Pediatric Intravenous Therapy: Steps, Challenges and Key Information

Pediatric intravenous therapy is one of the most challenging tasks a nurse performs. Pediatric blood vessels are smaller in diameter than an adult’s vessels, and this poses a challenge for the nurse to ensure that establishing an IV access is done safely, effectively,y and with as little possible discomfort to the patient. When done right, an intravenous access line allows for efficient delivery of fluids, medications, and even blood products and nutrition to the patient, which can aid in faster recovery.

One of the most important aspects of intravenous therapy in pediatric patients is to ensure that the nurse performing the procedure is competent to perform it correctly. Therefore, a sound knowledge of anatomy and physiology of the vessels, as well as the priority physiologic needs of the patient are necessary for any nurse providing care. Mastery of technique in intravenous insertion, as well as it monitoring and the management of potential complications, are also vital skills for a nurse to master.

In this article, we will revisit the principles of IV therapy in pediatric patients, and what are the conditions for which it is usually indicated, as well as special considerations among these patients. Steps in starting an IV  access site, its securement, and infection control will also be discussed and how the nurse can provide care to ensure that complications are prevented among these patients.

Indications for IV Therapy in Pediatric Patients

An intravenous therapy, or an IV line, may be ordered to be started on pediatric patients when there is a need to ensure adequate fluid balance, since this age group has a higher total body percentage of water. It may also be indicated in instances where oral fluid intake is not sufficient to meet the needs of the body, as well as a route for medications that has a more immediate effect when given through this route. Specifically, the following conditions are usually the reason why an IV infusion is ordered for pediatric patients:

• Fluid resuscitation and restoration of fluid and electrolyte balance in dehydrated patients or those suffering from shock;
• Route of fluid administration for patients who cannot tolerate oral intake of fluids.
• As a route for medications which may be irritating to other tissues, have a less palatable taste for pediatric patients, or drugs that are best absorbed into the blood stream;
• As a means to transfuse blood and blood products, and
• In some patients with severe nutritional impairment and have compromised gastrointestinal functioning, an IV may be used as a route of administering parenteral nutrition.

Pediatric Considerations in IV Therapy

Pediatric patients have a different way of perceiving and expressing pain as compared to most adults. Since IV therapy is considered an invasive procedure and is expected to bring about pain and discomfort to patients, an evaluation of the need to start it should be part of the assessment of the nurse caring for the patient. Moreover, if assessment reveals that there are other less invasive routes available for the treatment other than IV therapy, these should be explored without having to compromise overall patient safety and goals of care.

Physiological characteristics of the vessels of the pediatric patient should also be taken into consideration. Their vessels are smaller and are more fragile than those of an adult, and even if the nurse uses a smaller gauge IV catheter, there are still challenges in ensuring a safe and effective cannulation for patients. They also have less subcutaneous tissue, and their skin is more fragile, which increases the risk for infiltration of the IV access site. Proper securement, determining the angle of insertion, and the correct size of the cannula would play a very important role in this care goal. Also, pediatric patients have a higher risk of developing drug-related complications due to their higher metabolic rates and the immaturity of liver and kidney functions. In this regard, proper dosing and determining the safe dose range (SDR) for age is a must for nurses.

Consideration should also be made concerning pain and anxiety felt by the patient. Communicating with the patient using age-appropriate language and tone helps in providing them information, which can allay anxiety. The same is also true for parents and immediate care providers who may need to be given health education and instructions on caring for their family members.

See Also

• IV Therapy Tips and Tricks – For Beginners and Expert Nurses

Starting an IV Access Site

Prior to inserting an IV access site, an assessment of the status of the vessels must be carried out by the nurse, as well as the medical history of the patient. Allergies to latex or adhesives used in the procedure should be noted, as this can cause irritation, pain, and other adverse reactions in the patient if used. A thorough assessment of previous IV therapy experiences should also be noted, taking into consideration sites used successfully during previous therapies and complications of these previous experiences.\

Once an order for an infusion has been secured and verified, the nurse needs to ensure that all materials are prepared and ready in a tray. The following considerations should be made prior to starting an IV access site:

• Assess the vein to be used for the access site, starting distally from the wrists and progressing the assessment into the forearm. Note for skin integrity, signs of skin irritation and vessel stability. (NOTE: The Infusion Nurses Society (INS) Guidelines recommend using the vessels of the forearm for therapy as it is more stable, belongs in an area of less flexion and the skin is less pigmented in this area.)
• Assess the conditions that can influence the success of IV therapy access, such asthe presence of inflammation, hematoma and dehydration. Dehydration affects vessel prominence and also leads to the collapse of the vessels, making them difficult to cannulate.
• Explain the procedure to the patient and his family while using age-appropriate language. For younger children, the use of toys, videos, and illustrations would work best to help explain the procedure.
• For patients with low pain tolerance, expect an order for a topical anesthetic cream or spray to be applied to the insertion site. This helps decrease the pain perception of the patient and helps in the ease of inserting the IV catheter.

After assessment and consideration of unique patient needs and care requirements, the nurse then proceeds to insert the IV catheter. While there are some variations in the policy on insertion and establishing an access site, the INS 2024 guidelines recommend the following steps to be followed, which help ensure proper technique, adherence to infection control protocols and ensuring a safe and effective infusion.

• Gather equipment and supplies necessary for IV therapy.
  • An appropriately-sized IV catheter, depending on the age of the patient and the purpose of therapy. (NOTE: Smaller gauges for children and infants are preferred as they decrease the risk of vein rupture, cause less discomfort and are less likely to cause infiltration.
  • An alcohol or chlorhexidine-based antiseptic wipe
  • Sterile gloves and dressings
  • Securing materials such as transparent tapes, dressings and splints
  • Infusion administration set
  • Saline flush in pre-filled syringes
  • Infusion pump
• Perform hand hygiene using running water and a mild soap. Refer to facility protocol on the use of antiseptics.
• Apply a tourniquet 6-10 cm above the intended IV insertion site and disinfect the area using alcohol or chlorhexidine-based alcohol swabs. Use firm, circular motion to ensure removal of surface dirt and microorganisms. Allow the site to air dry. (NOTE: Never leave the tourniquet on for more than 1 minute to prevent vessel collapse.)
• Using the non-dominant hand, stabilize the vessel using the thumb and forefinger while keeping the skin taut. This ensures that the movement and rolling of the vessels are minimized.
• Using the dominant hand, insert the IV catheter into the vessel of choice using a 15-30 degree angle and slowly advance until flashback is noted on the flashback chamber.
• Advance the catheter 2-3mm more and then slightly pull back on the needle to shield the tip, preventing damage to the vessel. Next, lower the angle until it is parallel to the skin. Advance the catheter fully into the vessel.
• Release the tourniquet and apply pressure 2-3mm from the tip of the cannula to prevent bleeding.
• Withdraw the needle completely, discarding it in the designated container.
• Using the prefilled saline syringe, flush the access site with saline and note the smoothness of flow and resistance. Once patency is confirmed, connect the IV access site to the primed infusion set.
• Apply securement devices to stabilize the insertion site, such as cramps. Initially, secure the site by applying a transparent dressing. Set the desired flow rate in the infusion pump.
• Document the procedure, client response, and key parameters of the infusion.
• Monitor the IV infusion regularly, assessing for signs of complications, the quality of dressing, and the need to change the equipment.

Managing Complications and Nursing Care

Assess the created IV access site regularly, noting for early signs of local and/or systemic complications. The following table details the type of complications and the usual signs and symptoms elicited from assessment:

Tips for Pediatric IV Insertion

Most new nurses find pediatric IV insertion difficult. The key to mastering this procedure is practice, practice, and practice. Below are a few tips to help achieve a successful IV insertion.

Provide distraction

When used creatively, distraction helps shift a child’s focus away from fear of pain toward a more positive experience. For preschool and school-age children, letting them blow bubbles, sing their favorite song, or count aloud can be effective. Nurses may also play the child’s favorite cartoon to divert attention. If parents bring tablets or mobile devices, playing child-engaging video clips has been found to be very helpful.

Use less invasive restraining techniques

As mentioned, IV insertion can be a daunting experience for young patients. Restraining children during the procedure may increase psychological stress and should never be the nurse’s first course of action. When restraint is necessary, less invasive techniques may be used, such as asking the mother or father to hold or hug the child during IV insertion. This helps control body movement while providing warmth and emotional support.

Choose IV insertion sites based on age

Age-appropriate IV sites make insertion easier for both the nurse and the patient. For neonates, scalp veins are often the most appropriate and provide easier access for IV insertion. However, this site is discouraged in older infants due to increased movement that may lead to device dislodgement. Veins in the hands and feet may be used for pediatric patients, although the foot should be used only for infants who are not yet walking. Whenever possible, avoid inserting the IV in the hand the child uses for thumb sucking, as this increases the risk of dislodgement and the need for reinsertion.

Ask parents to stay beside the child

A major factor in reducing anxiety for children is the presence of their primary support system—their parents. While older children may remain calm without them, children seven years old and younger usually benefit from parental participation during this stressful procedure. To ensure full cooperation, nurses should explain the procedure and its purpose to parents beforehand.

Determine and use the appropriate needle size

For pediatric patients, 22- or 24-gauge needles are generally recommended. Smaller gauge catheters cause less discomfort and reduce the risk of vessel injury while still allowing adequate fluid delivery. For neonates, a 24-gauge IV device is preferred, while older children may use either a 22- or 24-gauge catheter depending on vein size and treatment needs.

Guard the IV site against dislodgement

Curiosity and active movement are natural behaviors among young patients. During hospitalization, it is important to protect the IV site from accidental dislodgement caused by movement or manipulation of the device. Transparent dressings or colorful stockinette bandages are commonly used for this purpose. If the insertion site is near a joint, an arm board with adequate padding may be used to prevent movement and protect skin integrity.

Is it possible to achieve venipuncture without pain? That may be nearly impossible. However, with proper technique, preparation, and supportive care, nurses can make this challenging experience more manageable and worthwhile for pediatric patients.

References

1. Kim, S.-W., & Choi, M.-Y. (2024). Effects of nurse’s knowledge and self-efficacy on nursing performance in pediatric intravenous fluid management. Child Health Nursing Research, 30(4), 288–297. https://doi.org/10.4094/chnr.2024.023
2. Vilão, A., Castro, C., & Fernandes, J. B. (2025). Nursing interventions to prevent complications in patients with peripherally inserted central catheters: A scoping review. Journal of Clinical Medicine, 14(1), 89. https://doi.org/10.3390/jcm14010089
3. Gorski, L. A., Nickel, B., Kleidon, T., et al. (2024). Infusion Therapy Standards of Practice (9th ed.). Journal of Infusion Nursing, 1S, S1–S285.
4. Potter, P. A., Perry, A. G., Stockert, P. A., & Ostendorf, A. (2025). Fundamentals of Nursing (12th ed.). Elsevier.