In the delicate realm of neonatal intensive care, the use of umbilical arterial catheters (UACs) has become a cornerstone for managing critically ill newborns. These slender lines, inserted into the umbilical artery, serve multiple indispensable functions such as continuous blood pressure monitoring, frequent blood sampling, and the administration of fluids, nutrition, and life-saving medications. Despite their undeniable utility, UACs have long been shrouded in controversy when it comes to enteral nutrition—the practice of feeding infants via the gastrointestinal tract. The crux of this debate hinges on potential risks, primarily mesenteric ischemia, a condition where reduced blood flow may compromise the intestines, theoretically exacerbated by the presence of a UAC.
Historically, this apprehension has steered clinical practices toward strict nil per os (NPO) protocols, withholding all enteral feeds in neonates harboring these catheters. This precautionary approach, although grounded in concern for intestinal safety, invariably delays the introduction of enteral nutrition. Delays in feeding are not trivial; enteral nutrition plays a pivotal role in gut maturation, microbial colonization, and overall growth trajectories in neonates. Emerging clinical insights and shifts in neonatal care paradigms are now challenging the entrenched NPO dogma. The contemporary viewpoint increasingly advocates for initiating enteral feeding despite the presence of UACs, fueled by a growing body of evidence that calls into question the presumed ischemic risks.
Understanding the physiological interplay between UAC placement and intestinal perfusion is critical to re-evaluating feeding protocols. UACs, by virtue of cannulating a major arterial branch, inherently alter hemodynamics. However, emerging investigations suggest that this alteration may not universally translate into compromised mesenteric blood supply. Neonatal vascular physiology, including autoregulatory mechanisms, may compensate to preserve gut perfusion. This emerging perspective is bolstered by clinical studies reporting no significant increase in enteral feeding complications such as necrotizing enterocolitis (NEC) in neonates with UACs allowed early enteral nutrition.
Despite these encouraging trends, the clinical landscape remains fragmented, with considerable variability in feeding practices across neonatal intensive care units (NICUs) worldwide. This heterogeneity reflects the persistent uncertainty and paucity of robust, high-quality data explicitly addressing the safety and timing of enteral feeding in neonates with UACs. It underscores a critical need for consensus-building and the development of evidence-based guidelines that can harmonize care strategies while safeguarding patient outcomes. Until such guidelines are established, neonatal clinicians grapple with balancing the benefits of early enteral feeding against the theoretical risks posed by arterial catheterization.
Recent advances in neonatal monitoring technology and vascular imaging have provided fresh opportunities to unravel the exact impact of UACs on mesenteric circulation. Techniques such as Doppler ultrasound afford real-time assessment of blood flow, enabling more nuanced evaluations that were previously unattainable. Early data from these modalities indicate that in many cases, mesenteric perfusion remains adequate despite UAC placement, further challenging the assumption that UACs invariably jeopardize gut blood flow. These findings pave the way for prospective studies aimed at defining safe thresholds and identifying patient subgroups who may benefit from or require modified feeding protocols.
The dialogue surrounding enteral nutrition in the context of UACs also reinvigorates broader debates about the timing and composition of neonatal feeding regimens. Incremental feeding protocols emphasizing gradual introduction of minimal enteral nutrition (also known as trophic feeding) are gaining favor. This approach seeks to stimulate gut function and maturation without overwhelming the infant’s immature digestive capacity or hemodynamic stability. In neonates with UACs, trophic feeds may serve as a pragmatic compromise, balancing theoretical ischemic risk with the undeniable advantages of enteral feeding, such as improved gastrointestinal motility and reduced reliance on parenteral nutrition.
Furthermore, the dynamic nature of neonatal physiology demands that feeding strategies be tailored to individual patient risk profiles. Factors such as gestational age, birth weight, underlying pathology, and duration of UAC placement critically influence feeding tolerance and risk of complications. A nuanced understanding of these variables in conjunction with vigilant clinical monitoring is paramount. Protocols that incorporate early initiation of feeding coupled with stringent surveillance for signs of feeding intolerance or ischemia may embody a balanced, patient-centric approach that reconciles clinical imperatives with safety concerns.
The evolving consensus in neonatal care increasingly views early and judicious enteral feeding in neonates with UACs as both feasible and beneficial. Multiple retrospective analyses and cohort studies now hint at the safety of such practices when accompanied by rigorous monitoring and appropriate clinical judgment. This paradigm shift holds the potential to expedite nutrition delivery, enhance growth outcomes, and reduce the duration of invasive parenteral nutrition and central line exposure—all pivotal factors influencing morbidity and mortality in this vulnerable population.
Yet, the road to definitive practice change is strewn with challenges. High-quality, prospective randomized controlled trials are conspicuously scarce, impeding the establishment of unequivocal guidelines. The heterogeneous nature of neonatal pathologies requiring UAC placement further complicates the design and interpretation of such studies. Moreover, the ethical imperative to ‘first do no harm’ often tempers enthusiasm for aggressive enteral feeding protocols, fostering a cautious, case-by-case approach in many NICUs.
In light of these complexities, multidisciplinary collaboration is paramount. Neonatologists, nurses, dietitians, and vascular specialists must synergize to refine care pathways that optimize nutritional delivery while mitigating risks. Continuous professional education and dissemination of emerging evidence will be key to fostering uniformity in practice and enhancing clinician confidence. Simulation-based training and protocol-driven care may also help standardize responses to feeding intolerance or vascular complications in neonates with UACs.
The question remains: is the routine introduction of enteral nutrition in neonates with an indwelling UAC justified in current clinical practice? The accumulating evidence leans toward a cautious ‘yes,’ recognizing that the potential benefits of early feeding outweigh the putative risks when managed judiciously. This recognition invites a paradigm shift away from reflexive NPO policies toward more proactive nutritional strategies tailored to individual neonate profiles and clinical contexts.
As neonatal research continues to evolve, the hope is that future data will elucidate precise mechanisms by which UACs influence mesenteric hemodynamics and feeding tolerance. Innovations in biomarker discovery and advanced imaging may soon allow clinicians to predict and monitor intestinal perfusion with unprecedented accuracy. Such tools would empower truly personalized nutrition plans, optimizing outcomes and minimizing risk.
In conclusion, the integration of emerging physiological insights and accumulating clinical evidence heralds a new era in the nutritional management of neonates with UACs. Abandoning outdated dogmas of mandatory fasting in favor of evidence-informed, tailored feeding protocols promises not only to enhance early-life nutritional status but also to lay stronger foundations for long-term health trajectories. The neonatology community stands at a watershed moment, balancing the promise of early enteral nutrition with the imperative for rigorous safety assurance, guided by science, innovation, and compassionate care.
Subject of Research: Safety of enteral nutrition practices in neonates with umbilical arterial catheters in situ.
Article Title: Safety of enteral nutrition practices in neonates with umbilical arterial catheters in situ: current evidence to guide clinical practice.
Article References:
Lima, G., Morton, S.U., Hair, A.B. et al. Safety of enteral nutrition practices in neonates with umbilical arterial catheters in situ: current evidence to guide clinical practice. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02509-5
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DOI: 24 November 2025
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