the catheter advance and to verify the tip position immediately, adjusting depth before securing the device. Recent retrospective data indicate that real-time ultrasound tip location reduces both malposition and radiation exposure during umbilical venous catheter placement, since a correctly placed catheter on the first attempt eliminates the need for repeat radiographs and repositioning procedures.

The evidence base for ultrasound guidance has been accumulating steadily. Prospective studies have used ultrasound to track umbilical venous catheter migration in preterm infants over time, revealing that catheters move as the infant grows and as abdominal pressure changes, a phenomenon with direct implications for how often tip position should be rechecked. Other work has demonstrated that aligning the catheter with the umbilical vein and the ductus venosus under ultrasound guidance improves the likelihood of reaching the ideal central position. Comparative studies of low-lying versus centrally positioned umbilical venous catheters have found higher complication rates when the tip remains in the portal system, reinforcing the argument that precise, verified central placement should be the standard of care rather than an aspiration. An Italian expert consensus on tip location methods for central venous access devices, published in 2026, further consolidates the case for intracavitary electrocardiography and ultrasound as complementary or alternative tools to radiography.

Securement and maintenance form the third pillar of the recommendation. Even a perfectly positioned catheter can migrate, and radiographic assessments of catheter movement over time show that displacement is common in the days following insertion. The recommendation addresses this with guidance on securement techniques, including the use of cyanoacrylate glue, which was evaluated in a randomized controlled trial for umbilical venous catheter securement, and transparent semipermeable dressings, whose moisture vapor transmission properties have been the subject of comparative testing. The authors also draw on infection prevention frameworks, including the Infusion Therapy Standards of Practice, the Epic3 national guidelines from England, and the SHEA neonatal intensive care unit white paper series on preventing central line-associated bloodstream infections, to define how catheters should be handled, accessed, and monitored throughout their dwell time.

For umbilical arterial catheters specifically, the recommendation revisits a long-standing debate about optimal tip position, informed by the Cochrane review originally conducted by Keith Barrington, which compared high-lying catheters positioned above the diaphragm with low-lying catheters below the renal arteries. The working group also acknowledges innovative adaptations, such as the off-label use of peripherally inserted central catheters as umbilical arterial catheters reported in a clinical case series, reflecting the resourcefulness of neonatal teams when conventional devices are unavailable. The broader context for the recommendation is a series of structured insertion bundles developed by the same network, including the SIUVEC protocol for safe insertion of umbilical venous catheters and the SIECC protocol for epicutaneo-cava catheters, both of which were designed to minimize complications during placement and management, and a prospective study of a bundle for central venous catheterization in neonates and children covering more than 700 cases.

The authors, led by Fiammetta Piersigilli of Cliniques Saint Luc and the University of Louvain in Brussels and Robin van der Lee of Radboudumc Amalia Children’s Hospital in Nijmegen, stress that the recommendation is the product of a multidisciplinary consensus spanning neonatologists, nurses, anesthesiologists, and vascular access specialists across Europe, with contributions from the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants. The work received no external funding, and the authors declare no competing interests. As the second installment in a ten-part series, the document signals a broader ambition: to bring the same rigor to every vascular access device in the neonatal unit that infection prevention campaigns brought to hand hygiene a generation ago. If the recommendation achieves its stated goals, the routine, verifiable, ultrasound-guided placement of umbilical catheters could become as standard in neonatal care as the devices themselves, turning one of intensive care’s most useful tools into a demonstrably safer one for the smallest patients.

Subject of Research: Standardized management of umbilical venous and arterial catheters in neonatal intensive care

Article Title: Management of umbilical venous and arterial catheter: Neonatal European Vascular Access Team- ESPR Recommendation 2

Article References: Management of umbilical venous and arterial catheter: Neonatal European Vascular Access Team- ESPR Recommendation 2. (n.d.). https://doi.org/10.1038/s41390-026-05465-8

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05465-8

Keywords: umbilical venous catheter, umbilical arterial catheter, neonatal intensive care, NEVAT, ESPR, ultrasound tip location, catheter malposition, central line-associated bloodstream infection, chlorhexidine skin antisepsis, neonate, vascular access, clinical recommendation