Vascular access is the circulatory lifeline of neonatal intensive care. Premature and critically ill infants depend on intravenous lines for nutrition, medications, and fluids, often for weeks at a time. Yet the devices that deliver these therapies fail frequently. Peripheral intravenous catheters in neonates are prone to infiltration, dislodgement, phlebitis, and occlusion, and each failure means another painful insertion attempt in an infant whose veins may be barely visible. Previous work by the same research group, including retrospective cohort studies such as the ABBA project, documented the scale of device-related complications and the factors associated with them. What remained poorly understood was the human and organizational side of the problem: how nurses actually decide when to insert, monitor, escalate, or abandon a line.

To answer that question, Matheus van Rens of Radboud University Medical Center and colleagues conducted semi-structured interviews with twelve neonatal nurses involved in vascular access and infusion therapy across three tertiary neonatal intensive care units in the Netherlands. The team analyzed the transcripts using reflexive thematic analysis, a method that treats the researcher’s perspective as an active ingredient in interpretation rather than a bias to be eliminated. Sample adequacy was guided by the concept of information power, an approach that determines whether enough interviews have been conducted based on the richness of the data and the specificity of the study aims, rather than by a fixed numerical target.

Four themes emerged from the analysis, and together they sketch a system that consistently rewards reaction over anticipation. The dominant finding was that vascular access care was characterized by reactive decision-making, with escalation to more secure or more appropriate devices typically occurring only after a complication had already appeared. Nurses described delayed escalation, repeated peripheral intravenous attempts, and inconsistent monitoring practices across all three centers. In other words, a catheter often had to fail before the team reconsidered whether a different strategy was needed from the start.

Behind this reactive pattern, the interviews revealed a web of interacting pressures. Organizational factors, including workload, staffing constraints, and the absence of structured decision-support embedded in daily workflows, shaped how much attention vascular access received at any given moment. Knowledge varied between individual nurses, and so did the implementation of existing guidelines, producing inconsistency both within and between units. The researchers also identified relational factors: parents were largely left out of decisions about vascular access, despite growing evidence from family integrated care research that involving parents in neonatal care improves outcomes for infants and families alike.

Perhaps the most striking theme was a persistent gap between risk awareness and clinical action. The nurses interviewed clearly understood which infants were at high risk of catheter failure and could articulate the consequences of repeated attempts. Knowing, however, did not translate into doing. This disconnection echoes classic patient safety literature, including James Reason’s models of human error, which emphasize that accidents rarely stem from individual carelessness alone but from systems that allow known risks to go unaddressed. The study’s authors frame their findings in exactly this spirit, pointing to organizational and behavioral factors that reinforce reactive practice regardless of individual competence or good intentions.

The technical literature has long documented the consequences of this gap. Studies of peripheral intravenous catheter failure in adult and pediatric populations have described the problem as accepted but unacceptable, a phrase coined by researchers reviewing the burden of device failure in hospitals. In neonates, multicenter observational studies have reported substantial complication rates for peripheral cannulation, and consensus tools such as the neonatal DAV-expert algorithm developed by European vascular access groups now exist to guide the selection of the most appropriate venous access for each newborn. The Dutch study suggests that the bottleneck is not a lack of technical knowledge or decision tools, but the absence of structures that trigger their use at the right moment.

The authors argue that the way forward lies in structured, anticipatory approaches integrated directly into clinical workflows. Rather than relying on individual nurses to remember to reassess a line or to escalate concerns through informal channels, units could build anticipatory planning into routine care, ensuring that the choice of device, the monitoring plan, and the escalation pathway are considered together at the moment of insertion and revisited systematically thereafter. The team has previously proposed a patient-centered framework based on the 7-Rights of vascular access, and the new findings support the idea that such frameworks must be embedded in practice rather than left as optional guidance.

The implications extend beyond the neonatal unit. Catheter-related bloodstream infections in intensive care were dramatically reduced in landmark studies when checklists and standardized bundles transformed culture and behavior, demonstrating that structured interventions can convert awareness into consistent action. The Dutch researchers point to similar potential in neonatal vascular access: if the reactive cycle of failure and rescue can be interrupted by anticipatory planning, the payoff could include fewer painful procedures, fewer infections, shorter stays, and more consistent care across centers. Practice variation in neonatal care is well documented, and standardizing the behavioral and organizational dimensions of vascular access may be as important as standardizing the technical ones.

The study also carries a methodological lesson for patient safety research. By listening to nurses rather than measuring devices, the investigators surfaced factors that retrospective audits of complication rates could never capture: the hesitation to escalate, the uneven distribution of knowledge, the silence of parents at the bedside. The authors acknowledge the limitations inherent in qualitative work, including the interpretive nature of thematic analysis and the potential identifiability of interview data, which is why the underlying datasets are available only on reasonable request. Yet the consistency of the four themes across three separate tertiary centers lends weight to the central conclusion. Vascular access care in neonatal intensive care, the nurses suggest, is shaped by interacting organizational, behavioral, knowledge-related, and relational forces that quietly reinforce reaction over prevention. Recognizing those forces, the researchers argue, is the first step toward designing workflows in which the smallest patients receive lines that are planned, monitored, and escalated with the same rigor that the technology itself deserves.

Subject of Research: Nurses' decision-making and reactive versus proactive practice in neonatal vascular access care

Article Title: Reactive rather than proactive: nurses’ perspectives on decision-making in neonatal vascular access

Article References: van Rens, M. F., Huis, A., Hugill, K., van der Lee, R., & de Boode, W. P. (2026). Reactive rather than proactive: nurses’ perspectives on decision-making in neonatal vascular access. Pediatric Research. https://doi.org/10.1038/s41390-026-05570-8

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05570-8

Keywords: neonatal intensive care, vascular access, nursing decision-making, peripheral intravenous catheters, patient safety, qualitative research, thematic analysis, catheter failure, escalation delays, family integrated care, clinical workflows, Pediatric Research

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 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 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, registered prospectively on the Open Science Framework and reported according to the PRISMA-ScR checklist, casts a wide net across eleven databases including PubMed, EMBASE, Scopus, CINAHL and the major Chinese literature platforms. From 762 initial records, the research team screened down to 41 eligible publications representing 39 unique studies conducted between 2015 and 2026. Nearly three-quarters of the studies appeared after 2020, a signal of how quickly clinical interest in midlines has accelerated. But the geographic picture was strikingly lopsided: 30 of the 39 studies came from China, seven from Italy, and just one each from the United States and India, a concentration the authors acknowledge limits the generalizability of any conclusions to other healthcare systems.

At the heart of the confusion is anatomy. The 2024 Infusion Therapy Standards of Practice from the Infusion Nurses Society define a midline catheter as a peripheral device inserted into the basilic, cephalic or brachial vein of the upper arm, with its tip terminating at the level of the axilla—strictly outside the central circulation. The Michigan Appropriateness Guide for Intravenous Catheters from 2015 went further still, describing tips ending in the basilic or cephalic vein themselves. European experts disagree. The 2023 ERPIUP consensus and the 2025 position statement from GloVANet and the World Congress of Vascular Access both endorse placing the tip deeper, in the thoracic tract of the axillary vein or even the subclavian vein. A 2020 Chinese expert consensus declined to recommend any specific position at all, calling instead for individualized assessment. The review’s evidence map traces this evolution year by year, showing a field that has split into two philosophical camps: one guarding the peripheral boundary, the other pushing deliberately closer to the central veins.

The stakes of this definitional brawl are not academic. Three recent meta-analyses have suggested that more proximal tip positions may be safer. Zhang and colleagues found that subclavian placement was associated with lower overall complication rates and reduced catheter-related thrombosis compared with axillary placement, while Sheng’s team reported broader advantages including longer dwell times and fewer episodes of phlebitis, bleeding, occlusion and dislodgement. A Bayesian network meta-analysis by Yang and colleagues likewise ranked subclavian placement favourably for thrombosis, occlusion, phlebitis and overall complications. But the new scoping review urges caution: these pooled analyses were built on studies that used wildly different anatomical categories, confirmation techniques and outcome definitions, and some carried wide credible intervals reflecting small sample sizes. The signal is real, the authors conclude, but it is a signal—not a standard.

How clinicians actually verify where a tip has landed turns out to be equally fragmented. The review identified three broad families of confirmation methods. The simplest is external body measurement: estimating insertion depth from surface landmarks, such as measuring from the puncture site to the sternoclavicular joint and subtracting two centimetres for a subclavian target, or to the midclavicular line minus three to four centimetres for the thoracic axillary vein. One study of 125 patients found that confirmatory ultrasound showed only 88.1 percent of tips measured this way actually landed at the expected site. The method is fast and equipment-free, but it is an indirect guess that cannot account for tortuous vessels, obesity, edema or joint contractures.

Ultrasound has emerged as the dominant alternative, described in 63.41 percent of the included publications. Real-time imaging allows operators to watch the catheter advance, identify the axillary vein where the cephalic vein drains into it, and track the tip as a double echogenic line. When the tip cannot be directly seen, clinicians can flush saline to generate a transient microbubble signal that reveals its location. The technique proved feasible in 98.9 percent of patients in one Italian study, and a retrospective Chinese analysis found ultrasound-guided localization cut complications from 20 percent to 6 percent compared with external measurement alone. Yet ultrasound has its own ceiling: the clavicle obscures the subclavian vein in most supine patients, morbid obesity defeated sonographic identification of the tip in roughly 1.1 percent of cases, and success rates for confirming axillary placement have dipped as low as 75 percent in some hands. Everything depends on the operator, and no objective, quantifiable benchmark yet exists.

Chest radiography, long the gold standard for central lines, fared worst in the review. Only about a quarter of studies used it, and for good reason. In one American cohort, X-ray failed to visualize the catheter tip at all in 28.14 percent of patients. Routine imaging of a non-central device also collides with the ALARA principle of minimizing radiation exposure, and the delay inherent in radiologist reporting forfeits the possibility of immediate bedside correction. On X-ray, the lateral border of the scapula serves as the anatomical boundary of the axillary vein, but the review shows even this landmark is applied inconsistently. The authors argue for multimodal confirmation pathways that reserve radiography for genuinely uncertain cases rather than reflexive routine use.

Beyond the tip itself, the review maps a thicket of variables that shape placement accuracy and complication risk. The catheter-to-vein ratio at the tip level has emerged as a particularly powerful predictor: one retrospective study identified a ratio above 45 percent as an independent risk factor for catheter failure, and a subsequent prospective cohort found that even a ratio above 33 percent correlated with elevated failure risk, aligning with ultrasound screening thresholds for peripheral access. Insertion site matters too—a few centimetres’ difference in puncture height within the mid-upper arm’s so-called green zone can shift a fixed-length catheter’s tip from the distal axillary vein all the way to the brachiocephalic vein. Catheter tip configuration adds another wrinkle, with database evidence suggesting open-tipped devices trigger more complications and removals than closed or valved designs, though inconsistent reporting makes the independent effect of material—silicon versus polyurethane—impossible to pin down. A randomized trial of antithrombogenic and antimicrobial coatings, for instance, found no significant difference in thrombosis rates.

The complication data compiled in the review’s evidence map span dizzying ranges. Reported overall complication rates ranged from under 1 percent to 60 percent depending on tip position and study, catheter-related thrombosis from 0.085 percent to 41.5 percent, and dwell times from five days to more than 150 days. Some findings cut against the proximal-placement trend: one pilot study of 27 patients found no significant association between tip position and fibroblastic sleeve formation or thrombosis, while another study comparing superficial with deeper tip placement found complication rates of 23.81 percent versus 7.55 percent. The review’s authors stress that these unweighted ranges describe the spread of the literature, not comparative effect estimates, and that dwell time in particular is an ambiguous metric—long indwelling may reflect success or simply prolonged exposure to endothelial irritation and biofilm.

What the review ultimately delivers is less an answer than an agenda. The authors call for professional societies to agree on standardized anatomical terminology, for prospective cohort studies and randomized trials using precise positioning techniques to clarify the relationship between tip location, catheter lifespan and patient comfort, and for clinical pathways built on multimodal confirmation that spares patients unnecessary X-rays. They are candid about their own limitations: the exclusion of mini-midlines shorter than 15 centimetres, the restriction to English and Chinese publications, the absence of formal quality appraisal, and the overwhelming Chinese dominance of the evidence base. But the core message stands. Midline catheters have earned their place in modern infusion therapy, and their popularity will only grow as care migrates out of hospitals. Until the field settles where the line should end—and how to prove it—a device praised for its simplicity will keep carrying a hidden burden of uncertainty that only coordinated, multinational research can lift.

Subject of Research: Midline catheter tip location, tip confirmation methods and associated clinical characteristics

Article Title: Mapping the Evidence on Midline Catheter Tip Location, Confirmation Methods and Associated Characteristics: A Scoping Review

Article References: Mapping the Evidence on Midline Catheter Tip Location, Confirmation Methods and Associated Characteristics: A Scoping Review. (n.d.). https://doi.org/10.1002/nop2.70876

Image Credits: AI Generated

DOI: 10.1002/nop2.70876

Keywords: midline catheter, vascular access, catheter tip location, ultrasound guidance, chest radiography, catheter-related thrombosis, scoping review, infusion therapy standards, catheter-to-vein ratio, nursing practice, peripheral intravenous therapy, evidence mapping

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

The recommendation, developed by the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research together with NEVAT, addresses two closely linked procedures: ultrasound-guided cannulation of deep central veins and the tunneling of catheters beneath the skin to secure them in place. Its authors include anesthesiologists, neonatologists, pediatric intensivists, and vascular access nurse specialists from hospitals across Austria, Italy, the Netherlands, Spain, Belgium, and beyond. That breadth of expertise is deliberate. Vascular access in newborns has long been fragmented across specialties, with anesthesiologists, surgeons, and neonatal nurses each bringing different habits, different equipment preferences, and different definitions of success. The new document argues that this variation itself is a patient safety hazard, and that only standardized, protocol-driven practice can close the gap between the best-performing units and the rest.

At the heart of the recommendation is a simple but transformative principle: no needle should enter a neonatal vein without ultrasound guidance, and no catheter should be considered properly placed until its tip position has been verified. The authors emphasize that ultrasound plays an essential role in every phase of insertion and evaluation of both centrally inserted central catheters, often abbreviated CICC, and femorally inserted central catheters, known as FICC. Before any puncture, the operator is expected to perform a systematic ultrasound survey of the candidate veins. For the upper body, this means assessing the internal jugular, subclavian, and brachiocephalic veins; for the lower body, the femoral and iliac vessels. Structured pre-insertion assessment protocols such as the rapid central vein assessment and the rapid femoral vein assessment, both developed by members of the same expert community, provide a repeatable checklist for this survey, documenting vein patency, diameter, compressibility, and surrounding anatomy before a single instrument is opened.

The technical core of the document concerns the supraclavicular approach to the brachiocephalic vein, an access route that has quietly revolutionized neonatal central line placement over the past decade. The brachiocephalic veins are formed by the junction of the internal jugular and subclavian veins and run a short, relatively straight course toward the superior vena cava. In adults they are routinely used for central access, but in neonates they were long considered too small and too deep to target safely. Ultrasound changed that calculus. With a high-frequency linear probe positioned just above the clavicle, an experienced operator can visualize the right brachiocephalic vein in cross-section, advance the needle in real time under the probe, and watch the guidewire enter the vein on screen. The same supraclavicular window then allows the operator to track the catheter tip as it descends toward the cavoatrial junction, providing immediate confirmation of central tip position without a separate radiograph.

The published evidence supporting this approach in the smallest patients is substantial. Case series have documented ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in infants weighing as little as 680 grams, and retrospective analyses have reported hundreds of successful cannulations in neonates and preterm infants with encouraging safety profiles. One study even suggested that the supraclavicular approach may reduce central line-associated bloodstream infections in preterm infants, possibly because the catheter can be tunneled away from the insertion site and secured more effectively. The new recommendation consolidates this experience into formal guidance, complete with illustrated steps for estimating the required intravascular catheter length, trimming the catheter to the correct size, and cannulating the right brachiocephalic vein in a 680-gram neonate. The inclusion of such granular procedural detail reflects a deliberate editorial choice: the authors want the document to function as a practical manual at the bedside, not merely as a statement of principle.

Site selection receives equally rigorous treatment. The recommendation adapts the zone insertion method, originally developed for peripherally inserted central catheters in adult upper arms, to the peculiar geography of the newborn. Extrapolated ZIM zones map out the cervicothoracic and inguinal-femoral regions, identifying which skin insertion points offer the best combination of vessel depth, vein diameter, and a straight catheter trajectory to the desired tip position. The logic is anatomical: a catheter that enters the vein at a shallow angle, travels a straight path, and avoids crossing joints or sharp vessel bends is less likely to cause mechanical complications such as vessel perforation, catheter malposition, or thrombosis. In a neonate, whose veins may grow along with the child over weeks of intensive care, preserving vessel integrity for future access is not a luxury but a necessity.

Tunneling, the second pillar of the recommendation, is presented as a key defense against infection and accidental dislodgement. By creating a subcutaneous tunnel between the venous entry point and a distant skin exit site, the operator increases the distance bacteria must travel to reach the bloodstream and anchors the catheter more securely in fragile, thinly keratinized neonatal skin. The document also addresses modern securement and dressing strategies, including cyanoacrite tissue adhesive, which has emerged in recent neonatal studies as a component of bundles that reduce catheter-related complications, and subcutaneously anchored sutureless fixation devices. These may sound like minor technical refinements, but in a population where a single line failure can mean repeated painful procedures, prolonged hospitalization, and increased infection risk, the cumulative effect of such refinements is clinically significant.

Tip location, the final verification step, receives its own detailed discussion. The recommendation describes structured ultrasound protocols for confirming that the catheter tip sits at the cavoatrial junction, the optimal position where the superior vena cava meets the right atrium. It also reviews the intracavitary electrocardiography method, in which a saline-filled catheter acts as a lead that records the characteristic electrical signature of the atrium, allowing real-time tip confirmation. Recent consensus work and comparative reviews have examined whether intracavitary ECG or real-time ultrasound should be the primary verification tool in neonates, and the new document frames both as complementary techniques within a structured protocol for tip navigation and tip location. The overarching message is that a chest radiograph alone, taken after the fact, is no longer an acceptable standard for confirming neonatal central line position when real-time alternatives exist.

The authors frame the entire package as a bundle, drawing on the seven-step SIC and SIF protocols designed to minimize complications of centrally inserted and femorally inserted central catheters respectively. Each step, from pre-insertion vein assessment through site selection, insertion, tip navigation, tip location, securement, and post-insertion evaluation, is specified in a way that can be audited and taught. The recommendation also aligns with broader international guidance on ultrasound-guided vascular access and with contemporary infusion therapy standards, situating neonatal practice within a coherent evidence framework rather than leaving it as an isolated pediatric exception. The authors acknowledge the contributions of parent organizations, including the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants, reflecting a growing recognition that families have a stake in how these procedures are performed and communicated.

What makes this recommendation potentially viral in the world of neonatology is its insistence that excellence in vascular access is not an innate gift of certain surgeons or a matter of institutional tradition, but a learnable, protocolized skill that any well-trained team can deliver. The work was not externally funded, and the authors declare no competing interests, positioning the document as a purely professional consensus. If units across Europe and beyond adopt its standards, the practical consequences could be measured in fewer failed first attempts, fewer misplaced catheters, fewer bloodstream infections, and fewer needle sticks for the smallest and most vulnerable patients in the hospital. For a field where a millimeter of precision can determine whether a 700-gram infant thrives or suffers a preventable complication, the arrival of a unified, ultrasound-first European standard marks a genuine turning point in the care of newborns.

Subject of Research: Ultrasound-guided central venous catheter insertion and tunneling in neonates

Article Title: Ultrasound-guided central vascular access and device tunneling: neonatal European vascular access team—ESPR recommendation 4

Article References: Breschan, C., Pittiruti, M., van der Lee, R., Oulego-Erroz, I., Werther, T., Piersigilli, F., Barone, G., 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., Schwaberger, B., Debuf, M.-J., Milan, A., Yousef, N., … Tuna, M. L. (2026). Ultrasound-guided central vascular access and device tunneling: neonatal European vascular access team—ESPR recommendation 4. Pediatric Research. https://doi.org/10.1038/s41390-026-05463-w

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05463-w

Keywords: neonatology, ultrasound, central venous catheter, brachiocephalic vein, ESPR, vascular access, preterm infants, catheter tunneling, tip location, patient safety, supraclavicular approach, Pediatric Research

The problem the authors set out to address is rooted in the peculiar biology of newborn skin. In preterm infants, the stratum corneum, the outermost barrier layer of the epidermis, is thin and poorly keratinized, which means the skin offers far less resistance to microorganisms and loses water far more rapidly than adult skin. This immaturity drives increased transepidermal water loss and leaves the skin fragile and prone to injury. At the same time, neonates who need intravenous nutrition, medications, or hemodynamic support often carry catheters for weeks, and every dressing change or manipulation of the device creates another opportunity for contamination, skin stripping, or accidental dislodgement. The combination of immature skin, prolonged catheter dwell times, and repeated handling makes the exit site a critical bottleneck in neonatal intensive care, where failures translate directly into catheter-related bloodstream infections, medical adhesive-related skin injury, dressing failure, and loss of vascular access that may be difficult or impossible to replace.

The recommendation covers the full range of devices used in neonatal units, including peripheral venous access devices, central venous access devices such as peripherally inserted central catheters, epicutaneo-caval catheters, femorally and centrally inserted central catheters, umbilical venous and arterial catheters, and intra-arterial lines. Each device type presents a slightly different exit site anatomy and risk profile, but the authors argue that the underlying principles of assessment, antisepsis, securement, and monitoring should be standardized across all of them. Standardization, they contend, is what allows a unit to detect deterioration early, compare outcomes over time, and reduce the unexplained variation in practice that has long characterized neonatal care from one center to another.

Central to the recommendation is the systematic assessment of both the exit site and the surrounding skin. Clinicians are advised to inspect the site at defined intervals, documenting the appearance of the skin, the presence of redness, swelling, or exudate, the integrity of the dressing, and the external catheter length, since a change in the length of catheter protruding from the skin is a classic early sign of migration. The authors emphasize the use of validated neonatal skin assessment tools, drawing on instruments such as the Neonatal Skin Condition Score, to make observations reproducible rather than subjective. Because adhesive-related injury is a well-recognized hazard in very preterm infants, the guidance also stresses careful technique when applying and removing dressings and adhesives, including the use of adhesive removers and gentle peel techniques to avoid stripping the fragile epidermis.

On the question of asepsis, the recommendation endorses the Aseptic Non Touch Technique framework, known as ANTT, distinguishing between Standard-ANTT for procedures involving small key sites and key parts, such as routine exit site care and dressing changes, and Surgical-ANTT for procedures that require a larger sterile field, such as catheter insertion. The ANTT approach, which originated in the United Kingdom and has been adopted widely across Europe, rests on the principle of identifying the key parts of the equipment and the insertion site that must remain free of microorganisms and protecting them from contact with non-sterile surfaces throughout the procedure. The authors point to quality improvement studies showing that standardizing and improving compliance with aseptic non-touch technique can reduce healthcare-associated infections in neonatal units, and they argue that a shared, teachable framework is more reliable than idiosyncratic local habits.

Skin antisepsis before and around catheter care is addressed with specific attention to gestational age, a nuance that distinguishes neonatal practice from adult guidelines. Chlorhexidine-based solutions are recommended as the agents of choice, consistent with their broad-spectrum activity and residual effect, but the concentration and formulation must be adapted to the maturity of the infant’s skin. Recent randomized feasibility work in preterm neonates, including the Arctic trial comparing 2% chlorhexidine gluconate in aqueous solution with 2% chlorhexidine gluconate in 70% isopropyl alcohol, illustrates the ongoing effort to balance antimicrobial efficacy against the risk of chemical burns and skin irritation in extremely immature skin. Alcohol-based preparations act faster and leave less residue, but they carry a higher risk of skin injury in preterm infants and must be allowed to dry fully; aqueous formulations may be preferred for the most fragile patients. The recommendation instructs clinicians to remove antiseptic residue after the procedure to limit cumulative exposure of the developing skin.

Perhaps the most technically distinctive elements of the guidance concern securement. Traditional suture fixation is problematic in neonates because sutures create additional skin breaks and infection risks, so the authors advocate sutureless securement strategies. One approach uses subcutaneously anchored sutureless devices that stabilize the catheter hub without penetrating the skin. The other, increasingly popular in European centers, is cyanoacrylate tissue adhesive, specifically octyl-butyl-cyanoacrylate glue, applied at the exit site to fix the catheter in place and simultaneously form a microbial barrier. Clinical studies in neonates, including randomized trials of cyanoacrylate securement for umbilical venous catheters and observational series in peripherally inserted central catheters and epicutaneo-caval catheters, have reported reductions in accidental dislodgement and promising trends in complication rates. The glue works by polymerizing on contact with tissue moisture, creating a flexible film that anchors the catheter and can be peeled away or sloughs off naturally as the skin exfoliates.

Dressing selection receives equally detailed treatment. The recommendation favors semipermeable transparent films with a high moisture vapor transmission rate, a property usually abbreviated as MVTR. This parameter, typically measured in grams of water vapor passing through a square meter of material per day, determines how well a dressing allows the skin underneath to breathe while still blocking external contaminants and maintaining a sterile field. In neonates, whose skin loses water at high rates and whose catheters may remain in place for weeks, a dressing with inadequate vapor permeability can trap moisture, causing maceration that weakens the skin barrier and promotes microbial growth, whereas an excessively permeable dressing may lose adhesion prematurely. The authors also describe dressing configurations tailored to specific devices, including setups for umbilical catheters, and provide guidance on when and how dressings should be changed, favoring change on indication, such as soiling, loosening, or visible deterioration, rather than on a fixed routine schedule that multiplies manipulation of fragile skin.

The document closes the loop with recommendations on complication monitoring and catheter removal, underscoring that exit site care does not end until the device is out and the site has healed. Clinicians are urged to maintain vigilance for local signs of infection, phlebitis, infiltration, and skin breakdown, and to remove catheters as soon as they are no longer clinically necessary, since dwell time is one of the strongest modifiable risk factors for catheter-related bloodstream infection. The authors acknowledge that the evidence base in neonates remains thinner than in adult vascular access, and that many elements of the recommendation rest on expert consensus informed by studies in related populations, a limitation they address by making the reasoning behind each element explicit.

The significance of the work lies less in any single novel technique than in its ambition to make excellent exit site care universal rather than accidental. By codifying assessment schedules, antisepsis protocols, securement technologies, and dressing standards into a single recommendation, the European group aims to give every neonatal unit, regardless of size or resources, a coherent playbook for protecting the skin-catheter interface. If widely implemented, the authors argue, standardized exit site management could reduce catheter-related infections, medical adhesive-related skin injuries, dressing failures, and device dislodgements, sparing fragile newborns painful reinsertions, prolonged antibiotic courses, and the serious systemic complications that begin, all too often, at a few square centimeters of immature skin.

Subject of Research: Evidence-based management of catheter exit sites in neonatal vascular access

Article Title: Exit site management: neonatal european vascular access team – ESPR recommendation 7

Article References: Piersigilli, F., Romitti, M. G., Van Eenoo, S., van der Lee, R., Hugill, K., van Rens, M., Iacona, G., Barone, G., Rodriguez-Perez, C., on behalf of the Pediatric and Neonatal Vascular Access SIG of the ESPR and NEVAT, Van Eenoo, S., van der Lee, R., van Rens, M., Debuf, M.-J., Milan, A., Yousef, N., Schwaberger, B., Pittiruti, M., Werther, T., … Tuna, M. L. (2026). Exit site management: neonatal european vascular access team – ESPR recommendation 7. Pediatric Research. https://doi.org/10.1038/s41390-026-05471-w

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05471-w

Keywords: neonatology, vascular access, catheter exit site, ANTT, chlorhexidine, cyanoacrylate glue, sutureless securement, transparent dressings, MVTR, catheter-related infection, medical adhesive-related skin injury, ESPR 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