The review, led by Rajendra Prasad Anne of Kasturba Medical College at Manipal Academy of Higher Education in India, together with colleagues from the United Arab Emirates and India, set out to answer a deceptively simple question: when a newborn needs central venous access on the first day of life, which device is safer? The team searched PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials up to November 2025, capturing both randomised controlled trials and non-randomised studies of interventions. Their primary endpoints were the outcomes that matter most at the bedside: central line-associated bloodstream infection, known as CLABSI, mortality, late-onset sepsis and catheter-related complications such as thrombosis, occlusion, bleeding and tip malposition.

After screening the literature, the researchers pooled seven studies, five randomised trials and two non-randomised studies, encompassing 1,522 neonates. That may sound modest against the scale of neonatal medicine, but in a field where individual trials are small and fragmented, a meta-analysis of this kind carries real weight. The reviewers applied the GRADE framework to rate the certainty of the evidence and used random-effects models to combine results, acknowledging from the outset that the underlying studies differed in populations, protocols and catheter-management practices.

The headline finding is, in one sense, a null result. When the randomised trials were pooled, there was no statistically significant difference between PICCs and UVCs in the risk of central line-associated bloodstream infection. The pooled risk ratio was 0.75, with a 95 percent confidence interval of 0.50 to 1.11, a range that crosses the threshold of no effect. Mortality told a similar story, with a risk ratio of 1.05 and a confidence interval of 0.58 to 1.90. In plain terms, the evidence does not demonstrate that choosing a PICC over an umbilical line in the first day of life reduces bloodstream infections or saves lives, a conclusion that challenges the intuition of teams who have favoured PICCs on infection-prevention grounds.

Beneath that null result, however, the analysis surfaced signals that neonatologists will not be able to ignore. Babies who received PICCs showed a trend toward higher rates of late-onset sepsis, with a risk ratio of 1.36 and a confidence interval of 0.97 to 1.91, hovering just at the edge of statistical significance. Hospital stays also tended to be longer in the PICC groups, by a mean difference of 3.2 days, though the confidence interval of minus 0.2 to 6.6 days included the possibility of no difference. Neither finding is definitive on its own, but both point in the same direction, and both carry clinical consequences if they are real.

The mechanical performance of the two devices diverged more sharply. PICCs were significantly less likely to become malpositioned, meaning their tips wandered from the intended central position less often than umbilical catheters, with a risk ratio of 0.65 and a confidence interval of 0.49 to 0.86. Yet the same fine-bore lines paid a price elsewhere: they were nearly three times as likely to occlude, with a risk ratio of 2.84 and a confidence interval of 1.23 to 6.57. Anyone who has watched a nurse struggle to flush a clotted neonatal PICC will recognise the practical reality behind that number. The review also found that PICC insertion took significantly longer than umbilical catheterisation, a meaningful consideration in the delivery room, where minutes can matter and where the umbilical vein offers an immediate, anatomically obvious route.

One of the most intellectually honest parts of the analysis concerns catheter dwell time. The reviewers noted that PICCs tended to remain in place longer than umbilical catheters in the included studies, and they flagged this as an important unresolved confounder. The logic is straightforward: the longer any central line stays in the body, the greater the cumulative opportunity for microorganisms to colonise it and for bloodstream infection to develop. If PICCs dwell longer, any apparent excess of late-onset sepsis could partly reflect exposure time rather than intrinsic device risk, and conversely, the absence of an infection advantage for PICCs becomes even more striking given their longer residence. Disentangling device effects from dwell-time effects will require trials that standardise catheter duration, something the existing literature has not done.

Why does this matter beyond the neonatal unit? Central line-associated bloodstream infections are among the most feared complications in intensive care, driving antibiotic use, prolonging hospitalisation and, in vulnerable preterm infants whose immune systems are immature, contributing to mortality and long-term neurodevelopmental harm. Late-onset sepsis, which typically strikes after the first seventy-two hours of life, is a leading cause of death and disability in very low birth weight infants. If the choice of access device on day one influences these outcomes, then a simple procedural decision could ripple through an entire lifetime. Conversely, if the devices are truly equivalent on infection outcomes, units can base their choices on other grounds: insertion speed, malposition risk, occlusion rates, staff training and the anticipated duration of therapy.

The practical implications cut in different directions. For teams that need immediate central access at resuscitation, the umbilical venous catheter remains the fastest and most familiar option, and the new analysis gives no reason to abandon it. For infants expected to need weeks of parenteral nutrition or prolonged antibiotic courses, the PICC’s lower malposition rate and longer usable lifespan may still justify its placement, provided teams are prepared for occlusions and for the longer insertion procedure. What the review does not support is the assumption that switching early from an umbilical line to a PICC will, by itself, lower infection rates. The authors conclude plainly that current evidence does not demonstrate a reduction in CLABSI, mortality or late-onset sepsis when neonatal PICCs are used instead of UVCs for early central venous access.

Like all meta-analyses, this one inherits the limitations of its ingredients. Seven studies and roughly fifteen hundred infants is a small evidence base for a question of this importance, and the two non-randomised studies included are inherently vulnerable to selection bias, since clinicians may choose one device over the other based on how sick a baby appears. The GRADE assessment reflects that uncertainty. Still, the work exemplifies a quiet revolution in neonatology: the systematic aggregation of small trials to extract answers that no single centre could deliver alone. The review was registered prospectively on PROSPERO under number CRD42024604746 and received no external funding, and the authors declare no competing interests. For the parents of the roughly 1,500 infants whose data underpin this analysis, and for the millions more who will pass through neonatal units, the message is a call for better trials, not a final answer. Until those arrive, the humble umbilical catheter, inserted in the first minutes of life, remains a formidable and entirely defensible first choice.

Subject of Research: Comparative safety of peripherally inserted central catheters versus umbilical venous catheters for central venous access in newborns

Article Title: Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes

Article References: Anne, R. P., Vardhelli, V., RD, R., & Murki, S. (2026). Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07761-y

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07761-y

Keywords: neonatology, central venous access, PICC, umbilical venous catheter, CLABSI, late-onset sepsis, meta-analysis, systematic review, premature infants, catheter complications, neonatal intensive care, bloodstream infection

The document is the eighth recommendation in a series produced by the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research, working together with NEVAT, a European network of vascular access specialists. The series is designed to cover the entire process of neonatal vascular access, and this installment focuses squarely on infection prevention. Its central message is that safe catheter care is not a single intervention but a chain of practices that must remain unbroken across insertion, maintenance and discontinuation, and that standardized protocols for assessment, insertion and evaluation are essential if units are to protect their most vulnerable patients.

The stakes could hardly be higher. Central-line-associated bloodstream infections, often abbreviated as CLABSI, remain a significant burden in neonatal intensive care, and Dutch surveillance data cited by the authors show that these infections continue to occur even in well-resourced units. For a premature infant, a bloodstream infection is not merely a temporary setback. Research summarized in the recommendation links neonatal sepsis to impaired neurocognitive outcomes, and studies of extremely preterm children show that late-onset meningitis and Candida infections are associated with worse neurodevelopmental trajectories. In other words, an infection that enters through a catheter can alter the course of a child’s entire life, which is why the authors argue that infection prevention strategies are key to safe neonatal vascular access.

Technically, the recommendation weaves together international guidance with adaptations specific to the neonatal intensive care unit. The authors draw on the ninth edition of the Infusion Therapy Standards of Practice, widely regarded as the reference framework for infusion care, as well as infection control strategies for acute-care hospitals updated in 2022 and a dedicated white paper series offering practical approaches to preventing central-line-associated bloodstream infections in neonatal units. The goal, the team explains, is to reduce the microbial burden around vascular devices by combining evidence-based measures with the practical realities of caring for infants who may weigh less than a kilogram and whose skin, immune system and veins are all uniquely vulnerable.

One of the technical pillars of the recommendation is aseptic technique, and in particular the Aseptic Non Touch Technique, known as ANTT. This practice framework, illustrated in one of the article’s figures, is built on the principle that the key parts of a vascular system, such as catheter hubs, connectors and injection ports, must never come into contact with non-sterile surfaces or hands. Studies from London hospitals and quality improvement projects in other settings have shown that improving compliance with ANTT during intravenous line maintenance can reduce healthcare-associated infections. By embedding this framework in neonatal practice, the European team aims to make the standard of asepsis uniform rather than dependent on the habits of individual clinicians or units.

Skin disinfection is another area where the recommendation engages with rapidly evolving evidence. The choice of antiseptic for central catheter insertion in neonates has long been contested, because chlorhexidine, the workhorse antiseptic in adult care, carries concerns about skin injury in premature infants. The authors reference a Cochrane review of antiseptic solutions for neonatal central catheter insertion and recent clinical trials comparing 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol with aqueous preparations, including the Arctic randomized feasibility trial. These studies reflect a genuine effort to determine which agent best balances antimicrobial efficacy against the delicate skin of a preterm infant, and the recommendation situates itself within this ongoing debate rather than pretending it is settled.

The recommendation also emphasizes that infection prevention begins before any catheter is inserted, with careful assessment of the infant’s veins and a deliberate choice of the most appropriate device. The authors cite the Assessment Better before Access project, a retrospective cohort study of neonatal intravascular device outcomes, and a pre-procedural systematic evaluation of superficial veins designed to optimize venous catheterization. The logic is straightforward: every failed peripheral attempt creates additional entry points for microorganisms and additional skin trauma, so choosing the right device the first time is itself an infection prevention measure. Consensus algorithms for selecting venous access in newborns, including work from Italian neonatal groups on umbilical venous catheters and epicutaneo-caval catheters, inform this assessment-first philosophy.

Once a line is in place, securement and dressing choices become critical to keeping microbes out. The recommendation discusses cyanoacrylate glue, a medical adhesive that seals the catheter entry site and has been tested in randomized trials for umbilical venous catheters and in observational studies for peripheral and central catheters in neonates, with evidence suggesting it can reduce complications as part of a broader bundle. It also considers subcutaneously anchored securement devices and modern dressing technologies, including dialkylcarbamoylchloride-coated dressings for catheter exit sites and the material properties of transparent semipermeable films. Each of these technologies aims to prevent the micro-movements of the catheter within the tract that allow skin flora to migrate inward, while also protecting the fragile skin from medical adhesive-related injuries, a recognized problem in neonatal units.

Perhaps the most distinctive feature of the recommendation is its attention to the social dimension of neonatal care. The authors highlight evidence that parent-infant skin-to-skin contact can be maintained even during peripheral catheter insertion, and they situate infection prevention within the broader movement toward family integrated care, in which parents are trained partners rather than visitors. Recent clinical trial data on close collaboration with parents in neonatal units and studies of family management skills suggest that involving families does not compromise safety and may enhance it. Hand hygiene, the subject of a Cochrane review on preventing infections in neonates, remains the simplest and most powerful tool available to staff and parents alike, and the recommendation frames it as a shared responsibility across the entire care environment.

Finally, the recommendation addresses the end of the catheter’s life. Timely discontinuation, careful removal technique and ongoing surveillance for bloodstream infection all form part of the lifecycle approach. The authors point to Dutch work on sustainable CLABSI surveillance and consensus toward new criteria, reflecting a European effort to measure these infections consistently so that units can compare performance and improve. Taken together, the document represents a rare attempt to consolidate scattered evidence into a single, practical standard for neonatal vascular access across the continent. For the clinicians who care for the smallest patients, and for the families who trust them, the message is clear: every catheter is a lifeline and a liability at once, and only disciplined, standardized, evidence-based practice from insertion to removal can keep the lifeline from becoming the pathway for harm.

Subject of Research: Infection prevention strategies for neonatal vascular access catheters

Article Title: Infection prevention: neonatal European vascular access team – ESPR recommendation 8

Article References: Infection prevention: neonatal European vascular access team – ESPR recommendation 8. (n.d.). https://doi.org/10.1038/s41390-026-05464-9

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05464-9

Keywords: neonatal intensive care, vascular access, CLABSI, infection prevention, catheter insertion, aseptic non touch technique, chlorhexidine, cyanoacrylate glue, preterm infants, hand hygiene, family integrated care, ESPR