Pediatric Peripheral IV Access: Age-Specific Technique, Site Selection, and Pain Management

Peripheral IV placement in pediatric patients is among the most technically challenging and emotionally significant clinical procedures in pediatric nursing. Children have smaller veins, increased anxiety, and physiologic differences that affect both site selection and catheter gauge selection. Evidence-based pain management and family-centered care are not optional extras — they are clinical standards that reduce procedure-related trauma, improve cooperation, and produce better outcomes.

Parent guide: Vascular Access Special Populations: Complete Reference

Developmental Considerations by Age Group

Neonate (Birth to 28 Days)

Venous anatomy: Extremely small, fragile veins. Peripheral access relies on dorsum of hand, dorsum of foot, saphenous vein, antecubital fossa, and scalp veins in infants.

Gauge selection: 24G or 26G; 22G may be used in larger neonates for specific indications (blood products).

Pain management: Oral sucrose (24% sucrose, 0.5–1 mL administered 2 minutes before procedure + non-nutritive sucking on pacifier) is evidence-based for procedural pain reduction in neonates (Cochrane review, Stevens 2016). Facilitated tucking (holding extremities close to body in flexed position) provides additional comfort.

EMLA: Not recommended for neonates <37 weeks gestation (risk of methemoglobinemia); use with caution in term neonates.

Skin fragility: Neonatal skin is extremely fragile; use gentle adhesive products; avoid alcohol-based adhesive removers; consider silicone-based adhesive when available.

Infant (28 Days to 12 Months)

Venous access sites:

• Dorsum of hand (preferred for short-term access)
• Antecubital fossa (median basilic, median cephalic)
• Saphenous vein (medial ankle)
• Dorsum of foot
• Scalp veins (see below)

Gauge: 24G standard; 22G acceptable for older infants.

Pain management:

• EMLA cream (2.5% lidocaine/2.5% prilocaine): Apply 45–60 minutes before procedure; requires occlusive dressing over application site. Effective for numbing skin in infants.
• LMX 4 (4% liposomal lidocaine): Apply 30 minutes before procedure; slightly faster onset than EMLA.
• Vapocoolant spray (Gebauer’s Pain Ease, ethyl chloride): Apply immediately before needle insertion for instant cooling effect (3–7 seconds of cooling). Fastest-acting but shorter duration than topical anesthetics.
• Oral sucrose: effective through approximately 6 months; after 6 months, effectiveness diminishes

Family presence: Parent or caregiver presence during IV placement reduces child distress and improves cooperation. Educate parents on their role (comfort positioning, distraction) before procedure.

Toddler (1–3 Years)

Behavioral considerations: Toddlers have limited understanding of procedures and limited coping skills. Fear, crying, and physical resistance are normative. Restraint may be necessary but should be minimal — restraint increases anxiety and should be a technique of last resort.

Venous access sites: Dorsum of hand, forearm, antecubital fossa. Avoid foot for ambulatory toddlers (interferes with walking).

Pain management:

• EMLA or LMX 4 (requires advance planning — most helpful in scheduled/planned procedures)
• Vapocoolant for unplanned urgent access
• Child life specialist involvement when available — distraction with age-appropriate tools (tablets, bubbles, pinwheels) significantly reduces pain and anxiety scores

Positioning: “Mummy wrap” (swaddling older infant/toddler snugly) or positioning in parent’s lap with parent providing comfort hold. Avoid holding the child in a “punishment” position.

School-Age Child (6–12 Years)

Communication: Children this age understand simple explanations and benefit from accurate, honest preparation. Use procedural language without euphemisms.

Pain management:

• All topical agents effective; advance application allows better pain control
• Cognitive distraction (counting, deep breathing, watching video) is highly effective
• Child choice in decision-making (“which arm?”, “which character bandage?”) increases sense of control and reduces distress

Gauge: 22G or 24G depending on venous caliber.

Adolescent (13–17 Years)

Similar to adult approach with age-appropriate communication and attention to autonomy and privacy. Adolescents may be more resistant to parental presence — follow patient preference.

Gauge: 20G or 22G; 18G for high-volume needs.

Site Selection by Anatomic Region

Hand and Wrist

Preferred in most pediatric patients. Dorsal hand veins are accessible, visible, and the standard first-choice site for most ages.

Metacarpal veins (dorsum of hand): Extend from digit bases across the dorsum. Accessible in most ages; relatively anchored at metacarpal heads.

Caution: Wrist veins (at the radial or ulnar prominence) are over flexion points — increased risk of infiltration with wrist movement. Avoid if ambulating.

Antecubital Fossa

Accessible veins (median cephalic, median basilic) in older infants and children. Positional restriction with elbow flexion; less preferred for ambulatory patients.

Foot and Saphenous Vein

Saphenous vein (medial ankle): Reliable access in infants and young children; not preferred in ambulatory patients.

Dorsum of foot: Second-line in infants; not appropriate in walking children (weight-bearing on IV site).

Scalp Veins (Infants)

Anatomically accessible veins: Frontal, parietal, temporal, and occipital veins.

When to use: When all limb veins have failed; short-term access only.

Technique:

• Shave a small area over the target vein (minimizes hair interference)
• Apply tourniquet as a rubber band around the scalp (above the ears, not over the fontanelle)
• Scalp veins are easily visualized but small — 24G or 26G catheters
• 23G butterfly needles acceptable for brief infusions
• Secure carefully to prevent displacement; avoid scalp veins overlying major sutures or fontanelle

Parent communication: Prepare parents before scalp IV placement — the appearance is unexpected and distressing to parents who are not forewarned.

Catheter Gauge Selection in Pediatrics

Pain Management: Evidence Summary

Family-Centered Care Principles

1. Explain the procedure to the child at an age-appropriate level before starting
2. Invite family presence (parent’s choice)
3. Offer child choices where genuine choices exist (“which arm?” “which character bandage?”)
4. Minimize number of attempts — after 2 failed attempts, reassess technique, call for additional expertise, or defer to a more experienced inserter
5. Never minimize pain or use deceptive reassurance (“this won’t hurt”) — accurate information builds trust
6. Debrief the child after the procedure — acknowledge their courage regardless of behavior during the procedure

Related Resources

Related guides:

• NICU Vascular Access Guide
• Vascular Access Special Populations

Patient education:

• Parent Guide: NICU Vascular Access

References

1. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standards 64–67). J Infus Nurs, 44(Suppl 1).
2. Stevens B, et al. (2016). Sucrose for analgesia in newborn infants. Cochrane Database Syst Rev, (7):CD001069.
3. Taddio A, et al. (2015). Reducing pain during vaccine injections in children. CMAJ, 187(13):975–982.
4. Fein JA & Zempsky WT. (2012). Topical anesthetics for painful procedures in children. Pediatr Emerg Care, 28(8):842–847.