The Centers for Medicare & Medicaid Services and the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative have emphasized the need for increased arteriovenous fistula (AVF) use and decreased central venous catheter use. A Fistula First National Vascular Access Improvement Initiative was undertaken to achieve these targets in adult patients through change concepts and process improvement. Despite increasing numbers of children receiving hemodialysis in the United States, AVF use rates decreased during the past 10 years. Studies of children dialyzed using AVFs showed superior dialysis delivery, improved access survival, and markedly lower infection rates. The purpose of this article is to alert nephrologists to consider a fistula first in long-term pediatric hemodialysis patients. In this article, we describe the status of vascular access in the United States and worldwide in children, the importance of AVF creation, and the need for surgical expertise, including microsurgery, in this population. Additionally, we introduce the International Pediatric Fistula First Initiative, a multidisciplinary team consisting of pediatric nephrologists, vascular access surgeons, and interventional radiologists aiming to increase awareness, offer educational tools, and implement the fistula first initiative in children.