What is the best site for intravenous (IV) placement in a one-month-old infant?

Best IV Access Sites for a One-Month-Old Infant

The umbilical vein is the preferred primary site for vascular access in a one-month-old infant, with peripheral veins in the dorsal hand or cubital fossa as the next best options when umbilical access is not feasible. 1

Primary Access Options (In Order of Preference)

1. Umbilical Venous Access

• Recommended as the primary method for neonates and young infants
• Provides reliable central access in emergency situations
• Lower complication rates compared to intraosseous access in this age group 1
• May still be patent in a one-month-old infant

2. Peripheral Venous Access

If umbilical access is not feasible or appropriate:

Best Peripheral Sites:

1. Dorsal Hand Veins

   • Highest success rate (42.4%) and longer catheter duration (49.4 ± 35.7 hours) 2
   • Requires fewer insertion attempts (63.8% successful on first attempt) 2
   • Easily visualized and stabilized

2. Cubital Fossa (Antecubital)

   • Second highest success rate (43.9%) and duration (50.3 ± 33.4 hours) 2
   • Good option when dorsal hand veins are not accessible

3. Forearm Veins

   • Moderate success rate with 38.9% first-attempt success 2
   • Less optimal than dorsal hand or cubital fossa

Alternative Options When Peripheral Access Fails

Intraosseous (IO) Access

• Reasonable alternative when umbilical and peripheral access fail 1, 3
• Should be considered only after multiple failed peripheral attempts
• Preferred sites for IO in infants:
  • Proximal tibia (2 cm distal to tibial tuberosity, 1 cm medial) 3
  • Avoid growth plates to prevent injury 3
• Complications include bone fracture, extravasation, compartment syndrome, and growth plate injury 3

Techniques to Improve Success

1. Ultrasound Guidance

   • Significantly improves success rates in difficult access cases
   • Reduces overall placement time (6.3 vs 14.4 minutes) 4
   • Requires fewer attempts (median 1 vs 3) and needle redirections 4

2. Preparation Techniques

   • Apply topical anesthetic cream (lidocaine/prilocaine) 1 hour before venipuncture 1
   • Maintain warm environment to promote vasodilation
   • Use distraction techniques to reduce infant distress during procedure 1

3. Proper Positioning

   • Secure assistance to gently restrain the infant
   • Ensure good lighting and proper positioning of the limb

Special Considerations

• Children younger than 2 years have lower first-attempt success rates (38.9% vs 53.5%) and longer time to successful placement (median 11 minutes) compared to older children 5
• For skin antisepsis in infants, caution is advised with 2% chlorhexidine due to risk of skin burns; many centers use 0.5% solution as an alternative 1
• Avoid using lower extremities when both are needed for procedures or when there are circulatory concerns in the limbs 6

Monitoring After Placement

• Monitor insertion site frequently for signs of infiltration or phlebitis
• The most common complications are extravasation (47.0%) and phlebitis (5.9%) 2
• Secure catheter properly to prevent dislodgement, particularly important in active infants

By following these guidelines and prioritizing the recommended access sites, clinicians can optimize the chances of successful IV placement while minimizing trauma and complications in one-month-old infants.