First attempt success rate of intraosseous access in preterm infants and neonates: a systematic review

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Objectives :While intraosseous (IO) access is an established and safe alternative route for vascular access in children and adults when intravenous (IV) access is not possible, its use in preterm and term neonates ≤28 days and young infants remains challenging. Success rates are lower in preterm infants and neonates due to anatomical and technical factors. We conducted a systematic literature review to examine the first-attempt success rates of tibial IO access in preterm and term neonates and young infants, comparing clinical outcomes with anatomical evidence to identify limitations, complications, and gaps in device suitability for this vulnerable population. Data Sources: Data were obtained through systematic searches of PubMed, Ovid MEDLINE and the Cochrane Library, covering English-language studies. The search was conducted in December 2025, using predefined search terms. Study selection: Eligible studies included prospective or retrospective clinical and cadaveric studies and reported per‑leg first‑attempt outcomes involving preterm and term neonates and young infants ≤6 months and ≤8 kg, reporting success rates for drill-assisted tibial IO access. Manual-assisted access methods, simulation and animal studies were excluded. Data extraction: Two reviewers independently screened and extracted data on study design, population, device type, success rates, and complications. Data Synthesis: A total of six studies were included, comprising 108 documented tibial intraosseous (IO) insertions. Clinical data accounted for 40 attempts, with 23 successful first attempts, while cadaveric data included 68 tibial sites, with 30 successful insertions. Using random-effects meta-analysis models applied separately to each study group, the combined first-attempt success rate in clinical studies was 54.1% [95% CI: 30.6% – 75.9%]. In cadaveric studies, the combined success rate was 44.1% [95% CI: 32.9% – 56.1%]. These success rates are substantially lower than those reported for older children and adults, in whom first-attempt IO placement typically exceeds 80–95% with drill-assisted systems. The decrease in preterm and term neonatal success reflects the anatomical, technical, and procedural challenges unique to this population. Conclusions: First-attempt intraosseous access success in neonates and young infants appears lower than in older paediatric populations, likely due to anatomical limitations and the use of devices not specifically designed for this patient group. Neonatal-specific device development and further prospective research are needed to improve procedural success and safety. Key points Question: What is the first-attempt success rate of intraosseous (IO) access in preterm and term neonates and young infants, and how reliable are current devices for this population? Finding: Across six eligible studies, first-attempt success was 54.1% in clinical studies and 44.1% in cadaveric studies. Success was lower in preterm and very-low-birthweight (VLBW) infants, with frequent malposition and overpenetration reported when adult-designed devices were used . Meaning: Current IO systems were not designed for neonates <3 kg; success rates appear lower and risks higher in preterm and very-low-birth-weight infants. These findings suggest the need for the development and evaluation of neonatal-specific IO devices and structured training approaches to improve procedural safety and success.

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