Challenges of IV starts in the Pediatric Population

The Pediatric population provides special challenges during stressful procedures, such as IV sticks. This article will provide tips to alleviate fear and anxiety when starting IV's. We can help alleviate stress by being creative and compassionate.


Challenges of IV starts in the Pediatric Population

One of the biggest challenges we face as pediatric registered nurses is how to alleviate the fear and anxiety associated with getting an intravenous catheter or IV. As a pediatric nurse for over a decade, this RN has been witness to many different reactions when it comes to needle sticks.

There is kicking, screaming, hiding in the bathroom, and the one that is truly heartbreaking is the genuine fear in the faces of our sweet little patients that we treat.

The good news is that there are many options available to us as caregivers to help our patients get the treatment they need, while alleviating the fear and anxiety that may go along with it. Some of these options include, but are certainly not limited to, the use of topical lidocaine and involving your child life specialist for distraction.

Ask any pediatric patient and they will tell you that topical lidocaine was their best friend during their hospital admission. Topical lidocaine is a three percent lidocaine cream that is used for anesthetic purposes to numb the skin.

If you are not familiar with this medication, get familiar! Contact your hospital pharmacist and they will be able to provide specific side effects, absorption rates, along with precautions. When placed approximately one hour prior to the IV insertion, the skin becomes numb due to the properties of the lidocaine, and the child will not feel the "poke."

We all know as healthcare professionals that things may happen without warning. You may find that you do not have that one-hour window to wait. In those cases, there is a fast-acting topical lidocaine that makes the skin numb in about half the time, approximately twenty to thirty minutes. Children that require chronic transfusions or repeated IV therapy will especially benefit from this medication because over time they learn that they can really trust that it will work, which will make subsequent visits less stressful.

The Child Life Specialist is another very helpful tool to have at the bedside during an IV insertion. Child Life Specialists are pediatric healthcare professionals who work in conjunction with the patients, their families, and the nurses during the child's hospital stay. They are a great resource and should be utilized prior to any invasive or stressful procedure. The primary role of the Child Llife Specialist is to alleviate fear and anxiety in our patients when they come for treatment by utilizing age appropriate distractions and coping mechanisms. Who better to have at your side during an IV insertion! These Child Life Specialists will do anything in their power to help a child during a stressful situation. "I Spy" is a favorite, along with bubble blowing, and singing.

In summary, there are many options available to us as pediatric nurses to alleviate the fear and anxiety associated with hospital stays and "sticks." Every child and situation is different and will provide their own set of challenges. It is up to us as healthcare professionals to be creative and compassionate advocates for our patients during their hospital stay. The pediatric population will present different and complex challenges due to their young age, inexperience and inability to reason at times.

Graduated in 1994 with BSN, have been working with the pediatric population over a decade. Vascular access RN at a major pediatric hospital in Florida

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Specializes in Reproductive & Public Health. Has 10 years experience.

Yes, the "magic cream" is so important for kids with chronic health issues. My daughter gets IVIG every month, and it really helped alleviate her fear, once she learned she could trust it.


105 Articles; 5,349 Posts

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

Child Life is an awesome resource - but vastly underutilized. They are very helpful on the PEDS floor in which I have clinical students.

KelRN215, BSN, RN

1 Article; 7,349 Posts

Specializes in Pedi. Has 16 years experience.

I agree that Child Life isn't utilized enough. When I worked in the hospital, I found that sometimes the IV nurse wanted to get in and out so quickly that the first instinct was to gather an army of "holders" rather than wait for Child Life. I remember one particularly awful IV start on a 4 year old. This kid could not have been more cooperative... we brought him into the treatment room, turned on the TV and he was completely still/enthralled with Curious George. I said to the IV nurse "I'll hold his hand and why don't we try to do it how he is"... she insisted we lay him down and, as I predicted, he completely freaked out when she layed him down and tried to wrap him up in a blanket and after 2-3 tries, we still had no IV. Take your lead from the child.

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

16 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.
Child Life is an awesome resource - but vastly underutilized. They are very helpful on the PEDS floor in which I have clinical students.

As the parent of a medically-complex individual I know first-hand how beneficial Child Life support can be. As a health care professional working in a high-acuity PICU I'm very frustrated by the fact that there are notices posted in several prominent places on our unit that say, "DO NOT offer any Child Life services to families without first consulting the Child Life specialist or Child Life supervisor. In an emergency please page so-and-so but be aware that your call may go unanswered" followed by a list of phone and pager numbers. So we don't even bother. Some of us have become proficient at hand- and footprints, talking to siblings about death and all those other uncomfortable situations.

EMLA and Maxilene are very effective at surface numbing and do make needlesticks less painful. My experience though is that the areas numbed aren't where the IV or blood draw ends up being done... even when anaesthesia is doing the poking. We do a lot of pokes outside our unit because we have no IV team and are the experts at placing IVs. There isn't time for the PICU staff nurse, who has multiple other responsibilities (rapid response and code team responses for example), to run up to the ward, look for a likely site, EMLA it and then return an hour later; it's not effective to have the ward nurse apply it because s/he isn't going to know which areas to numb. Typically, if we're called to the ward for IV starts or blood draws, the ward staff has already tried many times without success and leave us with the anatomically-I-know-there's-a-vein-there sites... and it's the middle of the night. So many of our pokes are done without benefit of local anaesthesia or Child Life... Sadly.


1 Article; 470 Posts

Great article!

slightly off topic, but, might help someone, who knows,

but, removing IVs can be stressful to some kids, too. At outpatient surgery center, we had twins, a boy and a girl, and only one was my patient. He was anesthetized during IV insert, for his surgery,

but, his mom was very anxious, really really warning me, how removing his IV will freak him out.

so i took a zillion lil alcohol swabs,

After telling child what i'd do--get his arm kinda wet with the swabbies---

then i dripped the alcohol, one swab at a time (a bottle of alcohol could speed this process up)

all over the tape, til it slipped off.

This particular child was so tense at first, that to start, i squeezed a swabbie over his non-IV arm, so he could see what it was like,

and then, as i always do with kids, i "interviewed" the child, the whole entire time, getting the child to talk,

about his lunchbox, his favorite thing to find in his lunch box, the recess routine his class does if it snows, his best pal at school, on and on, the kid totally forgot i was even removing the now-soaked tape off of his arm. that tape does slip right off, no tugging at all, if you saturate it with alcohol first.

When i am finally down to removing the IV itself, i did warn him at that last minute, that this part here might hurt just a tiny bit, or feel funny, by now, the kid is on a roll, talking his head off and very much enjoying the "interview" by now,

and right before i took out the IV, i asked him yet another question to tell me about, and wa-la, it was out. No big deal. His mom hugged me as i was leaving the room. I now know alllllllllll about that child and his school, ha ha!!

Another nurse had the other twin, the girl, who was brave about it all, but, after watching me "interview" the boy, she was expecting same thing, but her nurse just came in, and silently ripped off tons of tape off her arm, and SHE ended up being the one screaming.


28 Posts

Thanks for the post. I just want to share a story about my son, who was hospitalized last year because of AGE. I brought him to the hospital for admission and he needs to be inserted with IV since he is already moderately dehydrated, it's tough to insert an IV of course and he was 11 mos old at that time. The first IV inserted was dislodged so the pedia doctor on duty at that time needs to insert another one, which is already very traumatic to my child...and mind you, she did not use lidocaine cream, what she did was to mummy restraint my son for around 30 mins before successfully inserting an IV again.I was really really angry at that time, such a ruthless pedia doctor!!!my child's behavior changed since then, he would not lie in bed or would want to be alone for 2-3 days while we're in the hospital!Good thing he already recovered and never want to be in the care of that doctor again ever!

The topical numbing creams can cause vasoconstriction, so if the patient is already a tough access due to dehydration, it isn't always the best choice. I work in a peds ED, so all of our IV starts are considered stat- I do not have 20-30 minutes to wait for numbing cream to work, as the labs and meds from the stick should already be in progress. Distraction from child life or TV or a game helps a TON. I also take a calm approach and explain as developmentally appropriate what to expect. Parents who freak out as much as the kid don't and you can definitely see a difference in how kids react based on how their parents react and coach them. And if I'm going for a stick I'm not feeling terribly comfortable with, a child who has room to move and jerk certainly doesn't help matters, so I routinely use the burrito technique/army of friends for holding when necessary.

A hospitalized 11 month old who doesn't want to lie on the hospital bed or be away from mommy sounds like a very normal reaction to hospitalization to me. If your kid was pudgy and plump, as I'd expect an 11 month old to be, plus dehydrated, plus already lost a line, I'm not surprised it took what seemed like a long time to get a second line.


1,026 Posts

Thank you for posting. This information is very helpful.

FlyingScot, RN

2,016 Posts

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc. Has 28 years experience.

Quite frankly, I despise the numbing creams. Not only do they cause blanching at the site which makes it even more difficult to start an IV but sure as shootin' the attempt at the numbed site won't work and then you have to stick an un-numbed (is that a word?) site after PROMISING the kid/parent that you would numb their skin. I have started thousands of IV's in kids and I'm no slouch at it but those creams are the bain of my existence. Routine IV's on kids with great veins I'm fine with EMLA but the sick ones who need an IV sooner than an hour or two later or those with access issues I think it makes the problem worse. I have found that simply talking to the patients if they are no longer infants and explaining to them what you are doing and what they will feel and you give them permission to react generally works great. I can usually get 3 year olds to hold still with my "friend" who's gently "helping them remember to hold still". They also provide distraction to the child because they rarely have to exert much more than light pressure to hold the extremity still. They are the "good guy". I have never needed more than one person to assist. I'd be freaked out too if 5 strangers all of a sudden were lying on top of me. I've used parents as imobilizers by having them cuddle their child chest to chest on their lap leaving the extremities free. Sometimes I have to lie on the floor to get to the site but if it works I say go for it. Of course the child is aware that they are going to get an "owie". I don't believe in sneak attacks. I also use a papoose board. String me up if you'd like. I call it my "special bed" to "help you remember to hold still". This is why I only need one assistant. I find the PB freaks the parents out way more than the children, in fact most of the kids relax on the board because they are able to get their minds under control when their bodies are under control. I put them on the board (never the parent) but I have the parent take them off the board so they can be the "hero". Most of my IV's are started with minimal fuss and bother. A few tears but very little screaming in pain or fright. It's all in the approach. And afterwards always some sort of prize from me ( I give really good prizes) and usually a hug so they know that I'm a "good guy" too.

I graduate in May and want to eventually go into peds so I will definitely be saving this for future reference :)