Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy.
The following Task Force members or content experts have no conflicts of interest to declare: Daniele Trevisanuto, Gary M Weiner, Juin Yee Kong, Mandira D Kawakami, Maria Fernanda de Almeida, Marta Thio, Nicole Yamada, Ruth Guinsburg, Tetsuya Isayama, Helen G Liley, Yacov Rabi, Georg M Schmölzer.
Dr. Myra Wyckoff is a co-author of studies examining the response to epinephrine administered through an umbilical vein catheter and did not participate in decisions related to inclusion of these studies.
CoSTR Citation
Mandira D Kawakami*, Juin Yee Kong*, Ruth Guinsburg, Tetsuya Isayama, Yacov Rabi, Georg M Schmölzer, Marta Thio, Daniele Trevisanuto, Gary M Weiner, Myra H Wyckoff, Nicole Yamada, Maria Fernanda de Almeida, Helen G Liley, on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Initial vascular access for neonatal resuscitation [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, 2025 December 31. Available from: http://ilcor.org
*Co-first authors
Methodological Preamble and Link to Published Systematic Review
Establishing emergency vascular access for the administration of medications, fluid, or blood products is an important procedure during resuscitation and stabilization of newborn infants with persistent bradycardia that does not respond to assisted ventilation and chest compressions, cardiopulmonary arrest, cardiac arrythmias, and shock. This procedure may be required for infants in the birthing area, critical care unit, emergency department, or out-of-hospital environment. Establishing vascular access can be challenging, especially in the setting of cardiac arrest or altered perfusion. Although few infants will require this intervention {Foglia 2017 32, Kapadia 2020 132} healthcare professionals in various settings must be proficient at establishing emergency vascular access because delayed administration of resuscitation medications is associated with decreased survival. {Halling 2021 236, Tijssen 2015 1} In the first hours after birth, the umbilical vein may be patent, accessible, and provide direct central access. The duration of umbilical vein patency varies and may not extend throughout the neonatal period. In some clinical scenarios, including infants with periumbilical congenital anomalies, umbilical vein catheterization may not be feasible. Moreover, healthcare professionals without neonatology specialty training may lack confidence and proficiency in umbilical vein catheterization. {Haase 2020 405} Healthcare professionals working in pre-hospital settings and the emergency department may prefer to insert an intraosseous access device into the medullary cavity of a long bone. {Frascone 2009 329, Pfeiffer 2023 1294322} While this procedure may provide rapid access, serious complications have been described. {Pfeiffer 2023 1294322} Peripheral intravenous cannulation may offer another alternative; however, successful cannulation is more difficult in young children, may delay medication administration, and may not be feasible among infants with cardiovascular collapse. {Lee 2020 180, Vukovic 2016 637}
The International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force (NLS TF) has identified emergency vascular access as a priority for review. The topic was last reviewed in 2020 as part of a larger (nodal) systematic review including adult and pediatric populations (NLS 616). {Granfeldt 2020 150} At that time, no neonatal studies were identified to include in the review. In 2024, an evidence update (NLS 5652) identified potentially relevant observational studies suggesting that a new systematic review focused on the neonatal population was justified. {Liley 2025 }
Although the focus of this PICOST is to make treatment recommendations for emergency vascular access during delivery room (DR) resuscitation, the studies included in this systematic review extend beyond the DR setting. The inclusion criteria for the population, intervention, and comparison are broader than typically included in NLS Task Force systematic reviews and, therefore, may provide indirect evidence related to DR resuscitation. The primary indication for emergency vascular access during the first minutes after birth is to administer epinephrine for treatment of persistent bradycardia or asystole unresponsive to assisted ventilation or chest compressions. This is a rare event and there may be insufficient direct evidence to answer the question for this very narrow population and indication. In making the decision to include a broader population, we recognized that emergency vascular access may be needed during the neonatal period (first 28 days after birth or until 44 weeks postmenstrual age) in multiple settings and for a wide range of indications including volume resuscitation or medications for sepsis, hemorrhage, shock, arrythmias, or congenital heart disease. Emergency vascular access may be inserted outside the hospital by first responders, in the emergency department, or in the neonatal intensive care unit. We appreciate that the preferred method of vascular access may vary based on the time after birth, location, and indication but suggest that a broader review may be valuable for health care providers who encounter newborn infants in these settings. We have, therefore, included neonates who have any emergency indication in the population for this PICOST, not just resuscitation immediately after birth, recognizing that we may need to use indirect evidence to support recommendations made for emergency vascular access during DR resuscitation.
Systematic Review
Pending
PICOST
Population: Infants requiring emergency vascular access between birth and 28 days of age or 44 weeks postmenstrual age.
Intervention: Any type of vascular access (umbilical vein, intraosseous, peripheral vein, or other)
Comparator: Any other type of vascular access (umbilical vein, intraosseous, peripheral vein, or other)
Outcomes:
Time to achieve heart rate (HR) > 100 bpm (important)
Time required to successfully place the device (important)
Additional outcomes
Successful vascular access at the first attempt (important)
Number of attempts until successful vascular access (important)
Complications associated with the procedure (important)
Death during the event requiring emergency vascular access (critical)
Death before hospital discharge (critical)
The prioritization of critical and important outcomes was made according to Strand or by Task Force consensus. {Strand 2020 F328}
Study Designs: Randomized controlled trials, non-randomized controlled trials, interrupted time series, controlled before-and-after studies, and cohort studies were eligible for inclusion.
It was anticipated in advance of the search that there would be insufficient studies from which to draw a conclusion, and case series of at least 6 or more cases were included; however, smaller case series and individual case reports were included for articles describing complications of emergency vascular access methods.
Unpublished studies (e.g., conference abstracts, trial protocols) and cadaver, manikin, computer model and animal studies were excluded.
Timeframe: All years and all languages were included provided there was an English abstract.
The literature search strategy was developed by a research librarian. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and CINAHL were searched from inception date until July 30th, 2025.
Definitions
Emergency vascular access: Vascular access inserted during an acute life-threatening event that requires immediate action.
Umbilical vein access: A catheter or a needle inserted into the infant’s umbilical vein.
Intraosseous access: A needle inserted through the bone cortex that infuses fluid or medication into the medullary space.
Peripheral vein access: A needle or catheter inserted percutaneously into a superficial vein.
Successful vascular access: Placement of a needle or catheter that infuses into the intended structure without extravasation into the surrounding tissue.
Time to achieve HR > 100 bpm: This outcome will only be assessed for infants that had HR </= 100 bpm at the time the emergency vascular access device was inserted.
A Priori Subgroups
Intervention: During initial birth resuscitation vs. any other indication
Setting: Out-of-hospital vs. in-hospital procedure
Provider: Neonatology trained provider (physician, advanced practice nurse, physician’s assistant, or trainee) vs. other
Population: Post-menstrual age at the time of device insertion (≥37+0 weeks; 28+0 to 36+6 weeks; < 28+0 weeks); postnatal age at time of device insertion (</= 7 days, > 7 days)
PROSPERO Registration: CRD420251122463. Registered on August 11, 2025. Screening for eligible studies began after the protocol was registered.
Risk Of Bias
Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs {Sterne 2019 l4898} or the Robins-I tool for observational studies. {Sterne 2016 i4919} Additional information from study investigators was sought if required information was unclear or unavailable in the study publications/reports.
The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to assess the certainty of evidence (COE) for each outcome deemed critical or important. {Guyatt 2008 924}
Consensus On Science
Description of studies
No clinical trials directly comparing one vascular access device with another were found. The included studies consist of ten descriptive case series{Baik-Schneditz 2017 171, Ellemunter 1999 F74, Eriksson 2024 e2351535, Halling 2024 114058, Halling 2017 232, Heathcote 2018 1053, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632, Sproat 2017 F262} and six case reports. {Carreras-González 2012 233, De Curtis 1985 261, Katz 1994 258, Oesterlie 2014 413, Suominen 2015 1389, Vidal 1993 1201} In the included studies, emergency vascular access was established in a wide range of settings, including the DR, emergency department, neonatal intensive care unit (NICU), and out-of-hospital locations. As needed, corresponding authors were contacted for additional data. {Baik-Schneditz 2017 171, Halling 2024 114058, Halling 2017 232, Joerck 2023 853, Sproat 2017 F262} Because of the small number of included infants, heterogeneous settings and indications, and lack of within study comparisons between infants receiving different types of vascular access, a narrative synthesis of results is provided, but no attempt was made to statistically pool data.
Four studies described the use of an umbilical vein catheter (UVC) for emergency vascular access after birth in the DR. {Halling 2024 114058, Halling 2017 232, Heathcote 2018 1053, Sproat 2017 F262} Halling reported a single-center’s experience with 50 newborn infants receiving epinephrine in the DR. {Halling 2017 232} From this group, 20 infants received the first dose of epinephrine through an emergency UVC, and 24 additional infants received epinephrine through an emergency UVC after initially receiving endotracheal epinephrine (routes of administration confirmed by author). In a separate study, Halling reported the outcome for 408 newborn infants receiving chest compressions and epinephrine in the DR at 142 centers participating in a DR resuscitation registry. {Halling 2024 114058} From this group, 127 infants received the first dose of epinephrine through an emergency UVC, and 112 additional infants received epinephrine through a UVC after endotracheal epinephrine (routes of administration confirmed by author). Heathcote reported a single-center case series including 27 newborns >26 weeks’ gestation with Apgar score of 0 at 1 minute. Of these infants, insertion of an emergency UVC was attempted in 25 infants for resuscitation in the DR. {Heathcote 2018 1053} Sproat reported a single-center case series including 22 infants (23 to 40 weeks' gestation) with no detectable heart rate before 10 minutes of age where cardiopulmonary resuscitation was attempted. {Sproat 2017 F262} In this series, 13 infants had an emergency UVC inserted.
Four studies described the use of an intraosseous (IO) device for emergency vascular access. {Ellemunter 1999 F74, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632} Ellemunter reported a single center experience with 30 IO needle placements in 27 newborn infants (7 full term, 20 preterm) requiring emergency vascular access in the NICU within 5 hours of birth. {Ellemunter 1999 F74} Joerck reported a retrospective review of prospectively collected data from an Australian interhospital transfer service database that included 102 critically ill infants ≤44 weeks’ postmenstrual age (mean 39 weeks, range 24-44 weeks) who had an IO access device inserted. {Joerck 2023 853} The IO device was most often inserted in the emergency department (52%), but other settings included the birthing suite (12.7%), a pre-hospital setting (6.9%), and during intra-hospital transport (4.9%). Mileder reported a single-center case series that described 12 infants (8 term, 3 preterm) who underwent 15 IO access attempts during resuscitation in the birthing suite (n=10) and in the NICU (n=2). {Mileder 2020 571285} Using a nationwide pediatric hospital surveillance database, Schwindt reported a case series including 206 IO access attempts in 161 neonates <28 days old (145 term, 16 preterm) from in-hospital and pre-hospital settings. {Schwindt 2022 952632} In most (70%), the IO device was inserted during the first 24 hours after birth. At the time of IO device insertion, 57% were receiving cardiopulmonary resuscitation.
One case series described the insertion of a peripheral vein (PIV) catheter for initial stabilization in 61 preterm infants in the delivery room (DR). In this series, Baik-Schneditz described insertion of a PIV in nine newborn infants during the first 10 minutes after birth; however, only five infants are included in this review (two after cardiopulmonary resuscitation including chest compressions, three treated for suspected hypovolemia). {Baik-Schneditz 2017 171} In the other four infants, a PIV was inserted for elective administration of pre-medication to facilitate tracheal intubation. These four cases were not considered emergency vascular access and were excluded. Although the final count of included cases was less than six, and no infant in the series was bradycardic or receiving chest compressions at the time of PIV insertion, this case series was included in the narrative data synthesis because it provided unique evidence on the use of a PIV for emergency vascular access in the DR.
One case series described both IO and PIV access among neonates in an out-of-hospital setting. Eriksson reported a population-based retrospective case series describing emergency medical service providers responding to pediatric out-of-hospital cardiac arrests. {Eriksson 2024 e2351535} The study included 42 newborn infants immediately after birth and 43 infants less than 28 days of age (mean 14 days, interquartile range (IQR) 9-23 days).
Six case reports describing complications associated with emergency vascular access were included. {Carreras-González 2012 233, De Curtis 1985 261, Katz 1994 258, Oesterlie 2014 413, Suominen 2015 1389, Vidal 1993 1201}
Outcomes:
Time to achieve heart rate >100 bpm (important)
For the important outcome of time to achieve a heart rate >100 bpm, no eligible studies reported a comparison between the different devices. The only available evidence for this outcome (very low certainty) supports the use of an emergency UVC for epinephrine (adrenaline) administration. {Sproat 2017 F262}
One case series involving the insertion of a UVC for epinephrine administration in 11 newborns in the DR found a median duration of 19 minutes (range 13-45) from the time of birth to achieve a HR >100 bpm (unpublished data provided by author). {Sproat 2017 F262} No studies involving the use of IO access reported time to achieve heart rate >100 bpm. One case series involving the use of a PIV in 2 preterm newborns in the DR reported this outcome; however, after obtaining additional information from the author, these data were not included because all infants in the study had HR > 100 bpm prior to PIV insertion. {Baik-Schneditz 2017 171}
Time required to successfully place the device (important)
For the important outcome of time to successfully place the vascular access device, no eligible studies reported a direct comparison between devices. The available evidence (very low certainty) is limited to case series and suggests that insertion time may be similar between a UVC and IO access device. There is insufficient evidence to comment on the time required to achieve peripheral vein access in the setting of cardiac arrest or bradycardia.
One single-center case series reported the median time from birth to successful emergency UVC placement in the DR. {Heathcote 2018 1053, Sproat 2017 F262} In 21 newborns, Heathcote {Heathcote 2018 1053} reported a median of 9 minutes. The authors did not report the time from the beginning of the UVC insertion procedure until successful placement. Additional indirect evidence comes from three case series that reported the time from birth to first intravenous epinephrine administration using a UVC. {Halling 2024 114058, Halling 2017 232, Sproat 2017 F262} In 11 newborns receiving epinephrine through a UVC, Sproat found the median time from birth to first epinephrine dose was 13 minutes with a range 11-20 minutes (unpublished data provided by author). {Sproat 2017 F262} In the 20 newborn infants resuscitated in the DR at a single center who received their initial dose of epinephrine through a UVC, Halling reported a mean (SD) time of 5.4 (2.2) minutes (route of administration confirmed by author). {Halling 2017 232} Halling’s multicenter registry described 127 newborn infants receiving chest compressions and epinephrine in the DR and reported a median time of 8 minutes (95% CI 7-10 minutes) to administer the initial dose of epinephrine through a UVC (route of administration confirmed by author). {Halling 2024 114058}
The time required to successfully place an IO device was reported in two studies. {Ellemunter 1999 F74, Schwindt 2022 952632} In the NICU, Ellemunter reported an insertion time of less than 2 minutes for 30 IO insertion procedures performed in 27 neonates less than 5 hours of age. {Ellemunter 1999 F74} The IO insertion time was available for 90 neonates included in Schwindt’s case series. {Schwindt 2022 952632} Successful insertion was achieved in < 1 minute in 18 neonates, 1-2 minute in 36 neonates, 2-3 minutes in 17 neonates and >3 minutes in 19 neonates.
In 5 preterm infants in the DR, Baik-Schneditz reported that successful PIV insertion was achieved in a median of 7 minutes (range 3-10 minutes) after birth; however, all included infants had a HR > 100 bpm at the time of insertion. {Baik-Schneditz 2017 171}
Successful vascular access (important)
For the important outcome of successful vascular access, the available evidence (very low certainty) is limited to case series and suggests that insertion of a UVC in the DR setting may have a high probability of successfully achieving emergency vascular access. Most of the evidence related to IO access for neonates is outside the DR setting and suggests that intraosseous access devices may have a high probability of successfully achieving emergency vascular access. There is insufficient evidence to comment on the effectiveness of peripheral vein access during cardiac arrest or bradycardia.
Three case series reported successful emergency UVC placements during DR resuscitation. {Halling 2024 114058, Halling 2017 232, Heathcote 2018 1053, Sproat 2017 F262} Successful placement was described in all 44 infants reported in Halling’s single center case series and in all 239 infants reported in Halling’s multicenter registry study.{Halling 2024 114058, Halling 2017 232, Sproat 2017 F262} However, the total number of infants with an attempted emergency UVC insertion was not explicitly reported in either study. In the series reported by Heathcote, successful placement was achieved in 23/25 infants (92%) who had attempted emergency UVC insertion in the DR. {Heathcote 2018 1053}
Five case series reported the proportion of successful IO device insertions. {Ellemunter 1999 F74, Eriksson 2024 e2351535, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632} Ellemunter reported successful placement of an IO device in all 27 newborns in the NICU. {Ellemunter 1999 F74} Similarly, Joerck reported successful insertion in all 102 infants less than 44 weeks postmenstrual age in both hospital and out-of-hospital settings. {Joerck 2023 853} Mileder reported successful insertion in 9/12 neonates (75%) in the DR and NICU. {Mileder 2020 571285} Schwindt reported successful insertion in 146/161 neonates (91%) less than 28 days old in both in-hospital and out-of-hospital settings. {Schwindt 2022 952632} Eriksson reported successful insertion by emergency medical services during out-of-hospital cardiac arrest in 6/10 newborn infants (60%) after birth and 32/39 infants (82%) less than 28 days. {Eriksson 2024 e2351535}
Two case series reported the proportion of successful PIV insertion attempts. {Baik-Schneditz 2017 171, Eriksson 2024 e2351535} Baik-Schneditz reported successful insertion in all five preterm infants in the DR. {Baik-Schneditz 2017 171} At the time of PIV insertion, all infants had a heart rate > 100 bpm. During out-of-hospital cardiac arrest, Eriksson reported successful PIV access in 0/3 infants at birth and 3/7 neonates less than 28 days. {Eriksson 2024 e2351535}
Successful vascular access at the first attempt (important)
For the important outcome of successful vascular access on the first attempt, the available evidence (very low certainty) is limited to case series and suggests that emergency insertion of a UVC may be preferred in the DR setting. Outside the DR setting, IO access devices may have a high probability of successfully achieving emergency vascular access on the first attempt. There is insufficient evidence to comment on the effectiveness of PIV access during cardiac arrest or bradycardia.
One case series involving 27 newborns resuscitated in the DR reported successful first attempt emergency UVC insertion in 21/25 infants (84%).{Heathcote 2018 1053} The authors note that UVC insertion was difficult in 4 infants resulting in the first dose of epinephrine being administered using an alternative access method. Three case series described successful IO access at the first attempt. {Ellemunter 1999 F74, Mileder 2020 571285, Schwindt 2022 952632} Ellemunter reported first attempt insertion success for all 30 IO devices placed in 27 newborns in the NICU. {Ellemunter 1999 F74} Mileder reported first attempt IO device insertion success in 6/12 infants (50%) resuscitated in the DR and NICU. {Mileder 2020 571285} Schwindt reported first attempt IO device insertion success in 109/161 infants (68%) less than 28 days resuscitated both in-hospital and out-of-hospital. {Schwindt 2022 952632} One case series reported successful first attempt PIV access in 4/5 newborns (80%) in the DR. {Baik-Schneditz 2017 171} All of these infants had HR > 100 bpm at the time of PIV insertion.
Number of attempts until successful vascular access (important)
For the important outcome of number of attempts until successful vascular access is achieved, there is insufficient evidence to reach any conclusion.
Three case series reported the need for more than one attempt when securing emergency IO {Mileder 2020 571285, Schwindt 2022 952632} and PIV access. {Baik-Schneditz 2017 171} No study reported the number of attempts needed for successful emergency UVC access. When IO access was achieved in the DR and NICU, Mileder reported that 3/12 infants required two attempts. {Mileder 2020 571285} Among 146 neonates with successful IO access achieved both in and out-of-hospital, Schwindt reported requiring two attempts in 33/146 (23%) neonates, three attempts in 3/146 (2%) neonates, and four attempts in 1/146 (0.7%) neonates. {Schwindt 2022 952632} For PIV access in the DR, one case series reported the need for 2 attempts in 1/5 (20%) preterm newborns (unpublished data provided by author). {Baik-Schneditz 2017 171} However, all newborns in this series had a HR > 100 bpm at the time of PIV insertion (information provided by author).
Complications (important)
For the important outcome of complications associated with emergency vascular access, the available evidence (very low certainty) is limited to case series and suggests that IO access may be associated with a higher risk of serious complications; however, this finding may be seriously affected by publication bias and confounding by indication.
No studies reported complications associated with emergency UVC placement. One case report described gangrene of the buttocks due to internal iliac artery thrombosis following attempted umbilical vein needle puncture for epinephrine administration in 2 newborns resuscitated in the DR, with one death occurring 7 days after the procedure. {De Curtis 1985 261} Four case series {Ellemunter 1999 F74, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632} and 5 case reports {Carreras-González 2012 233, Katz 1994 258, Oesterlie 2014 413, Suominen 2015 1389, Vidal 1993 1201} described complications related to IO access, including dislocation and malfunction of the IO needle, tibial fractures, subcutaneous and severe soft tissue necrosis, hematoma, extravasation, osteomyelitis, soft tissue infection, limb amputation and other unspecified events. In the two largest case series, Schwindt reported severe complications related to IO access in 9/155 (6%) neonates {Schwindt 2022 952632} while Joerck reported complications in 11/102 (10.8%) neonates. {Joerck 2023 853} One case series including 5 newborn infants reported no complications associated with six attempts at PIV access. {Baik-Schneditz 2017 171}
Death during the event requiring emergency vascular access (critical)
Death before hospital discharge (critical)
For the critical outcomes of death during the event requiring emergency vascular access and death before hospital discharge, no eligible studies reported a comparison between devices. The available evidence (very low certainty) is limited to case series. For this review, emergency vascular access is defined as vascular access inserted during an acute life-threatening event that requires immediate action. Given the high risk of confounding by indication, small number of reported subjects, heterogeneous population reported, and descriptive nature of the included studies, the probability of death is likely associated with the critical condition of the reported population rather than causally related to the vascular access procedure or the device. There is insufficient evidence to reach a conclusion comparing the risk of death associated with the different emergency vascular access devices.
Four case series reported the proportion of infants that died during the event requiring emergency UVC placement in the DR {Halling 2024 114058, Halling 2017 232, Heathcote 2018 1053, Sproat 2017 F262} These studies reported death in 12/44 newborn infants (27%) {Halling 2017 232}, 100/239 newborn infants (42%) {Halling 2024 114058}, 9/27 newborns (33%) newborn infants {Heathcote 2018 1053}, and 0/11 newborn infants. {Sproat 2017 F262}
One case series reported no deaths during the resuscitation procedure after emergency IO device insertion among 27 infants resuscitated in the NICU. {Ellemunter 1999 F74} One case series reported no deaths during the resuscitation procedure among 5 preterm infants after PIV access in the DR. {Baik-Schneditz 2017 171}
Three cases series reported the proportion of neonates who had an emergency UVC inserted and died before hospital discharge. {Halling 2024 114058, Heathcote 2018 1053, Sproat 2017 F262}. These studies reported death in 84/125 newborn infants (67%) {Halling 2024 114058}, 17/27 newborn infants (67%) {Heathcote 2018 1053}, and 5/11 newborn infants (45%). {Sproat 2017 F262} Four case series reported the proportion of neonates who had an IO access device inserted and died before hospital discharge. {Ellemunter 1999 F74, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632} These studies reported death in 12/27 (44%) {Ellemunter 1999 F74}, 19/102 (19%) {Joerck 2023 853}, 8/12 (67%) {Mileder 2020 571285}, and 58/161 (36%). {Schwindt 2022 952632} No study involving the use of PIV access reported this outcome.
Subgroup considerations
No data for the planned subgroup analyses were available.
The UVC was primarily used during initial birth resuscitation of term and preterm infants in delivery rooms for severe bradycardia or asystole requiring epinephrine and fluids. {Halling 2024 114058, Halling 2017 232, Heathcote 2018 1053, Sproat 2017 F262} The IO device was used in both hospital and out-of-hospital settings with a broader mix of indications and providers. It was used mostly within the first week after birth, but the studies included infants up to 44 weeks’ postmenstrual age. {Ellemunter 1999 F74, Eriksson 2024 e2351535, Joerck 2023 853, Mileder 2020 571285, Schwindt 2022 952632} The lowest gestational age reported for UVC insertion was 23 weeks. {Sproat 2017 F262} The lowest gestational age and birthweight reported for IO access was 24 weeks and 515 grams. {Ellemunter 1999 F74, Joerck 2023 853, Mileder 2020 571285}Peripheral vein access was reported in two studies. One described infants immediately after birth in the DR and one reported events occurring among infants <28 days of age receiving chest compressions administered by emergency services personnel outside the hospital setting. {Baik-Schneditz 2017 171, Eriksson 2024 e2351535} The lowest gestational age and birthweight reported for PIV access was 24 weeks and 630 grams. {Baik-Schneditz 2017 171}
Treatment Recommendations
During resuscitation of infants immediately after birth, we suggest inserting an umbilical vein catheter as the primary method to obtain emergency vascular access (conditional recommendation, very low certainty evidence).
During resuscitation of infants immediately after birth, if insertion of an umbilical vein catheter is not successful or not feasible, we suggest that inserting an intraosseous device may be a reasonable alternative to obtain emergency vascular access (conditional recommendation, very low certainty evidence).
After the immediate newborn period, when the umbilical vein is no longer patent, we suggest that inserting an intraosseous device is a reasonable method to obtain emergency vascular access (conditional recommendation, very low certainty evidence).
There is insufficient evidence to make a recommendation on the use of a peripheral vein catheter for emergency vascular access in the setting of neonatal cardiac arrest or bradycardia.
Justification and Evidence to Decision Framework Highlights
In making this recommendation for newborn infants requiring emergency vascular access for neonatal resuscitation and stabilization, the Task Force considered that there were no human clinical studies comparing the different access devices (UVC, IO, PIV), so conclusions are based on case series and case reports. Efficacy, effectiveness, cost, resources, equity, acceptability, and safety of one procedure over another could not be directly assessed due to the small number of included infants, heterogeneity of settings and indications, and lack of comparisons between the devices within the same study. This limited evidence base inevitably increases the subjectivity of the judgements, which were concluded by Task Force consensus.
In the included case series and case reports, emergency vascular access was successfully established using either a UVC or an IO device in a wide range of settings, including the DR, emergency department, NICU, and out-of-hospital locations. When the umbilical vein is patent, insertion of a UVC does not require puncture of the infant’s skin or bone cortex. Serious complications have been associated with the use of IO access devices during neonatal resuscitation. Moreover, neither the equipment nor training required to insert an IO device may be routinely available in the birth setting leading to concerns about feasibility. However, insertion of a UVC may not be successful or feasible if an abdominal wall defect is present, after the immediate newborn period when the umbilical vein is no longer patent, or in settings where the provider does not have the training or equipment to access the umbilical vein. In these circumstances, an IO device may be a reasonable method to secure emergency vascular access. The evidence to assess the efficacy and safety of attempting emergency PIV access during neonatal cardiovascular collapse is too limited to make any recommendation.
Knowledge Gaps
The lack of clinical trials and observational studies comparing different emergent vascular access routes (umbilical venous, intraosseous, peripheral venous, or others) in infants from birth to 28 days of age or up to 44 weeks postmenstrual age leaves important evidence gaps regarding key outcomes related to this choice, including:
1. Regarding each one of the different types of vascular access (umbilical venous, intraosseous, peripheral venous)
- Optimal device to achieve vascular access
- Optimal techniques to insert the devices
- Optimal site for successful venous access
- Optimal method to determine correct placement of any emergency vascular access device
- How to best secure and maintain any emergency vascular access device
- Short- and long-term safety of umbilical vein, intraosseous, or peripheral vein placement
- Optimal training for device placement
- Cost-effectiveness related to insertion of any emergency vascular access
2. Regarding the comparison between umbilical venous, intraosseous, peripheral venous routes
- Time from start of cardiopulmonary resuscitation (CPR) to achieve successful vascular access
- Time from beginning of procedure to achieve successful vascular access
- Time from start of CPR to achieve heart rate >100 bpm after the insertion of the vascular access
- Time to achieve heart rate >100 bpm after the insertion of the vascular access device
- Successful vascular access at the first attempt
- Number of attempts until successful vascular access
- Pharmacokinetics and plasma availability of drugs administered through the different types of vascular access
- Cost-effectiveness of different types of vascular access
- Complications related to the types of vascular access and costs related to these complications
3. Research is required on:
- Specific populations - extremely low birth weight, very low birth weight; extremely preterm, very preterm, late preterm, term neonates; infants with congenital anomalies
- Different resource settings - high, medium and low resource setting
- Location - DR, emergency department, neonatal intensive care unit, and out-of-hospital
- Indication for vascular emergency access - initial birth resuscitation or any other indication
- Provider - neonatology trained provider (physician, advanced practice nurse, physician’s assistant, or trainee), first responders in out of hospital setting, providers at emergency room
- Post-natal age at device insertion - at birth, first week or 7 days or more after birth.
Prospective local and international registries should collect information on success and complications associated with emergency vascular access procedures.
Note to Webmaster: CoSTR posting should be linked to ETD summary table
Appendix: NLS 5652 Vascular Access Appendix Literature Search
EtD Table: NLS 5652 Vascular Access ETD
References
Baik-Schneditz N, Pichler G, Schwaberger B, Mileder L, Avian A, Urlesberger B. Peripheral Intravenous Access in Preterm Neonates during Postnatal Stabilization: Feasibility and Safety. Front Pediatr. 2017;5171.
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