The new document, published in the journal Pediatric Research, is the fifth in a series of ten recommendations developed jointly by the Neonatal European Vascular Access Team, known as NEVAT, and the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Pediatric Research, or ESPR. Led by Matheus van Rens and Robin van der Lee of Radboud University Medical Center in the Netherlands, together with an international consortium of neonatologists, nurses, anesthetists, and vascular access experts spanning institutions from Brescia to Brussels, London to Sofia, the recommendation tackles a deceptively simple question: how should clinicians manage the humble peripheral intravenous cannula in a newborn? The answer, the authors argue, demands a complete shift in mindset, away from tradition and toward structured, individualized vascular access planning.

The scale of the problem is striking. Vascular access is, as the authors describe it, a pervasive facet of contemporary neonatal practice, yet it lacks standardization, and some common practices simply lack supporting evidence. Peripheral catheters in neonates fail at notoriously high rates, with complications such as infiltration, in which infused fluid leaks into surrounding tissue, and extravasation, in which vesicant medications escape the vein and can cause devastating skin and tissue injury. A multicenter observational study cited in the recommendation documented substantial complication rates in neonatal peripheral cannulation, and retrospective cohort work from the same Dutch group, including the ABBA project, which stands for Assess Better Before Access, has catalogued the device outcomes and modifiable risk factors that drive those failures. Each failed catheter means another painful puncture attempt, another delay in therapy, and another source of stress for fragile infants and their families.

What makes the new recommendation novel is its integration of three pillars: advanced visualization technology, standardized assessment protocols, and modern securement strategies. On the technology front, the authors highlight the growing role of near-infrared light devices, which project an image of subcutaneous veins onto the skin, making otherwise invisible vessels easier to target. Cross-sectional research in a level III neonatal intensive care unit evaluated the efficiency of such systems for peripheral cannulation, and a 2024 meta-analysis of randomized controlled trials examined the effectiveness of near-infrared light devices for venous cannulation in children and adolescents. Ultrasound, too, features prominently, building on prior work that systematically mapped the diameter of deep veins in newborns and on international evidence-based recommendations for ultrasound-guided vascular access. The message is clear: in the smallest patients, seeing the target before you puncture it is no longer a luxury but a standard of care.

Equally important is the recommendation’s embrace of structured pre-procedural assessment. The document incorporates a protocol known as RaSuVA, short for Rapid Superficial Vein Assessment, a systematic pre-procedural evaluation of superficial veins designed to optimize venous catheterization in neonates. Rather than choosing an insertion site on the basis of convenience or habit, clinicians are encouraged to survey the available vasculature deliberately, matching the characteristics of the vein to the intended therapy and the expected duration of treatment. This individualized planning represents a philosophical departure from the one-size-fits-all approach that has historically dominated neonatal units, where the first accessible vein often won by default regardless of whether it was the right vessel for the job.

The recommendation also draws on the broader ERPIUP consensus, a European set of recommendations on the proper indication and use of peripheral venous access devices developed under the WOCOW project, as well as the ninth edition of the Infusion Therapy Standards of Practice, the most widely recognized reference framework in infusion nursing. By anchoring neonatal-specific guidance within these established international standards, the authors ensure that the care of a two-kilogram infant in Rotterdam or Rimini aligns with the same evidence base that governs adult vascular access worldwide, while respecting the unique anatomy, skin fragility, and developmental needs of newborns.

Securement and dressing strategies receive particularly detailed attention, and here the science has moved rapidly in recent years. Tissue adhesive, specifically octyl-butyl-cyanoacrylate glue, has emerged as a sutureless method of anchoring catheters, and retrospective observational studies in neonatal populations have evaluated its use for securing peripheral intravenous catheters. Related work has documented a decade of clinical experience with cyanoacrylate glue for venous access in a large university hospital, demonstrated its safety for securing epicutaneo-caval catheters in neonates, and, crucially, established safe and effective techniques for removing the adhesive without injuring fragile neonatal skin. The recommendation also weighs the properties of transparent semipermeable membranes, including their moisture-vapor transmission characteristics, against the documented risk of medical adhesive-related skin injuries in neonatal departments, a real concern given that the stratum corneum of a premature infant is thinner and more permeable than that of an adult.

Surveillance and early detection of complications form another pillar of the document. The authors cite research on the risks of peripheral intravenous therapy infiltration and extravasation, known by the acronym PIVIE, and on the potential for earlier notification of such events using novel sensor technology in a neonatal population. Complementary work has explored optical detection of infiltration during peripheral infusion in neonates, suggesting a future in which smart dressings and continuous monitoring could alert clinicians to a failing catheter before visible swelling appears. The recommendation also addresses the choice of catheter material and gauge, drawing on studies of how peripheral catheter type and material affect therapy failure in neonates, and considers the emerging role of long peripheral catheters as a middle ground between short peripheral cannulas and epicutaneous-caval central catheters.

Infection prevention and skin antisepsis round out the technical scope. The recommendation situates peripheral access within the broader context of strategies to prevent central line-associated bloodstream infections in acute-care hospitals and practical neonatal intensive care approaches to the same problem, while acknowledging the nuances of antiseptic selection in newborns. Research comparing 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol for skin disinfection during catheter insertion in premature neonates, alongside a Cochrane systematic review of antiseptic solutions for neonatal central catheter insertion, underscores both the promise and the caution required, since some antiseptic agents carry toxicity concerns in the smallest infants. Even family-centered care makes an appearance: a Dutch case report describes maintaining parent-infant skin-to-skin contact during peripheral catheter insertion, a reminder that technical excellence and developmental care need not be adversaries.

By shifting from habit-driven decisions to individualized vascular access planning, the ESPR and NEVAT consortium has set what its members describe as a new standard for safer, more effective neonatal intravenous therapy. The work was not externally funded, and the authors declare no competing interests, lending weight to its conclusions. For clinicians, the practical takeaways are concrete: assess the veins systematically before every insertion, use visualization technology where available, secure catheters with modern adhesives and dressings chosen for neonatal skin, monitor vigilantly for infiltration, and remove or replace devices based on clinical indication rather than arbitrary routine. For parents, the promise is subtler but no less profound: fewer failed attempts, fewer painful procedures, and a lower risk of the tissue injuries that can scar a child for life. In a field where the patients cannot speak and their veins are measured in fractions of a millimeter, that quiet revolution may prove to be one of the most consequential advances in neonatal care this decade.

Subject of Research: Evidence-based management of peripheral venous access devices in neonatal intensive care

Article Title: Management of Peripheral Venous Access Devices (PVADs): Neonatal European Vascular Access Team – ESPR recommendation 5

Article References: van Rens, M., van der Lee, R., van den Hoogen, A., Rodriguez-Perez, C., Piersigilli, F., Mader, S., Geiger, I., Barone, G., Van Eenoo, S., Hugill, K., on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group (SIG) of the European Society for Pediatric Research (ESPR) and Neonatal European Vascular Access Team (NEVAT), van Rens, M., Van Der Lee, R., van den Hoogen, A., Barone, G., van Eenoo, S., Hugill, K., Breschan, C., Pittiruti, M., … Tuna, M. L. (2026). Management of Peripheral Venous Access Devices (PVADs): Neonatal European Vascular Access Team – ESPR recommendation 5. Pediatric Research. https://doi.org/10.1038/s41390-026-05462-x

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05462-x

Keywords: neonatology, vascular access, peripheral venous catheters, ESPR, NEVAT, near-infrared vein imaging, cyanoacrylate glue, extravasation, RaSuVA, infusion therapy standards, neonatal intensive care, clinical recommendations

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 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

The document, led by Matheus van Rens and Robin van der Lee of Radboud University Medical Center in Nijmegen, together with an international consortium spanning the Netherlands, Italy, Belgium, Germany, Austria, Spain, Portugal, France, Bulgaria, the United Kingdom, and beyond, tackles a problem that is deceptively simple to state and notoriously difficult to solve: peripheral intravenous lines in newborns fail, and they fail often. Multicenter observational work cited by the group has documented substantial complication rates in neonatal peripheral cannulation, including infiltration, extravasation, phlebitis, and dislodgement. When a line fails, a baby endures another painful needle stick, clinicians lose precious time, and the delivery of critical therapy is interrupted. In an era when neonatal intensive care has become extraordinarily sophisticated, the humble peripheral cannula has remained a stubbornly weak link.

What makes the new recommendation distinctive is its insistence that vascular access should be planned, not improvised. The authors argue that decisions about which device to place in which baby should shift from habit-driven choices to individualized vascular access planning, in which the intended therapy, its expected duration, and the anatomy of the infant’s veins are assessed before the first needle is inserted. This philosophy builds on the group’s earlier research, including the ABBA project, whose name stands for assess better before access, a retrospective cohort study of neonatal intravascular device outcomes that underscored how much of the variability in device success traces back to decisions made at the very start of therapy. It also aligns with the neonatal DAV-expert algorithm, a consensus framework developed with the Italian vascular access groups GAVeCeLT and GAVePed for choosing the most appropriate venous access in newborns.

A central technical pillar of the recommendation is standardized vein assessment before cannulation. The document endorses the Rapid Superficial Vein Assessment protocol, known as RaSuVA, a pre-procedural systematic evaluation of the superficial veins designed to optimize venous catheterization in neonates. Rather than palpating blindly for a promising-looking vessel, clinicians using RaSuVA systematically survey candidate veins, often with the aid of visualization technology, and select the best available target before puncturing the skin. The logic is straightforward: the quality of the vein chosen at minute zero largely determines whether the catheter will still be functioning days later. Assessment protocols of this kind convert an art into a repeatable procedure, and they give vascular access teams a common language for documenting why a particular vein and device were chosen.

Visualization technology itself features prominently in the recommendation. Near-infrared light devices, which project an image of subcutaneous veins onto the skin by detecting the differential absorption of infrared light by hemoglobin, have been studied in neonatal units as aids to peripheral cannulation. A cross-sectional study in a level III neonatal intensive care unit examined the efficiency of such systems, and a 2024 meta-analysis of randomized controlled trials assessed their effectiveness for peripheral intravenous cannulation in children and adolescents. The recommendation’s authors position these tools within a broader assessment strategy rather than as magic bullets, emphasizing that technology works best when combined with a structured protocol and trained hands. For premature infants whose veins are nearly invisible to the naked eye, even modest improvements in first-attempt success can spare significant distress.

Once a catheter is in place, keeping it there becomes the next battle, and here the recommendation embraces a material that might surprise readers outside the field: medical-grade cyanoacrylate glue. The same class of chemistry found in household superglue, formulated for tissue contact, has emerged as a sutureless securement method for vascular catheters. The group cites retrospective observational work on octyl-butyl-cyanoacrylate glue for securing peripheral intravenous catheters in neonates, as well as a decade of clinical experience with cyanoacrylate securement in a large university hospital and studies of its use for epicutaneo-caval catheters in newborns. Glue-based securement anchors the catheter, seals the puncture site, and may reduce the micro-motion at the catheter tip that contributes to vein irritation. The consortium has even published a dedicated protocol for the safe and effective removal of the adhesive from fragile neonatal skin, acknowledging that a securement method is only as good as its removal strategy.

Securement, however, is a balancing act. The skin of a premature infant is structurally immature, and adhesive dressings can cause medical adhesive-related skin injuries, a problem documented in neonatology departments. The recommendation therefore engages with the properties of transparent semipermeable membranes, including their moisture-vapor transmission characteristics, and with modern infusion therapy standards that govern dressing changes and site inspection. The goal is a securement system that holds the catheter firmly, allows the skin to breathe, permits visual inspection of the insertion site, and peels away without tearing the epidermis. These may sound like small engineering details, but in a two-kilogram infant, they are the difference between a line that lasts a week and one that fails within hours.

Perhaps the most forward-looking element of the recommendation is its attention to detecting failure early. Infiltration and extravasation, in which infused fluid leaks out of the vein into surrounding tissue, are among the most common and feared complications of peripheral therapy in neonates, and severe extravasation injuries can cause lasting tissue damage. The authors highlight research into novel sensor technology for earlier notification of such events in the neonatal population, as well as work on optical detection of infiltration during peripheral intravenous infusion in newborns. The premise is compelling: rather than waiting for a nurse to notice swelling or for an alarm to sound after tissue has already been harmed, continuous monitoring could flag the leak at its onset, allowing the infusion to be stopped before injury occurs. Combined with retrospective analyses of the modifiable and unmodifiable factors that drive device-related complications, this surveillance-oriented approach reframes catheter failure not as bad luck but as a preventable event with detectable precursors.

The recommendation also situates peripheral devices within the full spectrum of neonatal vascular access, including long peripheral catheters, which occupy the gap between short peripheral cannulas and centrally placed epicutaneous-caval catheters, and the prevention of catheter-related bloodstream infections, a field with its own established evidence base. Antiseptic skin preparation before catheter insertion, including the use of chlorhexidine gluconate in isopropyl alcohol in premature neonates, is addressed in light of Cochrane evidence on antiseptic solutions for neonatal central catheter insertion. Even the experience of the baby and family is not neglected: the consortium has published work on maintaining parent-infant skin-to-skin contact during catheter insertion, reflecting a growing conviction that technical excellence and developmental care are not competing priorities but complementary ones.

What emerges from the document is less a single technique than a system: standardized nomenclature, consistent with the NAVIGATE project’s position statement on vascular access device terminology; structured pre-procedural assessment; evidence-informed device selection; modern securement; vigilant surveillance; and gentle removal. The authors acknowledge that some long-standing practices in neonatal vascular access lack supporting evidence, and their recommendation is explicitly an effort to close that gap with structured, evidence-based guidance. For a field in which the difference between success and failure is measured in millimeters of vein and hours of dwell time, the arrival of a unified European standard for peripheral venous access marks a quiet but consequential shift. If the recommendation achieves its aims, the smallest patients in intensive care will spend less time being stuck with needles and more time simply being babies.

Subject of Research: Evidence-based management of peripheral venous access devices in neonatal care

Article Title: Management of peripheral venous access devices (PVADs): Neonatal European Vascular Access Team – ESPR Recommendation 5

Article References: Management of peripheral venous access devices (PVADs): Neonatal European Vascular Access Team – ESPR Recommendation 5. (n.d.). https://doi.org/10.1038/s41390-026-05515-1

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05515-1

Keywords: neonatology, vascular access, peripheral venous access devices, ESPR recommendations, NEVAT, RaSuVA, cyanoacrylate glue, near-infrared vein visualization, extravasation, neonatal intensive care, catheter securement, Pediatric Research

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