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

The research, conducted at Adana City Training and Research Hospital and published in BMC Pediatrics, analyzed 58 preterm infants who underwent a total of 63 catheterization episodes. The cohort was extraordinarily premature, with a median gestational age of 27 weeks and a median birth weight of just 900 grams. These are babies whose skin is translucent, whose lungs are still maturing, and whose veins are fragile enough that every invasive procedure carries disproportionate risk. For this population, the authors argue, the question of catheter tip location is not a technical nicety but a matter of immediate clinical safety, because a malpositioned catheter can cause vessel perforation, cardiac arrhythmia, pleural effusion, or the inadvertent infusion of hypertonic solutions into surrounding tissue.

The technique the team evaluated is conceptually simple. Instead of relying on a plain radiograph, in which the radiopaque catheter may be indistinguishable from overlapping bones and soft tissues, clinicians instill a small bolus of iohexol—a non-ionic, low-osmolar iodinated contrast agent available at concentrations of 300 or 350 milligrams of iodine per milliliter—directly through the catheter lumen. The contrast fills the catheter and briefly opacifies its full course, so the subsequent X-ray captures not just a faint line but a sharply defined trajectory from the insertion site all the way to the tip. The authors describe a characteristic radiographic appearance they call the butterfly sign, produced when adequate opacification of the catheter creates a winged pattern at the point where the device enters the vessel. When radiographs showed superposition of structures or the absence of this butterfly sign, the team considered the image suboptimal and repeated the procedure with additional contrast.

Defining success required an anatomical standard. For catheters inserted through the upper extremities, the target tip position was set between the second and fifth thoracic vertebral levels, corresponding to the lower superior vena cava or the cavoatrial junction. For lower extremity insertions, the acceptable range was between the ninth and tenth thoracic vertebral levels, where the catheter tip should rest within the inferior vena cava. These landmarks matter because the ideal tip location balances two competing hazards: a tip that is too peripheral increases the risk of phlebitis and thrombosis, while a tip that advances too far toward or into the heart can provoke arrhythmias or cardiac perforation. In adults, tip verification is routine; in infants weighing under a kilogram, the margin of error shrinks to a few millimeters, and the bony landmarks themselves are tiny and difficult to interpret.

The results revealed how far current practice falls short of that ideal. Only 20 percent of the catheters in the study were positioned at the predefined target level on initial placement. In other words, four out of five catheters required some form of correction or repositioning before they could be considered safely located. This striking figure underscores the central argument of the paper: without a reliable visualization method, clinicians may be unknowingly operating with malpositioned devices, and the true rate of malposition in ultrathin PICCs has likely been underestimated simply because plain radiography could not detect it. Contrast-enhanced imaging, by making the catheter’s path explicit, converts a guess into a measurement.

Efficiency of the technique also emerged as a key finding. Across the 63 catheterization episodes, the team performed 71 contrast administrations in total, meaning that a single dose was sufficient in 84 percent of cases. The remaining episodes required a second administration, typically because the initial radiograph failed to demonstrate adequate opacification or because the butterfly sign was absent. For a population in which every handling event carries stress, heat loss, and infection risk, the ability to confirm tip position with one dose and one image represents a meaningful advantage over repeated plain films or blind repositioning attempts.

Safety was, understandably, the most scrutinized dimension of the study. Iodinated contrast agents are well tolerated in adults, but preterm infants have immature renal function, small circulating blood volumes, and a thyroid gland that avidly takes up iodine, raising theoretical concerns about contrast-induced nephropathy and iodine-induced thyroid dysfunction. The researchers therefore monitored serum creatinine at three time points—baseline, 48 to 72 hours after contrast administration, and again at 3 to 7 days—and evaluated kidney injury using the KDIGO classification. Among the 45 catheterization episodes that could be fully evaluated for renal outcomes, stage 1 acute kidney injury occurred in five cases, an incidence of 11.1 percent. Importantly, the authors report no allergic reactions, no catheter occlusions attributable to the contrast, and no clinically significant contrast-related thyroid dysfunction during the observation period.

It is worth interpreting the renal findings with appropriate caution, as the authors themselves do. Stage 1 acute kidney injury is common in extremely preterm infants for many reasons unrelated to contrast exposure, including hypotension, respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, and exposure to nephrotoxic medications. Without a matched control group of infants who received ultrathin PICCs without contrast, the 11.1 percent figure cannot be attributed to iohexol itself. The study’s retrospective, single-center design limits causal inference, and the authors are explicit that no evident short-term safety signal emerged in this cohort rather than claiming definitive safety. Larger, ideally prospective, comparative studies would be needed to quantify any true renal or thyroid risk attributable to the procedure.

Even with those caveats, the clinical implications are substantial. Ultrathin 1 French PICCs have become increasingly popular in neonatology precisely because they suit the smallest veins of micro-preemies, allowing parenteral nutrition and long-term intravenous therapy without the complications of repeated peripheral cannulation. But their adoption has outpaced the availability of reliable verification methods, and many units still rely on plain radiographs that may simply fail to show the device. The contrast-enhanced protocol described in this study offers a low-cost, widely accessible alternative that requires no special equipment beyond the contrast agent and standard radiography already present in any neonatal intensive care unit. The butterfly sign, in particular, gives clinicians a simple visual quality check: if the sign is absent, the image is not trustworthy, and the study should be repeated rather than acted upon.

The broader lesson of the study extends beyond one catheter type or one hospital. In modern medicine, devices are often miniaturized faster than the diagnostic tools needed to monitor them, and the gap is filled by improvisation. This research demonstrates that a deliberate, protocolized approach—defining anatomical targets, standardizing contrast doses, setting explicit criteria for image adequacy, and prospectively tracking renal function—can close that gap even in the most fragile patients. For the 900-gram infant whose catheter tip sits a few millimeters from the heart, the difference between an invisible line on an X-ray and a clearly opacified trajectory may be the difference between uneventful therapy and a catastrophic complication. As neonatal intensive care continues to push the boundaries of viability at ever lower gestational ages, techniques like contrast-enhanced radiography remind us that sometimes the most impactful innovations are not new devices at all, but better ways of seeing the ones already in place.

Subject of Research: Contrast-enhanced radiography for localizing ultrathin PICC tips in preterm infants

Article Title: Contrast-enhanced radiography for localization of ultrathin (1 F) PICCs in preterm infants: a retrospective observational study

Article References: Çeki̇nmez, E. K., Gülaşı, S., Demi̇r, O., Coşkun, H., & Bulut, H. Ç. (2026). Contrast-enhanced radiography for localization of ultrathin (1 F) PICCs in preterm infants: a retrospective observational study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07573-0

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07573-0

Keywords: preterm infants, PICC, contrast-enhanced radiography, iohexol, catheter malposition, neonatology, NICU, acute kidney injury, butterfly sign, radiography, very low birth weight, catheter tip localization