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 physiological logic of intraosseous access is elegant and has been understood for decades. The medullary cavity of long bones is not a sealed compartment but a sponge-like network of venous sinusoids that drains through emissary veins into the central circulation. This means that medications, fluids, and blood products infused into the marrow reach the systemic bloodstream nearly as rapidly as they would through a peripheral vein. In adults and older children, intraosseous access has become a standard element of cardiac arrest algorithms, endorsed by resuscitation councils worldwide. In neonates, however, adoption has lagged, driven by anxiety about the fragility of neonatal bones, the small dimensions of the puncture sites, and a paucity of robust safety data specific to the smallest and most premature infants.

The new recommendation is born of that gap. Led by Bernhard Schwaberger of the Medical University of Graz and Anna Milan of Guy’s and St Thomas’ NHS Foundation Trust in London, together with an international consortium spanning Austria, the United Kingdom, the Netherlands, Belgium, Italy, France, Bulgaria, Spain, Portugal, and beyond, the working group consolidated existing evidence, anatomical data, and device-specific considerations into a practical, unified guide. The authors frame their recommendation around a stark clinical reality: without emergency vascular access, resuscitative drugs such as adrenaline cannot be delivered, volume expansion cannot occur, and newborn resuscitation guidelines, including the 2025 European Resuscitation Council and American Heart Association directives cited in the document, become unachievable in practice.

One of the cornerstones of the document is anatomical precision. The proximal tibia, long the default site for neonatal intraosseous insertion, is not uniformly safe across gestational ages. Cadaveric and ultrasound-based anatomical studies cited by the working group have mapped the distance from the skin to the tibial cortex and the depth of the medullary cavity in term and preterm neonates, revealing how narrow the safety margin can be. A needle advanced too far can breach the posterior cortex and infuse fluid into the soft tissues behind the leg, a complication with documented catastrophic consequences, including compartment syndrome and, in one reported case, limb amputation following calcium infusion. The recommendation therefore promotes risk-based site selection, taking into account gestational age, weight, and the presence of oedema or bony abnormalities, and encourages clinicians to consider alternative sites such as the distal femur or proximal humerus when the tibia carries elevated risk.

Device selection receives equally careful treatment. Traditional manual needles, spring-loaded devices, and powered drill systems each carry distinct advantages and failure modes in neonates, whose tibial cortices may be softer and thinner than in older patients. A randomised simulation study comparing three intraosseous access devices in term neonates demonstrated meaningful differences in insertion success and speed, and the recommendation integrates such findings into practical advice: units should standardise on a small number of devices, ensure that those devices are immediately available in delivery rooms and neonatal intensive care units, and train all relevant staff in their use rather than relying on improvisation with whatever equipment happens to be at hand.

The document also confronts the evidence deficit surrounding drug delivery through the marrow route in newborns. Animal studies in asphyxiated newborn lambs and piglets comparing intraosseous with intravenous adrenaline administration have informed neonatal life support guidelines, and clinical data from pediatric out-of-hospital cardiac arrest populations suggest that intraosseous access is associated with survival outcomes comparable to intravenous access. Yet systematic reviews and meta-analyses of intravenous versus intraosseous drug delivery in cardiac arrest remain nuanced, and the recommendation stresses that intraosseous access should be understood as a bridge: a rapidly achievable route that secures drug and fluid delivery during the acute emergency while definitive intravenous access is established or until the crisis resolves.

Safety during and after insertion forms the third pillar of the guidance. The working group advocates strict aseptic technique, informed by infusion therapy standards and infection prevention guidelines for vascular catheters, and highlights the need for appropriate skin antisepsis in neonates, a population in which even antiseptic agents carry toxicity concerns. Pain management is addressed explicitly, referencing procedural pain guidelines for newborns, since bone marrow puncture is undeniably painful even in unconscious patients and deserves analgesic consideration whenever the clinical situation permits. Secure fixation of the needle, careful limitation of infusion pressures, and vigilant monitoring of the limb for swelling, discolouration, or extravasation are prescribed to reduce the risk of the devastating limb complications documented in case reports, from tibial fracture to dry gangrene.

Management of the device once inserted is treated with the same rigour as its placement. Intraosseous needles are emergency devices with a finite dwell time, and the recommendation advises that they be removed as soon as stable intravenous access is achieved, typically within a matter of hours, to minimise the risks of infection, dislodgement, and marrow injury. Documentation of insertion site, device type, insertion depth, and removal time is encouraged, consistent with the broader nomenclature and documentation frameworks developed by the vascular access community, including the Navigate Project position statement on vascular access device terminology. The authors emphasise that intraosseous devices should be recorded as vascular access devices in their own right, with the same standard of stewardship applied to central and peripheral catheters.

Training emerges as perhaps the most consequential theme. The recommendation promotes standardised, simulation-based education so that the procedure does not depend on the presence of an experienced individual at three in the morning. Evidence from tertiary centres that routinely use intraosseous access during neonatal resuscitation, and from nationwide surveillance data in Germany demonstrating that intraosseous access in neonates is feasible and safe when performed by trained personnel, supports the contention that familiarity breeds safety. The authors also address the retrieval and transport setting, noting that emergency transfer services increasingly rely on intraosseous access in neonates and that standardised protocols across retrieval teams and receiving units are essential for continuity of care.

What distinguishes this recommendation from previous statements is its deliberate neonatal focus and its synthesis of previously scattered knowledge. The authors acknowledge that much of the underlying evidence derives from older children, adults, animal models, and case series, and they call for continued research, particularly prospective studies of insertion sites, devices, and outcomes in preterm populations. In the interim, the document offers clinicians something they have historically lacked: a single, authoritative, anatomically informed and evidence-grounded reference for when, where, and how to place an intraosseous needle in a newborn, and how to care for it afterwards. For the tiniest patients in the most precarious moments of their lives, standardised excellence in this procedure may translate directly into lives saved and limbs preserved.

Subject of Research: Neonatal intraosseous vascular access: clinical recommendations for insertion and management of intraosseous devices in critically ill newborns

Article Title: Insertion and management of intraosseous devices: Neonatal European Vascular Access Team – ESPR Recommendation 9

Article References: Schwaberger, B., Milan, A., van der Lee, R., Piersigilli, F., Ouwehand, T., 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., Debuf, M.-J., Yousef, N., Barone, G., Pittiruti, M., Werther, T., Boyadzhiev, S., Singh, Y., … Iacona, G. (2026). Insertion and management of intraosseous devices: Neonatal European Vascular Access Team – ESPR Recommendation 9. Pediatric Research. https://doi.org/10.1038/s41390-026-05475-6

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05475-6

Keywords: intraosseous access, neonatal resuscitation, vascular access, newborn emergencies, ESPR recommendations, pediatric research, neonatal intensive care, proximal tibia, needle insertion, drug delivery, resuscitation guidelines, neonatal safety