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From where to begin, to last-resort options: Tips and tricks I’ve picked up during hundreds of pediatric IV placements

Think you've mastered the infant IV? Test your knowledge with a quiz and see how you do. 

Caring for sick infants is hard. Getting IV access is even harder. Infants are wriggly, their veins are small and they often have excess adipose tissue. All these factors contribute to the difficultly of placing a line. [At the end of this article, download a printable, sharable guide to pediatric IV access points.]

The challenge is compounded by the fact that infants make up a fraction of EMS calls and even fewer need IV access. Many providers are left lacking confidence about obtaining IVs in this population.

I have worked previously as a pediatric critical care paramedic, an ER technician and now as a resident physician who still starts the occasional infant IV. Here are some tips and tricks I have picked up during hundreds of pediatric IV starts over the years.

Size matters, but when it comes to infants, I am a firm believer the correct size is a 24. I have seen providers attempt 22 gauge IVs on these kids, but the simple fact is there is just no need.

Let’s explore the math. The average 6 month old weighs around 7 kgs. A 20 mL/kg bolus is only 140 mLs of fluid. A 24 gauge IV has a free flow rate of 20 mL/min so your bolus can, in theory, run in over 7 minutes. A 70 kg adult getting a 20 mL/kg bolus would need two 18 gauges running wide open to get a bolus in over the same time.

In other words, in our smaller patients, that 24 gauge is like a pipe! Anything bigger risks blowing the vein and causing unnecessary pain.

There are also multiple lengths of 24 gauge IVs. I have a strong preference to the shorter versions. They are easier to thread the catheter into a short vein (e.g., in the hand) without as much risk of blowing the vein. The short catheters also have faster flow rates than their longer counterparts. If you don’t believe me, Google Poiseuille’s Law. Checking to see if your department carries shorter, small-bore catheters may be worth your time.

There are a few options for where to place a pediatric IV, some better than others.

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Pediatric intraosseous insertion can be stressful, but it's a critical tool to have if you can't get IV access

I personally find children at about 6 months old the hardest to get lines on. These miniature humans seem to have reached peak chubbiness to muscle ratio. Add in some dehydration, and finding a vein in that sea of adipose is going to be hard.

Rather than play poke and hope, I often use transillumination. You don’t need a fancy purpose-built vein finder. All you need is a bright light, whether it be a small mag light, an otoscope or the flashlight on your phone. Placing this under the infant’s hand, foot or side of the leg will allow it to shine through and you will be able to visualize the vasculature. Unfortunately, older infants are a bit too beefy for this to always work, but this has helped me on countless occasions to find a vein that was deep in the tissue.

Some warm water in a glove or a commercial neonatal heel warmer may help plump up a vein as well. Just use caution in applying conventional hot packs or putting hot water in a glove as these can cause burns to the infant’s fragile skin.

Holding the child still is arguably the most important part of starting a line on an infant. They are going to move and if they do, you will fail to get your line.

To counteract this, I papoose 100% of infants and small children who are not obtunded. I use a sheet or blanket, leaving their head and selected extremity exposed. I make sure they are snug enough they can’t wriggle out. If you have extra providers on scene, I have one keep their hands on the baby’s waist and chest to minimize movement. This is also a great job for a parent if it is just you and a partner.

I then have a crew member hold whichever extremity we have selected, applying opposing forces over the large joints so the infant cannot bend at the elbow or knee. This is easy – just have your holder grip above the elbow on the tricep and push up toward the sky. Then have them place their other hand below the elbow, pushing down toward the floor. This will immobilize the arm so it cannot flex or extend. The same technique can be applied to the leg to neutralize large joint movement.

I will use my free hand to both pull the skin taught and immobilize the foot or the hand while starting the IV with the other. If I am trying for an IV in the AC vein, I will have the holder gently rotate the hand facing toward the sky and have them directly put pressure on the base of the thumb. This will help keep the infant from twisting the arm or pulling away.

I cannot emphasize the importance of taking the time to make sure everyone has a good hold prior to starting, it will make the procedure go smoother and your chances of success will be much higher.

Next time you start an infant IV, make sure to take your time in finding your site, use a 24 gauge and have multiple people help you get a solid hold. If you do all these things, pretty soon you will be owning the infant IV.

Fill out the form below to download a printable, sharable guide to pediatric IV access points. 

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Zachary Tillett is currently an emergency medicine resident in Maine. Prior to becoming a physician, he spent time in the D.C. region as an EMS provider, as well as a pediatric and neonatal critical care paramedic. After residency, he is planning on pursuing an EMS fellowship and continuing to work as both an emergency and EMS physician.

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