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 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