The clinical stakes are considerable. Umbilical catheters provide direct access to the central circulation of a newborn in the first days of life, a period when peripheral veins are tiny, fragile, and often inadequate for the concentrated nutrition and vasoactive drugs that preterm and critically ill infants require. The umbilical vein offers a route to the inferior vena cava and the right atrium, while the umbilical arteries allow monitoring of blood gases and blood pressure and continuous infusion of medications. But the same anatomical shortcuts that make these devices so useful also make them dangerous when they are misplaced. A venous catheter that stops short of the inferior vena cava can deliver hypertonic fluid directly into the portal circulation of the liver, causing tissue damage, thrombosis, or even hepatic necrosis. An arterial catheter positioned too high or too low can compromise blood flow to the spinal cord, the intestines, or the lower limbs.

The new recommendation emphasizes that the risks are not hypothetical. Recent systematic reviews and meta-analysis cited by the working group document a substantial burden of adverse events associated with umbilical vascular catheters, including bloodstream infections, thrombosis of the portal venous system, hepatic injury from inadvertent infusion of parenteral nutrition into liver parenchyma, and catheter malposition. One retrospective study published in 2025 specifically examined the pursuit of zero central line-associated bloodstream infections in umbilical catheterization, underscoring that these infections are largely preventable with rigorous insertion and maintenance bundles. A risk prediction model developed by Australian researchers further highlights that adverse events are frequent enough, and predictable enough, to warrant systematic prevention strategies rather than case-by-case vigilance.

At the heart of the recommendation is a call for standardized protocols covering three distinct phases of catheter management: assessment before insertion, the insertion procedure itself, and post-insertion evaluation of catheter tip position. The authors argue that each phase contains critical decision points where deviation from best practice compounds risk. Before insertion, clinicians must assess whether an umbilical catheter is truly the most appropriate vascular access device for the infant’s expected needs and duration of therapy, drawing on structured decision-making tools such as the neonatal device-expert algorithm previously developed by members of the same group. The recommendation aligns with the nomenclature established by the Navigate project, a global position statement that created a common vocabulary for vascular access devices, in part because inconsistent terminology has historically made it difficult to compare evidence and practices across centers.

The insertion phase receives particularly detailed attention. The recommendation describes a technique in which the catheter is advanced under controlled conditions with attention to asepsis, pain management, and securement. Procedural pain in neonates is a recognized concern, and the authors point to established guidelines for procedural pain management in newborns as an integral component of any catheterization. Skin antisepsis is another technical focus. The document reviews the evidence comparing aqueous 2 percent chlorhexidine gluconate with 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol, noting recent studies in moderate and extremely preterm infants suggesting that the alcohol-based preparation is safe after the first week of life and may be associated with a reduced incidence of catheter-related bloodstream infections. A randomized feasibility trial known as the Arctic trial, together with a Cochrane review of antiseptic solutions for central catheter insertion in neonates, informs this guidance, and national surveys of neonatal practice in Italy reveal how rapidly adoption of alcohol-based chlorhexidine has been spreading.

Perhaps the most consequential technical shift endorsed by the recommendation concerns how clinicians confirm that the catheter tip has reached its intended destination. For decades, the default method has been a plain chest and abdominal radiograph obtained after insertion, with the clinician estimating tip position relative to vertebral bodies and cardiac silhouette. The recommendation now champions ultrasound-based tip navigation and tip location, performed in real time during insertion. Structured protocols such as Neo-Echotip, developed for central venous access devices in neonates, allow the operator to watch the catheter advance and to verify the tip position immediately, adjusting depth before securing the device. Recent retrospective data indicate that real-time ultrasound tip location reduces both malposition and radiation exposure during umbilical venous catheter placement, since a correctly placed catheter on the first attempt eliminates the need for repeat radiographs and repositioning procedures.

The evidence base for ultrasound guidance has been accumulating steadily. Prospective studies have used ultrasound to track umbilical venous catheter migration in preterm infants over time, revealing that catheters move as the infant grows and as abdominal pressure changes, a phenomenon with direct implications for how often tip position should be rechecked. Other work has demonstrated that aligning the catheter with the umbilical vein and the ductus venosus under ultrasound guidance improves the likelihood of reaching the ideal central position. Comparative studies of low-lying versus centrally positioned umbilical venous catheters have found higher complication rates when the tip remains in the portal system, reinforcing the argument that precise, verified central placement should be the standard of care rather than an aspiration. An Italian expert consensus on tip location methods for central venous access devices, published in 2026, further consolidates the case for intracavitary electrocardiography and ultrasound as complementary or alternative tools to radiography.

Securement and maintenance form the third pillar of the recommendation. Even a perfectly positioned catheter can migrate, and radiographic assessments of catheter movement over time show that displacement is common in the days following insertion. The recommendation addresses this with guidance on securement techniques, including the use of cyanoacrylate glue, which was evaluated in a randomized controlled trial for umbilical venous catheter securement, and transparent semipermeable dressings, whose moisture vapor transmission properties have been the subject of comparative testing. The authors also draw on infection prevention frameworks, including the Infusion Therapy Standards of Practice, the Epic3 national guidelines from England, and the SHEA neonatal intensive care unit white paper series on preventing central line-associated bloodstream infections, to define how catheters should be handled, accessed, and monitored throughout their dwell time.

For umbilical arterial catheters specifically, the recommendation revisits a long-standing debate about optimal tip position, informed by the Cochrane review originally conducted by Keith Barrington, which compared high-lying catheters positioned above the diaphragm with low-lying catheters below the renal arteries. The working group also acknowledges innovative adaptations, such as the off-label use of peripherally inserted central catheters as umbilical arterial catheters reported in a clinical case series, reflecting the resourcefulness of neonatal teams when conventional devices are unavailable. The broader context for the recommendation is a series of structured insertion bundles developed by the same network, including the SIUVEC protocol for safe insertion of umbilical venous catheters and the SIECC protocol for epicutaneo-cava catheters, both of which were designed to minimize complications during placement and management, and a prospective study of a bundle for central venous catheterization in neonates and children covering more than 700 cases.

The authors, led by Fiammetta Piersigilli of Cliniques Saint Luc and the University of Louvain in Brussels and Robin van der Lee of Radboudumc Amalia Children’s Hospital in Nijmegen, stress that the recommendation is the product of a multidisciplinary consensus spanning neonatologists, nurses, anesthesiologists, and vascular access specialists across Europe, with contributions from the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants. The work received no external funding, and the authors declare no competing interests. As the second installment in a ten-part series, the document signals a broader ambition: to bring the same rigor to every vascular access device in the neonatal unit that infection prevention campaigns brought to hand hygiene a generation ago. If the recommendation achieves its stated goals, the routine, verifiable, ultrasound-guided placement of umbilical catheters could become as standard in neonatal care as the devices themselves, turning one of intensive care’s most useful tools into a demonstrably safer one for the smallest patients.

Subject of Research: Standardized management of umbilical venous and arterial catheters in neonatal intensive care

Article Title: Management of umbilical venous and arterial catheter: Neonatal European Vascular Access Team- ESPR Recommendation 2

Article References: Management of umbilical venous and arterial catheter: Neonatal European Vascular Access Team- ESPR Recommendation 2. (n.d.). https://doi.org/10.1038/s41390-026-05465-8

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05465-8

Keywords: umbilical venous catheter, umbilical arterial catheter, neonatal intensive care, NEVAT, ESPR, ultrasound tip location, catheter malposition, central line-associated bloodstream infection, chlorhexidine skin antisepsis, neonate, vascular access, clinical recommendation

The survey, published in the Journal of Perinatology, gathered responses from 848 tertiary neonatal units across 100 countries, spanning all six World Health Organization regions. Each unit was represented by a single clinician — 60 percent medical staff and 40 percent nursing staff — identified as most familiar with their unit’s vascular access practices. The 18-item questionnaire, distributed between February 2019 and August 2021, probed four domains: guideline availability, insertion practices, monitoring routines, and device removal policies. The results, reported in accordance with STROBE and CROSS reporting standards, paint a picture of remarkable heterogeneity in a field where consistency could mean the difference between health and harm.

The starkest variation emerged in guideline availability. While 85 to 98 percent of units reported having local protocols for umbilical venous catheters — the flexible tubes threaded through the umbilical stump into the large central veins of newborns — coverage for peripheral intravenous catheters ranged from a low of 29 percent in African units to a high of 97 percent in South America. That means in some regions, the most commonly used device in neonatal medicine is being inserted and managed with little formal guidance, leaving practice to individual habit and institutional folklore rather than evidence.

Device preference also followed a clear hierarchy. For the most fragile infants, the umbilical venous catheter reigned supreme: 70 percent of units caring for babies born at 23 weeks and 63 percent of those caring for 24-week infants chose it as the initial vascular access device. The preference makes technical sense. Umbilical catheters exploit a natural anatomical window — the vessels of the umbilical cord remain patent for days after birth — whereas threading a peripherally inserted central catheter through the minuscule veins of a 500-gram infant demands exceptional dexterity. Yet the choice carries risk: reported rates of umbilical catheter malposition, thrombosis, and infection range from 8 to 36 percent, and bloodstream infection has been documented in up to 12 percent of cases.

Securement techniques, the methods used to keep these devices from migrating once placed, have barely evolved in half a century. Sixty percent of units still anchor umbilical catheters with a stitch through Wharton’s jelly, the gelatinous connective tissue within the cord, tied with a suture, while 43 percent use a goal-post dressing. Only 7 percent employ a commercial securement device. The authors note that these approaches have remained largely unchanged for five decades, a stagnation they attribute partly to market forces: with relatively low usage volumes, manufacturers have little financial incentive to develop neonatal-specific securement technology. Securement failure is not a trivial matter — a migrating catheter can cause bloodstream infection, thrombosis, or even hepatic injury.

Monitoring practices showed equally troubling gaps. Only 56 percent of units assessed peripherally inserted central catheter sites at intervals shorter than eight hours, and a striking 58 percent reported using no formal tool at all to detect extravasation — the leakage of infused fluids into surrounding tissue. This is particularly concerning because extremely preterm infants are the highest-risk pediatric population for extravasation-related tissue injury; their fragile skin can be damaged by even small volumes of infiltrated fluid, sometimes leaving permanent scarring. Where formal scales were used, uptake varied from 45 percent of North American units to just 21 percent in Africa, suggesting that even where awareness exists, structured assessment has not become routine.

Insertion practices revealed a spectrum of rigor. Hand hygiene during peripheral catheter insertion was nearly universal at 90 percent, but glove choice split the world: 57 percent of units used sterile gloves while 43 percent settled for clean gloves, with South America and Oceania favoring sterility and North America leaning toward clean gloves. Tourniquets were routine in more than 70 percent of Oceanian and North American units but used in only 36 percent of African units. Vein-finding technology — infrared devices that illuminate subcutaneous vessels — was used routinely by 46 percent of Oceanian units but a mere 7 percent in South America, despite growing evidence supporting ultrasound-guided and technology-assisted vascular access in neonates.

Perhaps the most intriguing finding concerned gestational age thresholds. Units that offered active care to infants born at 22 to 23 weeks — the very edge of viability — were roughly twice as likely to have comprehensive vascular guidelines as units whose threshold began at 24 to 25 weeks. These same units practiced more frequent hand hygiene, used more insertion aids and transparent dressings, and performed more intensive catheter site surveillance. The authors suggest this heightened vigilance may be associated with lower rates of systemic infection, an observation that hints at a paradox: the units caring for the smallest, most vulnerable babies may have developed the most disciplined vascular cultures precisely because their patients leave no margin for error.

The survey period overlapped with the onset of the COVID-19 pandemic, which the authors acknowledge may have affected staffing, resources, and procedural practices, and self-reported data carry inherent recall bias. Still, with item completion rates above 90 percent and representation from every inhabited continent, the study offers an unprecedented baseline. The authors call for international consensus, targeted research, and investment in neonatal-specific technology — including tissue adhesives, ultrasound guidance, and standardized extravasation scoring — to bring vascular access care into the same evidence-based era that resuscitation and respiratory management already enjoy.

For the roughly 13 million preterm infants born worldwide each year, and especially the fraction born at the threshold of viability, the message is clear: the tubes that carry their lifeline are inserted, secured, and watched over in wildly different ways depending on where they happen to be born. Standardizing those practices, the authors argue, is not a bureaucratic nicety but a matter of safety, equity, and survival for the world’s smallest patients.

Subject of Research: International variation in vascular access device practices for extremely preterm infants

Article Title: Vascular device practices in extremely preterm infants: an international cross-sectional survey

Article References: Mishra, U., de Souza, S., Buchmayer, J., Maheshwari, R., D’Çruz, D., Walker, K., Gözen, D., Lowe, K., Wright, A., Marceau, J., Culcer, M., Priyadarshi, A., Moore, J., Shah, V., Vaidya, U., Khashana, A., Godambe, S., Cheah, F., Zhou, W., … Jani, P. (2026). Vascular device practices in extremely preterm infants: an international cross-sectional survey. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02892-7

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02892-7

Keywords: extremely preterm infants, vascular access, umbilical venous catheter, peripheral intravenous catheter, peripherally inserted central catheter, neonatal intensive care, extravasation, guideline variation, catheter securement, infection prevention, global health, Journal of Perinatology

The recommendation comes from the Pediatric and Neonatal Vascular Access Special Interest Group of the ESPR, working alongside NEVAT, a European network dedicated to vascular access care. The author group, led by Matheus van Rens and Robin van der Lee of Radboudumc Amalia Children’s Hospital in Nijmegen, the Netherlands, includes neonatologists, nurses and vascular access experts from institutions across the Netherlands, Belgium, Italy, Austria, the United Kingdom, France, Portugal, Spain, Bulgaria and beyond, with international contributors such as Yogen Singh of the University of California Davis Children’s Hospital. Their stated goal is deceptively simple: ensure that the right vascular access device is chosen from the very start of therapy, rather than discovered through a process of trial and error at the patient’s bedside.

The clinical problem the VAMP addresses is well documented in the authors’ own prior work. In the ABBA project, short for Assess Better before Access, a retrospective cohort study of neonatal intravascular device outcomes published in Frontiers in Pediatrics in 2022, the group catalogued how frequently neonatal vascular access devices fail before therapy is complete. Peripheral intravenous catheters in newborns are notoriously short-lived, and repeated replacement attempts mean repeated needle sticks, repeated pain and repeated exposure to complications. Research cited by the group, including a 2023 study in the Journal of Vascular Access examining how catheter type and material affect therapy failure in neonates, underscores that even the physical properties of the device matter in this population, whose veins may be smaller than a millimeter in diameter.

The stakes extend beyond immediate mechanical failure. Neonatal sepsis, which can be triggered by catheter-associated bloodstream infections, has been linked in a 2024 systematic review and meta-analysis in BMC Pediatrics to adverse neurocognitive outcomes later in life. Pain experienced in the first days and weeks of life is likewise not a transient concern; a 2020 review in Frontiers in Pediatrics by Williams and Lascelles summarized clinical and experimental evidence that early neonatal pain can have lasting implications for painful conditions later in life. In other words, every unnecessary needle stick and every preventable catheter infection is not merely an acute event but a potential contributor to long-term developmental burden. This is why the VAMP authors frame vascular access decision-making as a neuroprotective issue, a theme they developed further in a 2025 patient-centered framework based on the 7-Rights concept published in Pediatric Research.

Technically, the VAMP functions as a structured, patient-centered decision pathway, presented by the authors as a flow diagram that guides clinicians through the assessment of an individual newborn’s veins, the expected duration and type of therapy, and the characteristics of available devices before any needle is inserted. The approach draws on a growing body of standardized pre-procedural assessment protocols. Among these is the Rapid Superficial Vein Assessment, or RaSuVa, described by D’Andrea and colleagues in 2024 as a systematic pre-procedural evaluation of superficial veins to optimize venous catheterization in neonates. Similar systematic ultrasound protocols exist for deeper vessels: the Rapid Central Vein Assessment, or RaCeVa, published by Spencer and Pittiruti in 2019, and the Rapid Femoral Vein Assessment, or RaFeVa, described by Brescia and colleagues in 2021, both of which standardize ultrasound evaluation before central catheterization. The VAMP embeds this assessment-first philosophy into routine neonatal practice.

The framework also builds on and harmonizes existing consensus documents rather than replacing them. The authors position VAMP alongside the neonatal DAV-expert algorithm, a GAVeCeLT/GAVePed consensus published in the European Journal of Pediatrics in 2023 for choosing the most appropriate venous access in newborns, and the ERPIUP consensus on the proper indication and use of peripheral venous access devices, a WoCoVA project published in the Journal of Vascular Access. Other reference points include the UK Vessel Health and Preservation framework updated in 2020, the miniMAGIC appropriateness guide for intravenous catheters in pediatrics published in Pediatrics in 2020, the Infusion Therapy Standards of Practice ninth edition from 2024, and the NANN neonatal peripherally inserted central catheter guideline for practice in its fourth edition. By synthesizing these sources into a single European recommendation, the ESPR group aims to reduce the fragmentation that currently produces wide variation in practice between units and countries.

Insertion technique and device maintenance form a second pillar of the plan. The recommendation references novel insertion bundles developed by Italian collaborators, including the SIUVeC protocol for safe insertion of umbilical venous catheters and the SIECC protocol for epicutaneo-cava catheters, both designed to minimize placement and management complications, as well as the SIC seven-step strategy for centrally inserted central catheters. Once a device is in place, the plan emphasizes evidence-based securement and site care, drawing on trials of cyanoacrylate glue as part of bundles to decrease neonatal PICC-related complications and to secure umbilical venous catheters, and on experience with dialkylcarbamoylchloride dressings at catheter exit sites in pediatric and neonatal populations. Care bundles of this kind have already been shown in a 2018 systematic review and meta-analysis in Archives of Disease in Childhood to reduce central line-associated bloodstream infections in neonatal units, and the SHEA NICU white paper series from 2023 offers practical approaches to the same goal.

Two technological themes run through the recommendation with particular force. The first is point-of-care ultrasound, which the authors describe as central to modern neonatal vascular access, from pre-procedural vein mapping to real-time guidance during insertion. A 2024 review in the European Journal of Pediatrics by Pittiruti, Annetta and D’Andrea summarized the role of ultrasound for vascular access in neonates and children, and a 2023 systematic review and meta-analysis in Diagnostics examined the role of ultrasound specifically in epicutaneo-caval catheter insertion. A related narrative review from 2025 weighs intracavitary electrocardiography against real-time ultrasound for tip navigation and tip location of central venous access devices in the neonate, a question also addressed in a 2025 Italian expert consensus on tip location methods. The second theme is standardization itself: the VAMP’s authors contend that a uniform, reproducible method, applied by every clinician on every shift, is what converts scattered best practices into reliable outcomes.

Notably, the recommendation also extends beyond the technical to the human. The framework incorporates family-centered principles, citing recent work on family integrated care in Acta Paediatrica, a 2024 study in Advances in Neonatal Care on family management skills reported by parents of preterm infants, and a 2025 nonrandomized clinical trial in JAMA Network Open on outcomes following close collaboration with parents interventions in neonatal intensive care units. Pain assessment and management in preterm infants, summarized in a 2022 practice update in Children, are likewise woven into the plan, reflecting the view that vascular access decisions should minimize discomfort as well as complications. The involvement of the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants, acknowledged by the authors for contributions and critical readings of earlier drafts, signals that parent perspectives were part of the drafting process itself.

The authors state that proper use of the VAMP ensures choosing the right vascular access device from the start of therapy, that the method offers a structured and patient-centered approach, that its implementation ensures more uniform practice regarding vascular access in neonates, and that it has the potential to greatly decrease the number of vascular access-related complications in this population. As the first in what the group describes as a ten-recommendation project, VAMP represents the opening move of a coordinated European effort to professionalize neonatal vascular access in the way that adult vascular access care has been professionalized over the past two decades. If the framework achieves its stated aims, the routine insertion of a cannula in a premature newborn could shift from an improvised procedure, repeated until something works, into a planned, ultrasound-informed, family-aware intervention with fewer sticks, fewer infections and fewer of the long-term consequences that follow them. For the smallest patients in intensive care, that shift could matter for a lifetime.

Subject of Research: A structured European recommendation for vascular access device selection and management in neonatal intensive care

Article Title: Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1

Article References: van Rens, M., Hugill, K., Piersigilli, F., Schwaberger, B., Mader, S., Geiger, I., Singh, Y., Ouwehand, T., van den Hoogen, A., Van Eenoo, S., van der Lee, R., on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group (SIG) of the ESPR and NEVAT, van Rens, M., Van Der Lee, R., van den Hoogen, A., Rodriguez-Perez, C., Barone, G., van Eenoo, S., Hugill, K., … Tuna, M. L. (2026). Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1. Pediatric Research. https://doi.org/10.1038/s41390-026-05467-6

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05467-6

Keywords: neonatology, vascular access, VAMP, ESPR, central venous catheters, PICC, ultrasound, neonatal sepsis, care bundles, point-of-care ultrasound, umbilical venous catheter, family integrated care

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