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

Intra-arterial catheters, or IACs, are thin tubes placed directly into peripheral arteries, most commonly the radial artery at the wrist or the posterior tibial artery at the ankle. Once in place, they allow beat-to-beat blood pressure monitoring and painless blood sampling, sparing fragile infants the repeated needle punctures that would otherwise be required. The new recommendation emphasizes that the value of these devices comes with real risks: arterial lines can cause ischemia, infection, bleeding, and injury to delicate neonatal vessels and surrounding nerves. Because premature infants may weigh less than a kilogram and have arteries with internal diameters of well under a millimeter, the technical margin for error is extraordinarily narrow. The authors argue that this combination of high stakes and high variability is precisely why a standardized, evidence-based approach is overdue.

A central technical theme of the recommendation is the use of ultrasound guidance during insertion. Traditional arterial cannulation relies on palpation, feeling the pulse and advancing the needle blindly toward it. In neonates, whose vessels are tiny, mobile, and easily compressed by the palpating finger, this approach frequently fails and can traumatize the vessel. Recent studies cited by the panel, including retrospective observational work on real-time ultrasound-guided peripheral arterial cannulation in infants and case series demonstrating success even in very low birth weight infants who are conventionally considered difficult to cannulate, show that ultrasound dramatically improves first-pass success. A 2023 Cochrane systematic review of ultrasound-guided arterial cannulation in children supports the technique’s advantages, and dedicated protocols such as the Safe Insertion of Arterial Catheters approach have been developed specifically to minimize complications by combining ultrasound imaging with structured technique.

The recommendation also addresses the choice of insertion site, which is far from trivial. The radial artery of the forearm remains the most common target, but the panel reviews the vascular anatomy of the limb in detail, noting that collateral circulation, the backup blood supply that keeps tissue alive if the cannulated artery occludes, must be adequate before a line is placed. The ulnar artery has been proposed as an alternative cannulation site in neonates, and the posterior tibial artery offers another option for lower-limb access. Femoral artery catheterization, by contrast, is treated with considerable caution. Although some cohort studies have reported acceptable outcomes, published cases of limb length shortening associated with femoral arterial lines in the neonatal period highlight the potential for long-term harm when a major vessel supplying a growing leg is compromised. The guidance therefore steers clinicians toward peripheral sites with robust collateral flow whenever clinically feasible.

Catheter selection itself receives technical attention. Ultrasound can be used not only to guide the needle but also to measure the cross-sectional internal diameter of the target artery before cannulation, allowing clinicians to match catheter size to vessel size. Oversized catheters are thought to increase the risk of flow obstruction and ischemic injury, while undersized catheters may kink or fail to transmit accurate pressure waveforms. The recommendation draws on studies of distal radial artery diameter in neonates and infants to support this measurement-based approach, embedding it within the broader vessel health and preservation framework that underpins the whole series: choose the right device, for the right patient, at the right time, and preserve the vasculature for future needs.

Once the catheter is in place, securement becomes the next battleground for standardization. The panel reviews the evidence on transparent semipermeable membranes, including comparative studies of their moisture-vapor transmission properties, and on medical adhesive-related skin injuries, which are a documented hazard in neonatology where the stratum corneum of premature skin is paper-thin. Tissue adhesives such as octyl-butyl-cyanoacrylate glue, already studied for securing peripheral intravenous catheters in neonates, and dialkylcarbamoylchloride-impregnated dressings used at catheter exit sites are discussed as part of a modern securement toolkit. Limb fixation technique is another practical focus: the recommendation describes positioning and splinting methods for both upper and lower limbs that keep the catheter functional without immobilizing the joint so rigidly that circulation or skin integrity is compromised. The goal is a line that stays put, stays patent, and does not injure the skin it crosses.

Perhaps the most striking pharmacological element of the guidance concerns topical nitroglycerin. Arterial spasm is a common reason that cannulation attempts fail and a suspected contributor to ischemic complications after lines are placed. A systematic review and meta-analysis published in Archives of Disease in Childhood found that local nitroglycerin facilitates peripheral arterial cannulation in children, and separate systematic reviews in neonates have examined topical nitroglycerin for treating ischemic injuries, including analyses of nitroglycerin patch application in premature babies with peripheral arterial ischemia. By synthesizing this evidence, the recommendation gives clinicians a rational, evidence-based adjunct: a vasodilator applied to the skin to relax the vessel, improve the odds of a successful first attempt, and potentially rescue compromised perfusion, all while acknowledging the need to monitor for hypotension in infants whose blood pressure is already precarious.

The management phase of an arterial line’s life, from flushing regimens to pressure monitoring to the decision to remove the device, is also covered. Direct arterial pressure measurement differs systematically from indirect cuff-based techniques, and the panel points to comparative studies in pediatric intensive care to remind clinicians that the two are not interchangeable. Infusion therapy standards, most recently the ninth edition of the Infusion Nurses Society standards of practice, provide the backbone for aseptic technique, dressing changes, and surveillance, consistent with national evidence-based guidelines for preventing healthcare-associated infections. The recommendation frames all of this within a patient-centered structure built on the 7-Rights framework and the standardized nomenclature developed through the NAVIGATE project, so that a catheter described in one hospital means the same thing in another, a prerequisite for meaningful quality improvement and research.

What makes this document notable is not a single dramatic discovery but the quiet rigor of consensus built on evidence. The work was not externally funded, the authors declare no competing interests, and the writing team spans neonatologists, nurses, and vascular access specialists from institutions across the Netherlands, France, Austria, Belgium, Italy, the United Kingdom, Bulgaria, Portugal, Spain, and beyond, with input from foundations representing parents of newborn infants. For a field in which some practices, as the authors bluntly state, lack supporting evidence, the recommendation represents a deliberate turn from tradition toward accountability. If the remaining installments in the ten-part series match this one, neonatal units across Europe may soon share a common technical language for the lines that keep their smallest patients alive, and the infants hooked to those lines may face fewer failed attempts, fewer injured vessels, and safer first days of life.

Subject of Research: Evidence-based management of intra-arterial catheters in neonates

Article Title: Management of intra-arterial catheters: neonatal european vascular access team—ESPR recommendation 6

Article References: van der Lee, R., Yousef, N., Schwaberger, B., De Bisschop, B., Piersigilli, F., Ouwehand, T., Van Eenoo, S., Hugill, K., van Rens, M., 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 der Lee, R., De Bisschop, B., Van Eenoo, S., van Rens, M., Debuf, M.-J., Milan, A., Barone, G., Pittiruti, M., Werther, T., … Tuna, M. L. (2026). Management of intra-arterial catheters: neonatal european vascular access team—ESPR recommendation 6. Pediatric Research. https://doi.org/10.1038/s41390-026-05470-x

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05470-x

Keywords: neonatology, intra-arterial catheters, vascular access, ultrasound guidance, radial artery, nitroglycerin, catheter securement, preterm infants, ESPR, NEVAT, blood pressure monitoring, ischemia