What are the risks of repeated peripheral cannulation in neonates?
Peripheral intravenous cannulation is essential for delivering medications, fluids and nutrition in neonatal care. However, first-attempt success rates can be low, and peripheral intravenous catheters (PIVCs) frequently fail before therapy is complete. Repeated insertion attempts can increase procedural pain, vessel trauma, treatment delays and loss of future access sites, particularly in preterm and low birthweight infants. Selecting the most appropriate vascular access device early in the treatment pathway may help reduce these risks.
Key points
- Neonates often require multiple cannulation attempts due to difficult vascular access.
- Repeated insertions can damage limited peripheral veins and increase patient distress.
- Premature device failure may interrupt treatment and necessitate re-cannulation.
- Pain exposure associated with repeated procedures may have neurodevelopmental implications.
- Early vascular access planning can help reduce procedural burden and preserve vessel health.
Peripheral vascular access options
| Device type | Typical use | Advantages | Limitations |
| Short peripheral cannula (PIVC) | Short-duration therapy | Widely available, familiar technique | High failure rates, limited dwell time |
| Midline catheter | Extended peripheral therapy | Longer dwell time, fewer replacements, reduced complication rates compared with repeated PIVCs | Not suitable for all infusates |
| Peripherally inserted central catheter (PICC) | Long-term or central therapy requirements | Central access for complex therapies | Greater insertion complexity and central line-associated risks |
Key takeaway: For neonates requiring intravenous therapy beyond a short duration, proactive vascular access planning may reduce repeated insertions, preserve vessel integrity and support uninterrupted treatment.
Why is repeated cannulation a concern in neonatal care?
A familiar clinical scenario
A 28-week preterm infant is admitted to the neonatal unit requiring intravenous antibiotics, fluids and ongoing treatment. Over the first few days, several peripheral cannulas fail due to infiltration or loss of patency, resulting in repeated insertion attempts and disruption to therapy. Situations like this are common in neonatal care and highlight the importance of considering the most appropriate vascular access device early, before valuable peripheral veins become compromised.
Peripheral intravenous cannulation is one of the most common invasive procedures performed in neonatal and paediatric practice. Despite being routine, establishing and maintaining reliable vascular access remains challenging due to small vessel calibre, fragile vasculature and limited insertion sites.¹
First-attempt success rates in neonates may be as low as 58%, meaning many infants experience multiple insertion attempts before access is achieved.² Peripheral intravenous catheters also demonstrate high rates of premature failure, with studies reporting failure rates of up to 36% and unplanned removal rates approaching 59%.³
Repeated tissue trauma can lead to inflammation, vessel damage and progressive loss of suitable access sites, making future cannulation increasingly difficult.
What are the clinical consequences of repeated cannulation?
Repeated peripheral cannulation can affect both immediate treatment delivery and longer-term vascular access preservation.
Clinical implications include:
- Interrupted therapy delivery, resulting in delayed or incomplete treatment.
- Loss of viable access sites, particularly problematic in preterm infants with limited peripheral veins.
- Increased risk of complications, including infiltration, extravasation and phlebitis.
- Higher procedural workload for clinical teams.
- Greater patient distress and physiological instability during repeated procedures.
How does repeated pain exposure affect neonates?
Neonatal care environments expose infants to frequent painful procedures, with reports of 7 to 17 interventions per day in intensive care settings.⁴ Peripheral cannulation represents a substantial contributor to this burden.
There is evidence linking cumulative pain exposure in preterm infants with altered brain development, dysregulated stress responses and adverse neurodevelopmental outcomes.⁶ From a clinical governance perspective, reducing avoidable procedural pain is aligned with best practice in developmental care and atraumatic handling.
Reducing avoidable procedures is therefore not only a technical objective but also an important component of developmental care and neuroprotection.
When should vascular access be reassessed?
Although guidelines support clinically indicated replacement rather than routine resiting,¹² catheter dwell times frequently remain shorter than the duration of prescribed therapy.³
Vascular access reassessment may be appropriate when:
- Treatment is expected to continue beyond several days.
- Multiple cannulation attempts have already occurred.
- Previous devices have failed prematurely.
- Ongoing intravenous antibiotics, fluids or nutrition are required.
- Suitable peripheral access sites are becoming limited.
Early reassessment may help prevent a cycle of repeated device failure and replacement.
Is there a middle ground between PIVCs and PICCs?
Vascular access discussions are often framed as a choice between repeated use of short peripheral intravenous catheters (PIVCs) or escalation to central venous access. However, for some neonates and children requiring intravenous therapy beyond a few days, midline catheters may offer an alternative that bridges the gap between these two approaches.
Midline catheters are designed to provide longer-lasting peripheral vascular access while avoiding central venous placement. Typically inserted using a guidewire-assisted (Seldinger) technique, they can be particularly valuable in patients with small or fragile vessels where preserving venous access is a priority. Their soft polyurethane construction, small diameter and securement features are intended to minimise vessel trauma and support longer dwell times than conventional peripheral cannulae.
Comparison of common approaches
| Consideration | Repeated PIVCs | Midline catheter | PICC |
| Expected therapy duration | Short | Intermediate (typically several days to weeks) | Long |
| Number of insertions likely required | Higher | Lower | Typically one |
| Central venous placement required | No | No | Yes |
| Suitable for small or fragile vessels | Variable | Yes | Yes |
| Guidewire-assisted insertion | No | Yes | Yes |
| Risk of repeated vessel trauma | Higher | Lower | Lower |
| Suitable for central therapies | No | No | Yes |
| Need for radiographic confirmation | No | No | Usually yes |
For appropriately selected patients requiring ongoing intravenous therapy, midline catheters may help reduce repeated venepuncture, preserve peripheral veins and maintain reliable vascular access without the need for central venous catheterisation. They can be particularly valuable when treatment is expected to continue beyond the typical lifespan of a short peripheral cannula, but central access is not clinically indicated.
Key takeaway: Midline catheters can provide a planned, vessel-preserving approach for neonates and children who require intravenous therapy for longer than a few days, helping to reduce repeated cannulation while avoiding unnecessary central line placement.
What does the evidence show about Midline catheters?
Midline catheters have been developed to address the limitations of conventional peripheral intravenous cannulae in patients requiring longer durations of therapy. By combining peripheral placement with extended dwell capability, they may help reduce the cycle of repeated cannulation and premature device failure.
Research and clinical experience have demonstrated several potential benefits:
- Reduced complication rates compared with repeated short peripheral catheter use, with some studies reporting reductions in overall device failure and related complications.¹⁰
- Fewer replacement procedures, helping reduce repeated venepuncture and cumulative vessel trauma.
- Support for longer-duration peripheral therapy, providing reliable vascular access for patients whose treatment extends beyond the expected lifespan of a standard peripheral cannula.¹³˒¹⁴
- Avoidance of central venous catheterisation in selected patients, reducing exposure to risks associated with central line placement when central access is not clinically required.¹¹
- Improved patient experience, through fewer insertion procedures and less disruption to treatment.
Evidence also suggests that the risk of peripheral intravenous catheter failure increases after several days of dwell time, supporting early reassessment of vascular access requirements in patients with ongoing therapy needs.¹² For neonates and children with limited vascular access, selecting a midline catheter when longer-term peripheral therapy is anticipated may help maintain treatment continuity while reducing the need for repeated cannulation.
From a clinical standpoint, this supports proactive vascular access planning, matching device selection to the anticipated duration and complexity of therapy. For patients who require more than short-term peripheral access but do not need a central venous catheter, midline catheters may provide an effective intermediate option that supports vessel preservation and continuity of care.
How can clinicians minimise repeated insertion attempts?
A proactive vascular access strategy focuses on selecting the right device for the anticipated duration and nature of therapy rather than reacting to repeated failures.
Practical considerations
Assess therapy requirements early
- Expected duration of treatment
- Medication characteristics
- Anticipated need for reliable access
Preserve vessel health
- Avoid unnecessary re-siting
- Consider extended-dwell options where appropriate
- Escalate access planning before peripheral sites become exhausted
Support insertion success
- Use techniques that minimise vessel trauma
- Consider guidewire-assisted approaches when clinically appropriate
- Optimise catheter stabilisation to reduce accidental dislodgement
Clinical benefits
- Fewer catheter insertions
- Reduced cumulative tissue trauma
- Improved continuity of therapy
- Preservation of future access sites
- Reduced procedural pain exposure
What role does vascular access planning play in patient outcomes?
Effective vascular access planning extends beyond device insertion. It supports:
- Consistent treatment delivery
- Reduced procedural burden for staff
- Avoidance of unnecessary escalation to central access
- Improved patient and family experience
- Alignment with NHS quality, safety and patient-experience objectives
For neonates requiring ongoing intravenous therapy, selecting the most appropriate device at the earliest opportunity can help protect limited vascular access while reducing the burden of repeated procedures.
By moving from a reactive approach to a planned episode-of-care strategy, clinicians may be better able to protect vulnerable vasculature, minimise repeated insertions and support safer, more consistent treatment delivery.
References
- Chen JY. Peripheral intravenous cannulation in infants and children. Pediatr Neonatol. 2023.
- Del Campo Cano I, et al. Peripheral venous access in neonates: number of punctures and success rates. Eur J Pediatr. 2026.
- Lee CC. Reducing complications and extending lifespan of PIVCs in newborns. Pediatr Neonatol. 2023.
- Campbell-Yeo M, et al. Managing pain in newborns. Paediatr Child Health. 2025.
- Slater R, et al. Childhood pain and long-term impact. BMC Med. 2025.
- Vinall J, Grunau RE. Impact of repeated pain-related stress in preterm infants. Pediatr Res. 2014.
- Children’s Hospital of Philadelphia. Vascular access clinical pathway. 2025.
- NIVAS. Clinical standards for vascular access and infusion therapy. 2025.
- Tripathi S, et al. Midline catheter practice and complications: systematic review. Crit Care Med. 2021.
- Fabiani A, et al. HERITAGE study: midline vs long peripheral catheters. Am J Infect Control. 2024.
- Swaminathan L, et al. Midline vs PICC outcomes. JAMA Intern Med. 2021.
- Zanella MC, et al. PIVC dwell time and infection risk. JAMA Netw Open. 2025.
- Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of short peripheral intravenous catheters: characteristics, management and outcomes worldwide. J Hosp Med. 2018.
- Caparas JV, Hu JP. Safe administration of prolonged intravenous therapy through ultrasound-guided peripheral intravenous catheters. J Infus Nurs. 2014.
