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