The recommendation comes from the Pediatric and Neonatal Vascular Access Special Interest Group of the ESPR, working alongside NEVAT, a European network dedicated to vascular access care. The author group, led by Matheus van Rens and Robin van der Lee of Radboudumc Amalia Children’s Hospital in Nijmegen, the Netherlands, includes neonatologists, nurses and vascular access experts from institutions across the Netherlands, Belgium, Italy, Austria, the United Kingdom, France, Portugal, Spain, Bulgaria and beyond, with international contributors such as Yogen Singh of the University of California Davis Children’s Hospital. Their stated goal is deceptively simple: ensure that the right vascular access device is chosen from the very start of therapy, rather than discovered through a process of trial and error at the patient’s bedside.

The clinical problem the VAMP addresses is well documented in the authors’ own prior work. In the ABBA project, short for Assess Better before Access, a retrospective cohort study of neonatal intravascular device outcomes published in Frontiers in Pediatrics in 2022, the group catalogued how frequently neonatal vascular access devices fail before therapy is complete. Peripheral intravenous catheters in newborns are notoriously short-lived, and repeated replacement attempts mean repeated needle sticks, repeated pain and repeated exposure to complications. Research cited by the group, including a 2023 study in the Journal of Vascular Access examining how catheter type and material affect therapy failure in neonates, underscores that even the physical properties of the device matter in this population, whose veins may be smaller than a millimeter in diameter.

The stakes extend beyond immediate mechanical failure. Neonatal sepsis, which can be triggered by catheter-associated bloodstream infections, has been linked in a 2024 systematic review and meta-analysis in BMC Pediatrics to adverse neurocognitive outcomes later in life. Pain experienced in the first days and weeks of life is likewise not a transient concern; a 2020 review in Frontiers in Pediatrics by Williams and Lascelles summarized clinical and experimental evidence that early neonatal pain can have lasting implications for painful conditions later in life. In other words, every unnecessary needle stick and every preventable catheter infection is not merely an acute event but a potential contributor to long-term developmental burden. This is why the VAMP authors frame vascular access decision-making as a neuroprotective issue, a theme they developed further in a 2025 patient-centered framework based on the 7-Rights concept published in Pediatric Research.

Technically, the VAMP functions as a structured, patient-centered decision pathway, presented by the authors as a flow diagram that guides clinicians through the assessment of an individual newborn’s veins, the expected duration and type of therapy, and the characteristics of available devices before any needle is inserted. The approach draws on a growing body of standardized pre-procedural assessment protocols. Among these is the Rapid Superficial Vein Assessment, or RaSuVa, described by D’Andrea and colleagues in 2024 as a systematic pre-procedural evaluation of superficial veins to optimize venous catheterization in neonates. Similar systematic ultrasound protocols exist for deeper vessels: the Rapid Central Vein Assessment, or RaCeVa, published by Spencer and Pittiruti in 2019, and the Rapid Femoral Vein Assessment, or RaFeVa, described by Brescia and colleagues in 2021, both of which standardize ultrasound evaluation before central catheterization. The VAMP embeds this assessment-first philosophy into routine neonatal practice.

The framework also builds on and harmonizes existing consensus documents rather than replacing them. The authors position VAMP alongside the neonatal DAV-expert algorithm, a GAVeCeLT/GAVePed consensus published in the European Journal of Pediatrics in 2023 for choosing the most appropriate venous access in newborns, and the ERPIUP consensus on the proper indication and use of peripheral venous access devices, a WoCoVA project published in the Journal of Vascular Access. Other reference points include the UK Vessel Health and Preservation framework updated in 2020, the miniMAGIC appropriateness guide for intravenous catheters in pediatrics published in Pediatrics in 2020, the Infusion Therapy Standards of Practice ninth edition from 2024, and the NANN neonatal peripherally inserted central catheter guideline for practice in its fourth edition. By synthesizing these sources into a single European recommendation, the ESPR group aims to reduce the fragmentation that currently produces wide variation in practice between units and countries.

Insertion technique and device maintenance form a second pillar of the plan. The recommendation references novel insertion bundles developed by Italian collaborators, including the SIUVeC protocol for safe insertion of umbilical venous catheters and the SIECC protocol for epicutaneo-cava catheters, both designed to minimize placement and management complications, as well as the SIC seven-step strategy for centrally inserted central catheters. Once a device is in place, the plan emphasizes evidence-based securement and site care, drawing on trials of cyanoacrylate glue as part of bundles to decrease neonatal PICC-related complications and to secure umbilical venous catheters, and on experience with dialkylcarbamoylchloride dressings at catheter exit sites in pediatric and neonatal populations. Care bundles of this kind have already been shown in a 2018 systematic review and meta-analysis in Archives of Disease in Childhood to reduce central line-associated bloodstream infections in neonatal units, and the SHEA NICU white paper series from 2023 offers practical approaches to the same goal.

Two technological themes run through the recommendation with particular force. The first is point-of-care ultrasound, which the authors describe as central to modern neonatal vascular access, from pre-procedural vein mapping to real-time guidance during insertion. A 2024 review in the European Journal of Pediatrics by Pittiruti, Annetta and D’Andrea summarized the role of ultrasound for vascular access in neonates and children, and a 2023 systematic review and meta-analysis in Diagnostics examined the role of ultrasound specifically in epicutaneo-caval catheter insertion. A related narrative review from 2025 weighs intracavitary electrocardiography against real-time ultrasound for tip navigation and tip location of central venous access devices in the neonate, a question also addressed in a 2025 Italian expert consensus on tip location methods. The second theme is standardization itself: the VAMP’s authors contend that a uniform, reproducible method, applied by every clinician on every shift, is what converts scattered best practices into reliable outcomes.

Notably, the recommendation also extends beyond the technical to the human. The framework incorporates family-centered principles, citing recent work on family integrated care in Acta Paediatrica, a 2024 study in Advances in Neonatal Care on family management skills reported by parents of preterm infants, and a 2025 nonrandomized clinical trial in JAMA Network Open on outcomes following close collaboration with parents interventions in neonatal intensive care units. Pain assessment and management in preterm infants, summarized in a 2022 practice update in Children, are likewise woven into the plan, reflecting the view that vascular access decisions should minimize discomfort as well as complications. The involvement of the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants, acknowledged by the authors for contributions and critical readings of earlier drafts, signals that parent perspectives were part of the drafting process itself.

The authors state that proper use of the VAMP ensures choosing the right vascular access device from the start of therapy, that the method offers a structured and patient-centered approach, that its implementation ensures more uniform practice regarding vascular access in neonates, and that it has the potential to greatly decrease the number of vascular access-related complications in this population. As the first in what the group describes as a ten-recommendation project, VAMP represents the opening move of a coordinated European effort to professionalize neonatal vascular access in the way that adult vascular access care has been professionalized over the past two decades. If the framework achieves its stated aims, the routine insertion of a cannula in a premature newborn could shift from an improvised procedure, repeated until something works, into a planned, ultrasound-informed, family-aware intervention with fewer sticks, fewer infections and fewer of the long-term consequences that follow them. For the smallest patients in intensive care, that shift could matter for a lifetime.

Subject of Research: A structured European recommendation for vascular access device selection and management in neonatal intensive care

Article Title: Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1

Article References: van Rens, M., Hugill, K., Piersigilli, F., Schwaberger, B., Mader, S., Geiger, I., Singh, Y., Ouwehand, T., van den Hoogen, A., Van Eenoo, S., van der Lee, R., on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group (SIG) of the ESPR and NEVAT, van Rens, M., Van Der Lee, R., van den Hoogen, A., Rodriguez-Perez, C., Barone, G., van Eenoo, S., Hugill, K., … Tuna, M. L. (2026). Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1. Pediatric Research. https://doi.org/10.1038/s41390-026-05467-6

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05467-6

Keywords: neonatology, vascular access, VAMP, ESPR, central venous catheters, PICC, ultrasound, neonatal sepsis, care bundles, point-of-care ultrasound, umbilical venous catheter, family integrated care

The introductory paper, published on 17 September 2026, is the work of Fiammetta Piersigilli of Louvain University’s Saint Luc neonatal intensive care unit in Brussels, together with Kevin Hugill, Robin van der Lee, Matheus F. P. T. van Rens, Giovanni Barone, Tobias Werther, Bernhard Schwaberger and Suzy Van Eenoo, writing on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research (ESPR) and the vascular access network NEVAT. The group spans institutions across Belgium, the Netherlands, Italy, Austria, Portugal, Bulgaria, France, Spain, the United Kingdom and the United States, reflecting a deliberate effort to build recommendations that transcend local custom and national tradition. The authors state plainly that vascular access is a pervasive facet of contemporary neonatal practice that lacks standardization, and that some long-standing practices have never been supported by solid evidence.

The technical challenge at the heart of neonatal vascular access is scale. A peripheral vein in a premature infant weighing 500 grams may be less than a millimeter in diameter, with a wall thinner than a human hair. Inserting a cannula into such a vessel demands extraordinary precision, and even a successful placement can fail within hours if the device is not secured and managed correctly. Peripheral intravenous cannulation, the most common procedure in neonatal care, carries substantial complication rates. A multicenter observational study cited by the authors reported significant rates of infiltration, phlebitis and inadvertent dislodgement in neonates, and subsequent research has identified both unmodifiable factors, such as gestational age and vein characteristics, and potentially modifiable factors, such as securement technique and dressing choice, that shape how long a device survives and how often it fails.

Beyond the mechanical risks, the series highlights a dimension of neonatal care that has gained increasing scientific attention in recent years: the developmental and neurobiological cost of repeated painful procedures. Neonates undergoing intensive care may experience dozens of invasive procedures during their stay, and systematic reviews have linked early procedural pain exposure to adverse developmental outcomes in children born preterm. Researchers have also framed the cumulative stress of intensive care as a form of toxic stress that can alter infant outcomes, making every avoided cannulation attempt and every extended device dwell time a meaningful gain for the developing brain. In this light, vascular access is not merely a technical task but a determinant of long-term neurodevelopment, which is precisely why the authors argue that objective, evidence-based standardization matters so much.

The ten recommendations that structure the special series cover the full lifecycle of a vascular access device, from the moment a clinician decides that one is needed to the moment it is removed. A central theme is that the decision to place a device should be made deliberately rather than reflexively. The authors point to the Abba Project, whose name stands for Assess Better before Access, a retrospective cohort study of neonatal intravascular device outcomes that encouraged teams to evaluate whether a device was truly necessary and which type was most appropriate before any needle touched the skin. Decision-support tools such as the neonatal DAV-Expert algorithm, developed through an Italian consensus process, guide clinicians toward the most suitable venous access for a given newborn, balancing expected duration of therapy, osmolarity and pH of infusates, and the condition of available vessels.

Assessment of the infant’s veins before insertion is another pillar of the recommendations. The Rapid Superficial Vein Assessment protocol, known as RASUVA, provides a structured pre-procedural evaluation of superficial veins to optimize catheterization, reducing the number of failed attempts. Once a device is in place, the series draws on insertion bundles that have demonstrated measurable reductions in complications. These include the SIUVEC protocol for safe insertion of umbilical venous catheters, the SIECC insertion bundle for epicutaneo-caval catheters, the so-called GAVECELT bundle applied to central venous catheterization in neonates and children in a prospective study of more than 700 cases, and the Neo-Echotip protocol, which uses ultrasound for tip navigation and tip location during placement of central venous access devices. Intracavitary electrocardiography, in which the catheter itself is used as an electrode to confirm tip position, offers an alternative to chest radiography for verifying that a catheter tip sits in the correct position, reducing radiation exposure and delays.

Securement and infection prevention receive equally rigorous treatment. Central line-associated bloodstream infections remain among the most feared complications of neonatal intensive care, and quality improvement work has shown that adopting evidence-based care bundles can drive infection rates toward zero. The recommendations also embrace a material innovation that has rapidly entered neonatal practice: cyanoacrylate glue, the same class of medical adhesive used in tissue bonding. Randomized and observational studies have evaluated octyl-butyl-cyanoacrylate glue for sutureless securement of epicutaneo-caval catheters, umbilical venous catheters and peripheral intravenous catheters in neonates, with results suggesting reduced dislodgement and fewer complications compared with traditional adhesive dressings and sutures. Because glue eliminates puncture sites from sutures and creates a microbial seal at the insertion point, it represents a technically elegant solution to one of the most persistent problems in the field.

Standardization also extends to language. The series incorporates the Navigate Project, a position statement from European vascular access societies establishing a common nomenclature for vascular access devices. The authors argue that inconsistent terminology, in which the same device may be called different things in different countries or even different wards of the same hospital, undermines research, benchmarking and safe communication between teams. A shared vocabulary allows complication rates to be compared meaningfully across units and allows evidence generated in one setting to be translated reliably into another. This effort aligns with broader international frameworks, including the Infusion Therapy Standards of Practice, whose ninth edition provides an overarching reference for infusion-related care, and the ERPIUP consensus on the proper indication and use of peripheral venous access devices in adults, whose methodology the neonatal group adapted to its own population.

What makes the series notable is its candor about the limits of the evidence. The authors emphasize that the recommendations consolidate existing knowledge and consensus rather than presenting definitive trial data, and they explicitly frame the series as a means of highlighting priorities for further research to address gaps in knowledge. Many practices in neonatal vascular access have evolved through apprenticeship and habit rather than randomized evidence, and the ten recommendations are as much a research agenda as a clinical guideline. By naming where the evidence is thin, the group hopes to direct future studies toward the questions that matter most for outcomes, from optimal dwell times to the long-term developmental impact of procedural pain.

For clinicians, the practical message is that objective standardization of neonatal vascular access is achievable now, with tools that already exist. For the smallest patients, whose veins are fragile and whose developing brains are exquisitely sensitive to stress, the stakes of getting this right could hardly be higher. If the series succeeds in bridging practice gaps and supporting evidence-based standardization across neonatal units worldwide, it may quietly transform one of the most routine yet consequential procedures in medicine, turning an area long governed by individual habit into one governed by shared, scrutinized and continually improved evidence.

Subject of Research: Standardization of neonatal vascular access through international expert consensus recommendations

Article Title: Introduction to the special article series to guide neonatal vascular access

Article References: Piersigilli, F., Hugill, K., van der Lee, R., van Rens, M. F. P. T., Barone, G., Werther, T., Schwaberger, B., Van Eenoo, S., on behalf of the Pediatric and Neonatal Vascular Access SIG of the ESPR and NEVAT, Van Der Lee, R., van Rens, M., van Eenoo, S., van den Hoogen, A., Rodriguez-Perez, C., Breschan, C., Pittiruti, M., Oulego-Erroz, I., Ouwehand, T., Debuf, M.-J., … Tuna, M. L. (2026). Introduction to the special article series to guide neonatal vascular access. Pediatric Research. https://doi.org/10.1038/s41390-026-05468-5

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05468-5

Keywords: neonatal vascular access, Pediatric Research, clinical consensus, central venous catheters, peripheral intravenous cannulation, cyanoacrylate glue, ultrasound guidance, catheter-related bloodstream infection, neonatal pain, ESPR, NEVAT, patient safety

The recommendations come from the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research, working together with NEVAT, a multidisciplinary vascular access network. Led by first author Tobias Werther of the Medical University of Vienna and corresponding author Robin van der Lee of Radboud University Medical Center in the Netherlands, the group spans institutions across Europe and beyond, from Lisbon and Treviso to Brussels, Sofia, and London. Their motivation is blunt: vascular access is a pervasive facet of contemporary neonatal practice, yet it lacks standardization, and some common practices lack supporting evidence. In other words, the procedures are universal, but the way clinicians prepare babies for them varies enormously from unit to unit, and not always in ways supported by data.

The scientific case for taking neonatal pain seriously has grown dramatically over the past two decades. Preterm infants in intensive care are exposed to a remarkable number of painful procedures during their hospital stay, and repeated early-life pain is no longer regarded as a transient inconvenience. Recent research cited by the group links cumulative early pain exposure in premature infants to atypical cerebellar development and later neurodevelopmental deficits, suggesting that unmanaged procedural pain may leave lasting traces in the developing brain. The developing nervous system of a newborn, and especially that of a very preterm infant, processes nociceptive signals with heightened sensitivity, and immature descending inhibitory pathways mean that pain signals arrive essentially unfiltered. The long-standing assumption that newborns barely feel pain, or that any distress is quickly forgotten, has been thoroughly dismantled by modern neuroscience.

A central pillar of the new recommendations is the principle of assessing pain before attempting to treat it. Because preverbal infants cannot report their experiences, clinicians must rely on validated behavioral and physiological indicators: facial expression, body movement, crying, changes in heart rate, and oxygen saturation. The authors emphasize the use of structured pain and sedation scales designed specifically for neonatal and pediatric patients in preverbal stages of development, noting that systematic reviews have evaluated the validity and reliability of such instruments, including for preterm infants. Without consistent measurement, the group argues, pain management becomes arbitrary, and the effectiveness of any intervention, whether pharmacological or non-pharmacological, cannot be judged. Assessment is framed not as a bureaucratic step but as the foundation on which every subsequent decision rests.

On the pharmacological side, the recommendations draw on a substantial evidence base. For minor procedures, oral sucrose has become one of the most widely studied analgesic interventions in neonatology, with Cochrane reviews confirming its effectiveness for procedural pain relief in newborns undergoing painful procedures, and subsequent trials working to identify the minimally effective dose. Sucrose appears to activate endogenous opioid pathways, and its effect can be amplified when combined with non-nutritive sucking, such as a pacifier. Breastfeeding and expressed breast milk also carry evidence for procedural pain relief, offering a natural alternative that combines analgesia with nutrition and maternal contact. Topical anesthetics such as lidocaine-prilocaine cream have been evaluated for needle-related pain, although the evidence in neonates remains more limited than in older children.

For more invasive procedures, particularly the ultrasound-guided placement of central venous catheters, the recommendations acknowledge that simple sweet-tasting solutions are not enough. Here the group points to analgosedation protocols, the deliberate combination of analgesic and sedative agents to keep infants comfortable and still during longer procedures. Randomized controlled trials have examined remifentanil for percutaneous intravenous central catheter placement in preterm infants, and more recent prospective studies have tested structured analgosedation protocols for ultrasound-guided catheterization in the neonatal intensive care unit, including combinations such as ketamine with fentanyl. Population pharmacokinetic studies have clarified how fentanyl exposure in preterm and term newborns depends on pre- and postnatal maturation, underscoring that dosing in this population is a precision exercise rather than a simple weight-based calculation. Intranasal routes for analgosedation have also been systematically reviewed as a practical option for infants in intensive care, while the evidence for intravenous midazolam infusion as a sedative in this population has been critically appraised by Cochrane reviewers.

Perhaps the most striking technical shift reflected in the recommendations is the rise of ultrasound as a routine tool in neonatal vascular access. Structured pre-procedural ultrasound assessment protocols, with acronyms such as Rasuva for superficial veins, Raceva for central veins before catheterization, and Rafeva for the femoral veins of the lower limb, allow clinicians to map vessel anatomy, diameter, and patency before the first needle stick. Structured protocols for ultrasound-based tip navigation and tip location during central venous access device placement further reduce the guesswork. The logic connecting this technology to pain relief is straightforward: every failed insertion attempt is an additional painful procedure, so improving first-attempt success through better planning directly reduces the cumulative pain burden. This philosophy was crystallized in the Abba Project, Assess Better before Access, a retrospective cohort study of neonatal intravascular device outcomes that demonstrated the value of careful pre-procedural assessment.

Alongside drugs and devices, the recommendations give prominent weight to non-pharmacological and family-centered strategies. Systematic reviews and meta-analyses have found that non-pharmacological methods reduce neonatal pain, and the group highlights interventions such as swaddling, facilitated tucking, and skin-to-skin care, for which Cochrane evidence supports a role in procedural pain relief. Notably, one reported practice involves maintaining parent-infant skin-to-skin contact even during peripheral intravenous catheter insertion, a departure from the traditional separation of baby and parent for any sterile procedure. Family integrated care models, in which parents are trained and empowered as partners in their infant’s care rather than visitors, are supported by emerging clinical trial evidence, including nonrandomized trials of close collaboration with parents interventions in neonatal intensive care units. The involvement of the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants in the drafting process signals that parent perspectives were built into the recommendations from the start, not appended afterward.

The recommendations also confront an uncomfortable implementation gap. National guidelines for procedural pain in newborns have existed for years, for example in Italy, where audits of their implementation revealed uneven adherence across units. The American Academy of Pediatrics issued an update on the prevention and management of procedural pain in the neonate nearly a decade ago, and pediatric clinical practice guidelines for acute procedural pain have been systematically reviewed, yet translation into bedside practice remains inconsistent. By focusing specifically on vascular access, the procedures that generate much of the procedural pain burden in neonatal care, the new document aims to close the distance between guideline and practice with concrete, procedure-specific recommendations rather than general exhortations.

For clinicians, the practical message is a sequence: assess the infant’s pain and distress with validated tools, plan the vascular access strategy with ultrasound before touching the patient, choose the appropriate combination of non-pharmacological comfort measures and pharmacological analgesia or analgosedation for the specific procedure, involve parents wherever possible, and reassess afterward to confirm that the strategy worked. For parents, the message is that their presence, touch, and breast milk are not sentimental extras but measurable components of pain care. The authors declare no competing interests and note that the work received no external funding, positioning it as a consensus effort by a community of specialists who see, daily, what unrelieved pain does to the smallest patients. As neonatal intensive care continues to push survival boundaries earlier and earlier, the group’s recommendations make the case that how these babies are treated matters as much as whether they survive, and that a needle inserted with skill, preparation, and compassion is a fundamentally different experience from one inserted without them.

Subject of Research: Management of pain and distress in neonates during vascular access device placement

Article Title: Neonatal vascular access: management of pain and distress during vascular access device placement

Article References: Werther, T., Marçal, M., Tuna, M. L., Salazar, A., van der Lee, R., Lago, P., Mader, S., Piersigilli, F., Van Eenoo, S., Hugill, K., van Rens, M., on behalf of the Pediatric and Neonatal Vascular Access SIG of the ESPR and NEVAT, Van der Lee, R., Van Eenoo, S., van Rens, M., Yousef, N., Schwaberger, B., De Bisschop, B., Ouwehand, T., … Van Delft, B. (2026). Neonatal vascular access: management of pain and distress during vascular access device placement. Pediatric Research. https://doi.org/10.1038/s41390-026-05482-7

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05482-7

Keywords: neonatal pain, vascular access, preterm infants, neonatal intensive care, analgesia, sucrose analgesia, ultrasound-guided catheterization, analgosedation, skin-to-skin care, family integrated care, pain assessment scales, central venous catheters