Umbilical Vein, Intraosseous, or Peripheral IV? What Is the Best Vascular Access During Neonatal Resuscitation?
- 2 days ago
- 3 min read
One of the most challenging moments in neonatal resuscitation occurs when a newborn infant requires medications or volume expansion during cardiopulmonary resuscitation.
Chest compressions are underway.
Ventilation is being optimized.
The baby's heart rate remains critically low.
Now comes another crucial question:
How do we obtain vascular access as quickly and safely as possible?
For decades, the umbilical venous catheter (UVC) has been considered the standard approach in the delivery room. More recently, intraosseous (IO) access has emerged as an alternative, particularly when UVC placement is difficult or impossible. Peripheral intravenous catheters (PIVs) have also been used in selected situations.
But which approach is actually best?
Surprisingly, despite decades of neonatal resuscitation, we still do not know.
Why We Performed This Review
Establishing vascular access during neonatal resuscitation is uncommon but critically important.
Rapid administration of epinephrine or fluids may improve the chances of return of spontaneous circulation, yet obtaining vascular access during neonatal cardiac arrest is technically challenging.
Clinicians currently have three principal options:
Umbilical venous catheter (UVC)
Intraosseous (IO) access
Peripheral intravenous catheter (PIV)
Although each method has advantages and disadvantages, no comprehensive review had evaluated the available evidence specifically in newborn infants.
As members of the International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, we performed the first systematic review dedicated to this important clinical question.
What Did We Study?
We searched four major medical databases from their inception through February 2026.
After screening 1,381 publications, only 16 studies met our inclusion criteria.
These included:
10 descriptive case series
6 case reports describing complications
Perhaps the most striking finding came before we even analyzed the data:
There were no randomized controlled trials and no comparative studies directly evaluating UVC, IO, and PIV access in newborn infants.
What Did We Find?
The available evidence suggests that both UVC and IO access are feasible during neonatal resuscitation, but the certainty of evidence is very low.
Umbilical Venous Catheters
UVCs were primarily used during delivery room resuscitation immediately after birth.
Across several case series, successful placement rates were generally high, and UVCs remain the preferred route for many neonatologists because the umbilical vein provides rapid access to the central circulation.
Intraosseous Access
IO devices were successfully used in both hospital and out-of-hospital settings.
Insertion was often rapid and generally successful, making IO access an attractive alternative when UVC placement is not feasible.
However, IO placement was also associated with more reported procedural complications, including extravasation, fractures, soft tissue injury, necrosis, and infection.
Peripheral Intravenous Catheters
Evidence supporting emergency PIV placement during neonatal resuscitation was extremely limited.
Only a handful of infants were described, making it impossible to draw meaningful conclusions regarding effectiveness or safety during neonatal cardiac arrest.
The Most Important Finding
Perhaps the most important conclusion was not about which device performed best.
It was that we simply do not have sufficient evidence to know which vascular access method is superior.
No study directly compared UVC with IO access.
No study demonstrated faster return of spontaneous circulation.
No study showed improved survival with one approach over another.
Despite the central role of vascular access in neonatal resuscitation, this remains a major evidence gap.
What Does This Mean for Clinical Practice?
Based on the available evidence, both umbilical venous catheterization and intraosseous access remain reasonable options during neonatal resuscitation.
The choice of device will often depend on the clinical situation, provider experience, available equipment, and the infant's condition.
If the umbilical cord remains accessible, UVC placement continues to be the preferred approach in many delivery rooms.
When UVC placement is delayed, technically difficult, or impossible, IO access may provide an important alternative.
However, clinicians should also remain aware of the potential complications associated with IO insertion, particularly in very small newborn infants.
Looking Forward
This review highlights an important opportunity for future neonatal research.
For many interventions in neonatal resuscitation, clinical practice has evolved faster than the supporting evidence.
Emergency vascular access is one such example.
Well-designed multicentre studies comparing UVC and IO access are now needed to determine which approach provides the fastest, safest, and most effective route for medication administration during neonatal cardiopulmonary resuscitation.
Answering that question has the potential to improve neonatal resuscitation guidelines and, ultimately, outcomes for newborn infants requiring advanced resuscitation.
Take-Home Message
Emergency vascular access is one of the most critical steps during neonatal resuscitation.
Our systematic review found that both umbilical venous catheters and intraosseous access are feasible options, but the available evidence is of very low certainty, and no study has directly compared these approaches.
Sometimes the most important finding in research is recognizing what we still do not know.
By identifying these evidence gaps, we can design the studies that will shape the next generation of neonatal resuscitation guidelines.
Research4Babies
Advancing neonatal research. Sharing knowledge. Improving newborn lives.
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