The review, led by Rajendra Prasad Anne of Kasturba Medical College at Manipal Academy of Higher Education in India, together with colleagues from the United Arab Emirates and India, set out to answer a deceptively simple question: when a newborn needs central venous access on the first day of life, which device is safer? The team searched PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials up to November 2025, capturing both randomised controlled trials and non-randomised studies of interventions. Their primary endpoints were the outcomes that matter most at the bedside: central line-associated bloodstream infection, known as CLABSI, mortality, late-onset sepsis and catheter-related complications such as thrombosis, occlusion, bleeding and tip malposition.

After screening the literature, the researchers pooled seven studies, five randomised trials and two non-randomised studies, encompassing 1,522 neonates. That may sound modest against the scale of neonatal medicine, but in a field where individual trials are small and fragmented, a meta-analysis of this kind carries real weight. The reviewers applied the GRADE framework to rate the certainty of the evidence and used random-effects models to combine results, acknowledging from the outset that the underlying studies differed in populations, protocols and catheter-management practices.

The headline finding is, in one sense, a null result. When the randomised trials were pooled, there was no statistically significant difference between PICCs and UVCs in the risk of central line-associated bloodstream infection. The pooled risk ratio was 0.75, with a 95 percent confidence interval of 0.50 to 1.11, a range that crosses the threshold of no effect. Mortality told a similar story, with a risk ratio of 1.05 and a confidence interval of 0.58 to 1.90. In plain terms, the evidence does not demonstrate that choosing a PICC over an umbilical line in the first day of life reduces bloodstream infections or saves lives, a conclusion that challenges the intuition of teams who have favoured PICCs on infection-prevention grounds.

Beneath that null result, however, the analysis surfaced signals that neonatologists will not be able to ignore. Babies who received PICCs showed a trend toward higher rates of late-onset sepsis, with a risk ratio of 1.36 and a confidence interval of 0.97 to 1.91, hovering just at the edge of statistical significance. Hospital stays also tended to be longer in the PICC groups, by a mean difference of 3.2 days, though the confidence interval of minus 0.2 to 6.6 days included the possibility of no difference. Neither finding is definitive on its own, but both point in the same direction, and both carry clinical consequences if they are real.

The mechanical performance of the two devices diverged more sharply. PICCs were significantly less likely to become malpositioned, meaning their tips wandered from the intended central position less often than umbilical catheters, with a risk ratio of 0.65 and a confidence interval of 0.49 to 0.86. Yet the same fine-bore lines paid a price elsewhere: they were nearly three times as likely to occlude, with a risk ratio of 2.84 and a confidence interval of 1.23 to 6.57. Anyone who has watched a nurse struggle to flush a clotted neonatal PICC will recognise the practical reality behind that number. The review also found that PICC insertion took significantly longer than umbilical catheterisation, a meaningful consideration in the delivery room, where minutes can matter and where the umbilical vein offers an immediate, anatomically obvious route.

One of the most intellectually honest parts of the analysis concerns catheter dwell time. The reviewers noted that PICCs tended to remain in place longer than umbilical catheters in the included studies, and they flagged this as an important unresolved confounder. The logic is straightforward: the longer any central line stays in the body, the greater the cumulative opportunity for microorganisms to colonise it and for bloodstream infection to develop. If PICCs dwell longer, any apparent excess of late-onset sepsis could partly reflect exposure time rather than intrinsic device risk, and conversely, the absence of an infection advantage for PICCs becomes even more striking given their longer residence. Disentangling device effects from dwell-time effects will require trials that standardise catheter duration, something the existing literature has not done.

Why does this matter beyond the neonatal unit? Central line-associated bloodstream infections are among the most feared complications in intensive care, driving antibiotic use, prolonging hospitalisation and, in vulnerable preterm infants whose immune systems are immature, contributing to mortality and long-term neurodevelopmental harm. Late-onset sepsis, which typically strikes after the first seventy-two hours of life, is a leading cause of death and disability in very low birth weight infants. If the choice of access device on day one influences these outcomes, then a simple procedural decision could ripple through an entire lifetime. Conversely, if the devices are truly equivalent on infection outcomes, units can base their choices on other grounds: insertion speed, malposition risk, occlusion rates, staff training and the anticipated duration of therapy.

The practical implications cut in different directions. For teams that need immediate central access at resuscitation, the umbilical venous catheter remains the fastest and most familiar option, and the new analysis gives no reason to abandon it. For infants expected to need weeks of parenteral nutrition or prolonged antibiotic courses, the PICC’s lower malposition rate and longer usable lifespan may still justify its placement, provided teams are prepared for occlusions and for the longer insertion procedure. What the review does not support is the assumption that switching early from an umbilical line to a PICC will, by itself, lower infection rates. The authors conclude plainly that current evidence does not demonstrate a reduction in CLABSI, mortality or late-onset sepsis when neonatal PICCs are used instead of UVCs for early central venous access.

Like all meta-analyses, this one inherits the limitations of its ingredients. Seven studies and roughly fifteen hundred infants is a small evidence base for a question of this importance, and the two non-randomised studies included are inherently vulnerable to selection bias, since clinicians may choose one device over the other based on how sick a baby appears. The GRADE assessment reflects that uncertainty. Still, the work exemplifies a quiet revolution in neonatology: the systematic aggregation of small trials to extract answers that no single centre could deliver alone. The review was registered prospectively on PROSPERO under number CRD42024604746 and received no external funding, and the authors declare no competing interests. For the parents of the roughly 1,500 infants whose data underpin this analysis, and for the millions more who will pass through neonatal units, the message is a call for better trials, not a final answer. Until those arrive, the humble umbilical catheter, inserted in the first minutes of life, remains a formidable and entirely defensible first choice.

Subject of Research: Comparative safety of peripherally inserted central catheters versus umbilical venous catheters for central venous access in newborns

Article Title: Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes

Article References: Anne, R. P., Vardhelli, V., RD, R., & Murki, S. (2026). Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07761-y

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07761-y

Keywords: neonatology, central venous access, PICC, umbilical venous catheter, CLABSI, late-onset sepsis, meta-analysis, systematic review, premature infants, catheter complications, neonatal intensive care, bloodstream infection