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 review, registered prospectively on the Open Science Framework and reported according to the PRISMA-ScR checklist, casts a wide net across eleven databases including PubMed, EMBASE, Scopus, CINAHL and the major Chinese literature platforms. From 762 initial records, the research team screened down to 41 eligible publications representing 39 unique studies conducted between 2015 and 2026. Nearly three-quarters of the studies appeared after 2020, a signal of how quickly clinical interest in midlines has accelerated. But the geographic picture was strikingly lopsided: 30 of the 39 studies came from China, seven from Italy, and just one each from the United States and India, a concentration the authors acknowledge limits the generalizability of any conclusions to other healthcare systems.

At the heart of the confusion is anatomy. The 2024 Infusion Therapy Standards of Practice from the Infusion Nurses Society define a midline catheter as a peripheral device inserted into the basilic, cephalic or brachial vein of the upper arm, with its tip terminating at the level of the axilla—strictly outside the central circulation. The Michigan Appropriateness Guide for Intravenous Catheters from 2015 went further still, describing tips ending in the basilic or cephalic vein themselves. European experts disagree. The 2023 ERPIUP consensus and the 2025 position statement from GloVANet and the World Congress of Vascular Access both endorse placing the tip deeper, in the thoracic tract of the axillary vein or even the subclavian vein. A 2020 Chinese expert consensus declined to recommend any specific position at all, calling instead for individualized assessment. The review’s evidence map traces this evolution year by year, showing a field that has split into two philosophical camps: one guarding the peripheral boundary, the other pushing deliberately closer to the central veins.

The stakes of this definitional brawl are not academic. Three recent meta-analyses have suggested that more proximal tip positions may be safer. Zhang and colleagues found that subclavian placement was associated with lower overall complication rates and reduced catheter-related thrombosis compared with axillary placement, while Sheng’s team reported broader advantages including longer dwell times and fewer episodes of phlebitis, bleeding, occlusion and dislodgement. A Bayesian network meta-analysis by Yang and colleagues likewise ranked subclavian placement favourably for thrombosis, occlusion, phlebitis and overall complications. But the new scoping review urges caution: these pooled analyses were built on studies that used wildly different anatomical categories, confirmation techniques and outcome definitions, and some carried wide credible intervals reflecting small sample sizes. The signal is real, the authors conclude, but it is a signal—not a standard.

How clinicians actually verify where a tip has landed turns out to be equally fragmented. The review identified three broad families of confirmation methods. The simplest is external body measurement: estimating insertion depth from surface landmarks, such as measuring from the puncture site to the sternoclavicular joint and subtracting two centimetres for a subclavian target, or to the midclavicular line minus three to four centimetres for the thoracic axillary vein. One study of 125 patients found that confirmatory ultrasound showed only 88.1 percent of tips measured this way actually landed at the expected site. The method is fast and equipment-free, but it is an indirect guess that cannot account for tortuous vessels, obesity, edema or joint contractures.

Ultrasound has emerged as the dominant alternative, described in 63.41 percent of the included publications. Real-time imaging allows operators to watch the catheter advance, identify the axillary vein where the cephalic vein drains into it, and track the tip as a double echogenic line. When the tip cannot be directly seen, clinicians can flush saline to generate a transient microbubble signal that reveals its location. The technique proved feasible in 98.9 percent of patients in one Italian study, and a retrospective Chinese analysis found ultrasound-guided localization cut complications from 20 percent to 6 percent compared with external measurement alone. Yet ultrasound has its own ceiling: the clavicle obscures the subclavian vein in most supine patients, morbid obesity defeated sonographic identification of the tip in roughly 1.1 percent of cases, and success rates for confirming axillary placement have dipped as low as 75 percent in some hands. Everything depends on the operator, and no objective, quantifiable benchmark yet exists.

Chest radiography, long the gold standard for central lines, fared worst in the review. Only about a quarter of studies used it, and for good reason. In one American cohort, X-ray failed to visualize the catheter tip at all in 28.14 percent of patients. Routine imaging of a non-central device also collides with the ALARA principle of minimizing radiation exposure, and the delay inherent in radiologist reporting forfeits the possibility of immediate bedside correction. On X-ray, the lateral border of the scapula serves as the anatomical boundary of the axillary vein, but the review shows even this landmark is applied inconsistently. The authors argue for multimodal confirmation pathways that reserve radiography for genuinely uncertain cases rather than reflexive routine use.

Beyond the tip itself, the review maps a thicket of variables that shape placement accuracy and complication risk. The catheter-to-vein ratio at the tip level has emerged as a particularly powerful predictor: one retrospective study identified a ratio above 45 percent as an independent risk factor for catheter failure, and a subsequent prospective cohort found that even a ratio above 33 percent correlated with elevated failure risk, aligning with ultrasound screening thresholds for peripheral access. Insertion site matters too—a few centimetres’ difference in puncture height within the mid-upper arm’s so-called green zone can shift a fixed-length catheter’s tip from the distal axillary vein all the way to the brachiocephalic vein. Catheter tip configuration adds another wrinkle, with database evidence suggesting open-tipped devices trigger more complications and removals than closed or valved designs, though inconsistent reporting makes the independent effect of material—silicon versus polyurethane—impossible to pin down. A randomized trial of antithrombogenic and antimicrobial coatings, for instance, found no significant difference in thrombosis rates.

The complication data compiled in the review’s evidence map span dizzying ranges. Reported overall complication rates ranged from under 1 percent to 60 percent depending on tip position and study, catheter-related thrombosis from 0.085 percent to 41.5 percent, and dwell times from five days to more than 150 days. Some findings cut against the proximal-placement trend: one pilot study of 27 patients found no significant association between tip position and fibroblastic sleeve formation or thrombosis, while another study comparing superficial with deeper tip placement found complication rates of 23.81 percent versus 7.55 percent. The review’s authors stress that these unweighted ranges describe the spread of the literature, not comparative effect estimates, and that dwell time in particular is an ambiguous metric—long indwelling may reflect success or simply prolonged exposure to endothelial irritation and biofilm.

What the review ultimately delivers is less an answer than an agenda. The authors call for professional societies to agree on standardized anatomical terminology, for prospective cohort studies and randomized trials using precise positioning techniques to clarify the relationship between tip location, catheter lifespan and patient comfort, and for clinical pathways built on multimodal confirmation that spares patients unnecessary X-rays. They are candid about their own limitations: the exclusion of mini-midlines shorter than 15 centimetres, the restriction to English and Chinese publications, the absence of formal quality appraisal, and the overwhelming Chinese dominance of the evidence base. But the core message stands. Midline catheters have earned their place in modern infusion therapy, and their popularity will only grow as care migrates out of hospitals. Until the field settles where the line should end—and how to prove it—a device praised for its simplicity will keep carrying a hidden burden of uncertainty that only coordinated, multinational research can lift.

Subject of Research: Midline catheter tip location, tip confirmation methods and associated clinical characteristics

Article Title: Mapping the Evidence on Midline Catheter Tip Location, Confirmation Methods and Associated Characteristics: A Scoping Review

Article References: Mapping the Evidence on Midline Catheter Tip Location, Confirmation Methods and Associated Characteristics: A Scoping Review. (n.d.). https://doi.org/10.1002/nop2.70876

Image Credits: AI Generated

DOI: 10.1002/nop2.70876

Keywords: midline catheter, vascular access, catheter tip location, ultrasound guidance, chest radiography, catheter-related thrombosis, scoping review, infusion therapy standards, catheter-to-vein ratio, nursing practice, peripheral intravenous therapy, evidence mapping