Venovenous extracorporeal membrane oxygenation (VV ECMO) has become an increasingly preferred modality for respiratory support in neonates and infants under 10 kg, driven by a growing recognition of its neurological safety advantages over venoarterial (VA) ECMO. Historically, VV ECMO was limited in this population due to small vessel size, anatomical constraints, and technical challenges in achieving stable high-flow access. Recent advancements, including the development of the Crescent Right-Atrial (RA) dual-lumen cannula and increasing adoption of multisite cannulation strategies, have significantly expanded VV ECMO feasibility in neonates and small infants. Institutional experiences now support the safety and efficacy of VV ECMO in this vulnerable group when performed with skilled teams and advanced imaging guidance. This review synthesizes current evidence, highlights evolving cannulation techniques, and presents innovative solutions aimed at improving outcomes for infants and children under 10 kg requiring VV ECMO.