Achieving reliable vascular access (VA) for children devoid of pain, anxiety, and complication is the goal of pediatric VA specialists. VA prevails across various settings, both inpatient and outpatient. In addition, VA spans acute and chronic medical requirements, ranging from the seemingly simple, one-time infusion to the complex, prolonged treatments requiring multiple, frequent infusions and sometimes a lifelong dependency. Regardless of the motive, selection of a vascular access device (VAD) should be driven by the individual’s treatment (medication properties and treatment duration and frequency) and pathophysiology (age, acute and/or chronic disease, existing vessel health, diagnosis, and individual risk factors) with the primary aim of avoiding patient harm. At the heart of achieving this is choosing the right VAD from the beginning. Most health care facilities attempt to achieve this by publishing local VA decision trees. Unfortunately, these are often generic, lack an evidence base, and do not provide direction for nonstandard VA needs.