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The nature of shallow aquifers and the impacts of seawater intrusion in small islands within the Pacific Ocean are reviewed. Many Pacific islands rely on shallow fresh groundwater lenses in highly permeable aquifers, underlain and surrounded by seawater, as their principal freshwater source. It is argued that, in small islands, the nature of fresh groundwater lenses and their host aquifiers coupled with frequent natural and ever-present anthropogenic threats make them some of the most vulnerable aquifier systems in the world. A simple steady-state approximation is used to provide insight into the key climatic, hydrogeological, physiographic, and management factors that influence the quantity of, and saline intrusion into freshwater lenses. Examples of the dynamic nature of freshwater lenses as they respond to these drivers are given. Natural and human-related threats to freshwater lenses are discussed. Long dry periods strongly coupled to sea surface temperatures impact on the quantity and salinity of fresh groundwater. The vulnerability of small island freshwater lenses dictates careful assessment, vigilant monitoring, appropriate development, and astute management. Strategies to aid future groundwater sustainability in small islands are presented and suggested improvements to donor and aid programs in water are also advanced.