Pediatric basic life support (BLS) for health care providers

INTRODUCTION — This topic review addresses general pediatric basic life support (BLS) principles for health care providers. Specific pediatric topics that include BLS management or opioid-associated emergencies are discussed separately:

●(See "Basic airway management in children" and "Airway foreign bodies in children", section on 'Foreign body removal'.)

●(See "Neonatal resuscitation in the delivery room".)

●(See "Opioid intoxication in children and adolescents".)

EPIDEMIOLOGY AND SURVIVAL — Early recognition and treatment of cardiac arrest improves survival for children and adults [1-3]. Effective pediatric BLS by trained health care providers or lay rescuers is the foundation of successful resuscitation [4].

Cardiac arrest — Cardiac arrest is a condition defined by the absence of pulses. The two types of pediatric cardiac arrest are hypoxic/asphyxial arrest and sudden cardiac arrest.

●Hypoxic/asphyxial arrest – Hypoxic/asphyxial arrest is the most common type of cardiac arrest in infants and children. It results from progressive tissue hypoxia and acidosis due to respiratory failure and/or shock [5]. Causes of respiratory failure and/or hypotensive shock leading to cardiac arrest in these age groups include septic shock, upper airway obstruction, pneumonia, sudden infant death syndrome, metabolic derangement (eg, hypoglycemia, inborn errors of metabolism, or electrolyte disturbance), neurological catastrophe (brain herniation or hemorrhage), poisoning (eg, opioid overdose), trauma, non-trauma exsanguination, and anaphylaxis [1,6-10].

This finding is in contrast to adults, for whom the most common cause of cardiac arrest is ischemic cardiovascular disease. (See "Adult basic life support (BLS) for health care providers", section on 'Epidemiology and survival'.)

●Sudden cardiac arrest – Sudden cardiac arrest, most often caused by the development of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), is less common in infants and children than in adults. Predisposing conditions or causes of ventricular arrhythmias in pediatric patients with sudden cardiac arrest include:

•Hypertrophic cardiomyopathy (see "Hypertrophic cardiomyopathy in children: Clinical manifestations and diagnosis")

•Myocarditis (see "Clinical manifestations and diagnosis of myocarditis in children")

•Anomalous coronary artery (from the pulmonary artery) (see "Congenital and pediatric coronary artery abnormalities", section on 'Variations of coronary artery origin from the pulmonary artery')

•Wolff-Parkinson-White syndrome (see "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis")

•Long QT syndromes (see "Congenital long QT syndrome: Epidemiology and clinical manifestations" and "Acquired long QT syndrome: Clinical manifestations, diagnosis, and management")

•Drug intoxication (table 1)

•Commotio cordis (ie, sharp blow to chest) (see "Commotio cordis")

●Respiratory arrest versus cardiac arrest – Infants and children with a respiratory arrest (not breathing normally but presence of pulses), are much more likely to recover if promptly treated than those with a cardiac arrest [1,11-13]. As an example, in an observational study of 95 children with out-of-hospital cardiac arrest, 82 percent of children with respiratory arrest were alive at one year compared with 14 percent of patients with a cardiac arrest [1].

Individual determinants of survival following pediatric cardiac arrest vary according to the setting (out of hospital versus in hospital) and individual patient factors as discussed below.

Out-of-hospital cardiac arrest — The majority of pediatric out-of-hospital cardiac arrests (OHCAs) are unwitnessed, occur at home, and occur in infants [9,10,14,15].

Survival to hospital discharge in pediatric OHCA is approximately 11 percent, with overall survival (and survival with good neurological function) varying by age [10]:

●Infants: 7 percent (5 percent)

●Children: 16 percent (13 percent)

●Adolescents: 19 percent (17 percent)

Survival from pediatric OHCA has not changed significantly over time or by region: the 7 to 10 percent overall survival from pediatric OHCA reported by a North American multicenter OHCA registry during 2007 to 2012 is consistent with data reported by other national registries [16-18].

Factors associated with increased survival after pediatric OHCA include [15,16,19]:

●Older age

●Witnessed arrest

●High-quality BLS including bystander cardiopulmonary resuscitation (CPR) and telephone dispatcher-assisted CPR (DA-CPR) [20-23]

●Automated external defibrillator (AED) use

●Initial shockable rhythm [24]

●Early presence of emergency medical services (EMS)

Sudden cardiac arrest due to a shockable rhythm (VF or pVT) occurs in up to 18 percent of all pediatric OHCAs but is less commonly the presenting rhythm in children one to eight years of age (8 percent) and infants [10,25,26].

Early CPR after a witnessed cardiac arrest and receipt of public access defibrillation (PAD) are key interventions that improve neurologic outcome [1,19,25,27-30]. As an example, in a registry study of 188 children with OHCA during school sports (87 percent receiving bystander CPR), 66 percent of the 119 patients who received PAD had favorable neurologic outcome compared with 30 percent who did not [31].

In-hospital cardiac arrest — Survival to hospital discharge in pediatric in-hospital cardiopulmonary arrest (IHCA) is approximately 49 percent (overall) and 41 percent (pulseless arrest) [10]. Adjusted probability of survival (and favorable neurological outcome among survivors) was 41 percent (70 percent) for CPR duration of 1 to 15 minutes and 12 percent (60 percent) for CPR duration greater than 35 minutes [32].

Rates of survival from pediatric cardiac arrest are higher for IHCA [11,12,33-38] than OHCA [1,7-10,14,19,25,27-30]. A narrative literature review of this topic until January 2019 cited a threefold higher rate of survival among infants and children with IHCA compared with OHCA.

Increased survival after pediatric IHCA is associated with [15]:

●Younger age (lower mortality despite higher incidence in infants)

●Shorter duration of CPR

●Initial shockable rhythm

●Previous monitoring

●Occurrence on weekdays and during daytime

Longitudinal studies from the United States have identified a trend towards improved survival after pediatric IHCA [10-12,35]. According to the "Get With the Guidelines" (GWTG) resuscitation registry during 2000 to 2018, survival to discharge increased 29 to 41 percent for all IHCA, 19 to 41 percent for pulseless arrest, and 57 to 66 percent for non-pulseless arrest [10,12].

●During 2000 to 2009, the GWTG registry demonstrated an increase in survival to discharge from IHCA while the rate of significant neurologic disability remained stable [11]. Survival improved despite a high prevalence (in up to 85 percent patients) of an initial non-shockable rhythm (asystole and pulseless electrical activity [PEA]) and was similar regardless of the initial rhythm (shockable or non-shockable) [11].

●During 1997 to 2012, a retrospective cohort study of almost 30,000 discharges after IHCA demonstrated that the incidence of IHCA almost doubled to one IHCA per 1000 discharges while survival after IHCA increased from 49 to 60 percent [35].

During 2018, the GWTG registry reported the prevalence of initial rhythm for IHCA in 571 patients [10]:

•Shockable: 9 percent

•Non-shockable: 77 percent (asystole: 28.5 percent; PEA: 48.5 percent)

•Unknown: 14 percent

Taken together, these findings suggest that rapid recognition of cardiac arrest and prompt performance of CPR during in-hospital resuscitation are important contributors to improved survival in IHCA, and that, unlike patients with OHCA, survival from IHCA is less dependent upon the presenting rhythm.

Additional studies have evaluated the contribution of advanced techniques, such as endotracheal intubation and extracorporeal membrane oxygenation (ECMO) during resuscitation and post-resuscitation care, to survival after IHCA:

●Endotracheal intubation – In a retrospective observational study of over 2200 United States children younger than 18 years of age with IHCA reported to a centralized registry from 2000 to 2014, endotracheal intubation during cardiac arrest was associated with a significantly lower adjusted survival to hospital discharge compared with a propensity-matched cohort of patients who were not intubated (36 versus 41 percent, respectively) [36]. There was no significant difference in return of spontaneous circulation (ROSC) or favorable neurologic outcome between the groups. Although confounding cannot be fully excluded given the study design, this evidence suggests that the emphasis on early endotracheal intubation during pediatric IHCA warrants re-examination and further study [37].

●ECMO during resuscitation and post-resuscitation care – Use of ECMO during resuscitation and post-resuscitation care in settings with existing ECMO protocols, expertise, and equipment may be beneficial for selected patients who fail conventional CPR after IHCA, especially children with underlying cardiac disease such as cardiomyopathy, myocarditis, or congenital heart disease. Survival after ECMO during resuscitation and post-resuscitation care is discussed in greater detail separately. (See "Pediatric advanced life support (PALS)", section on 'Extracorporeal membrane oxygenation (ECMO) with CPR (ECPR)'.)

Bradycardia with poor perfusion — Bradycardia with poor perfusion is a condition defined by heart rate <60/minute in a patient with cardiorespiratory compromise.

Evidence for hospital and pre-hospital treatment is as follows:

In-hospital bradycardia with poor perfusion - Survival in patients with a pulse during an inpatient BLS event is as high as 66 percent compared with 38 to 43 percent if the patient becomes pulseless [11,12].

In a retrospective observational study of 5592 children aged greater than 30 days to less than 18 years who received CPR at hospitals participating in the GWTG registry during 2000 to 2016, 50 percent had pulseless arrest and 50 percent had bradycardia with poor perfusion at the initiation of chest compressions, of which 31 percent progressed to pulseless arrest despite CPR [39]. Children who deteriorated to pulseless arrest despite receiving CPR for bradycardia with poor perfusion had a 19 percent lower likelihood of surviving to hospital discharge than those who were initially pulseless [39]. Risk-adjusted rates of survival to discharge were [39]:

•30 percent for bradycardia with poor perfusion progressing to pulseless arrest

•37.5 percent for initial pulseless arrest

•70 percent for bradycardia with pulse and poor perfusion

Survival to discharge for pediatric inpatients who received CPR was higher for bradycardia with poor perfusion (41 percent) compared with asystole or PEA (24.5 percent) [40].

●Out-of-hospital bradycardia with poor perfusion – Evidence suggests that bradycardia with poor perfusion in the out-of-hospital setting is undertreated. For example, in a retrospective study from the United States of 911 scene response encounters for over 1200 children (median age two years) who met current PALS criteria of bradycardia with poor perfusion (first heart rate <60/minute with altered mental status or hypotension for age), only 12.1 percent received bag-mask ventilation (the most frequently performed airway intervention and 24.7 percent received fluids. Receipt of any PALS-recommended intervention was associated with altered mental status and age-adjusted hypotension, but not with first heart rate <60/minute) [41]. Survival outcomes were not reported. This study supports continued education and assessment of US prehospital providers regarding indications for PALS-recommended interventions for bradycardia with poor perfusion.

INTERNATIONAL RESUSCITATION GUIDELINES — Based upon extensive review of clinical and laboratory evidence, the American Heart Association (AHA) has published frequent updates for pediatric BLS [4,42-44], and the International Liaison Committee on Resuscitation (ILCOR) has published annual treatment recommendations [45-47].

BLS guidelines differ according to patient age and other factors. These differences are defined as follows [43]:

●Newborn: birth to first hospital discharge (see "Neonatal resuscitation in the delivery room", section on 'Resuscitation')

●Infant: younger than one year of age (including neonates, ie, less than 30 days of age, after first hospital discharge)

●Child: one year of age to the start of puberty (axillary hair in males and breast development in females)

●Adult: any patient either with signs of puberty or of older age (see "Adult basic life support (BLS) for health care providers")

The approach to BLS in infants and children for a single rescuer is provided here (algorithm 1) and for two or more rescuers here (algorithm 2).

The 2020 AHA cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines reaffirm that the circulation-airway-breathing (C-A-B) sequence is still preferred for pediatric CPR [44,48]. Based upon the 2017 ILCOR treatment summary, conventional CPR has better outcomes than compression-only CPR (CO-CPR) and is preferred [45].

However, not all individual councils have adopted the 2020 pediatric BLS updates. As an example, for a single health care professional rescuer, A-B-C starting with the five stair step breaths are still advocated by the Resuscitation Council of the United Kingdom instead of C-A-B [49].

COVID-19 PATIENTS (SUSPECTED OR CONFIRMED) — The American Heart Association (AHA) has published interim guidance, including updated algorithms, for basic and advanced life support for children with suspected or confirmed coronavirus disease 2019 (COVID-19) [50-52].

For pediatric cardiac arrest, modifications to BLS include (algorithm 3):

●Don personal protective equipment (PPE) prior to entering the patient room or scene (eg, cap, gown, N95 face mask, tight-fitting eye goggles or face shield, gloves) per local guidelines and availability.

●Limit personnel who are performing cardiopulmonary resuscitation (CPR); consider using a mechanical CPR device for adolescents who meet height and weight criteria.

●Provide rescue breathing using a bag-mask device with a high-efficiency particulate air (HEPA) filter and ensure a tight mask seal.

Preliminary evidence suggests that quality of BLS and rescuer fatigue is not significantly hampered by PPE. As an example, in a multicenter controlled trial involving 108 health care providers, neither chest compression quality (rate, depth, and release velocity) nor self-reported fatigue worsened to a significant degree in health care providers who performed BLS on pediatric manikins while wearing PPE, suggesting that the current pediatric BLS recommendation for chest compression providers to switch every two minutes need not be altered with PPE use [53].

BASIC LIFE SUPPORT APPROACH — Indications for BLS in critically ill or injured infants and children addressed in this topic are:

●Cardiac (pulseless) arrest

●Bradycardia (specifically heart rate <60/minute) with poor perfusion [39,40]

BLS guidance for one rescuer is provided here (algorithm 1) [42,43] and for two rescuers here (algorithm 2) [44].

The sequence of key actions is described as follows [42-44]:

●Verify scene safety – Before beginning BLS, rescuers must ensure that the scene is safe for them and the victim (eg, removing the victim from a burning building or safely retrieving a drowning victim).

●Determine unresponsiveness, get help, and activate emergency medical response system – If the patient is unresponsive, then the rescuer should shout for nearby help and activate emergency medical services (EMS) via a mobile device (single rescuer outside of the hospital) or hospital system (eg, code button).

Alternatively, with two or more health care providers, one rescuer continues to care for the victim and a second rescuer activates EMS and retrieves an automated external defibrillator (AED) and other emergency equipment (eg, code cart).

If the patient is responsive, the rescuer should determine additional medical needs and need for activation of EMS based upon the patient's condition.

●Assess breathing and pulse – The rescuer should determine if the patient is breathing, only gasping, or not breathing while simultaneously checking for a pulse. Try to palpate a central pulse (brachial pulse in an infant; carotid or femoral pulse in a child) [54].

This assessment guides further actions as follows:

•No breathing or only gasping and no definite pulse within 10 seconds:

-Single rescuer – The approach depends upon whether the sudden collapse is witnessed or not:

Unwitnessed collapse – For an unwitnessed, sudden collapse, the rescuer should start cardiopulmonary resuscitation (CPR; compressions-airway-breathing [C-A-B]) with a ratio of 30 compressions to 2 breaths. (See 'Chest compressions' below and 'Compression to ventilation ratio' below.)

After about two minutes, if still alone, activate EMS and retrieve an AED (if not already done). Apply and activate the AED as soon as possible.

Witnessed collapse – The rescuer should activate EMS (if not already done) and retrieve an AED or, for advanced life support (ALS) providers, a manual defibrillator. The single rescuer should then use the AED (or manual defibrillator for ALS providers) as soon as it is available. If the AED is not nearby or not available, start CPR while awaiting EMS arrival.

-Two or more rescuers – The rescuer should begin CPR (C-A-B), starting with a ratio of 30 compressions to 2 breaths for a single rescuer and 15 compression to 2 breaths for two or more rescuers.

In infants and children, the method of compressions and depth of compressions varies by age. (See 'Chest compressions' below.)

Chest compressions in infants and children should always be accompanied by ventilation for infants and children who remain pulseless after the initial sequence of compressions. (See 'Compression to ventilation ratio' below.)

Substantial evidence indicates that health care providers are often unable to quickly determine whether or not a pulse is present [55-58]. Consequently, when a pulse is not definitely identified within 10 seconds, CPR should be initiated.

•No normal breathing but pulse is present (same actions for single or multiple rescuers):

-Start rescue breathing by providing one breath every two to three seconds (20 to 30 breaths per minute), which reflects a change from the 2015 guidelines suggested rate of every three to five seconds (12 to 20 breaths per minute) [44,59].

-Perform a pulse check for no longer than 10 seconds. Add chest compressions if the heart rate remains <60/minute with poor perfusion [40,43].

-Activate EMS, if not already done.

-Continue rescue breathing. Perform a pulse check every two minutes. If no pulse, begin CPR (C-A-B), starting with a ratio of 30 compressions to 2 breaths for a single rescuer and 15 compressions to 2 breaths for two or more rescuers.

In infants and children, the method of compressions and depth of compressions vary by age. (See 'Chest compressions' below.)

Chest compressions in infants and children should always be accompanied by ventilation for infants and children who remain pulseless after the initial sequence of compressions. (See 'Compression to ventilation ratio' below.)

•Normal breathing and pulse is present (same action for single or multiple rescuers):

-Monitor the patient until EMS arrives.

●Initiate CPR – The actions that constitute CPR are performing chest compressions, opening the airway, and providing ventilations, or C-A-B. (See 'Chest compressions' below and 'Breathing' below and "Basic airway management in children", section on 'Noninvasive relief of obstruction'.)

The sequence in which the actions of CPR for infants and children should be performed by health care providers is as follows:

•Initiate CPR in an infant or child who is unresponsive, has no normal breathing, and no definite pulse after 10 seconds.

•Start chest compressions before performing airway or breathing maneuvers (C-A-B).

•After 30 compressions (15 compressions if two rescuers), open the airway and give two breaths. (See 'Breathing' below.)

•If the heart rate is ≥60/minute after about two minutes of CPR, stop chest compressions and continue ventilation.

•Apply the AED or manual defibrillator:

-Single rescuer – For a witnessed collapse, retrieve the AED or, for ALS providers, the manual defibrillator and use it as soon as possible. For an unwitnessed collapse, perform about two minutes of CPR and then activate EMS (if not already done) and retrieve the AED or, for ALS providers, the manual defibrillator.

-Two or more rescuers – One rescuer initiates CPR while the other rescuer activates EMS and retrieves the AED or, for ALS providers, the manual defibrillator. The AED or manual defibrillator is then used as soon as it is available. (See "Technique of defibrillation and cardioversion in children (including automated external defibrillation)", section on 'Procedure' and "Technique of defibrillation and cardioversion in children (including automated external defibrillation)", section on 'Automated external defibrillator use in infants and children'.)

•Proceed based upon AED analysis as follows:

-Shockable rhythm – Give one shock and resume CPR immediately for about two minutes (until prompted by the AED to allow a rhythm check). Continue CPR with pulse check and AED rhythm check every two minutes until ALS providers take over or the victim starts to move.

-Non-shockable rhythm – Resume CPR immediately for about two minutes (until prompted by the AED to allow a rhythm check). Continue CPR with pulse check and AED rhythm check every two minutes until ALS providers take over or the victim starts to move.

The algorithms for a single and two or more rescuers are designed so that CPR is performed for approximately two minutes (five cycles for single rescuer and 10 cycles for two or more rescuers) before using an AED in a patient with an unwitnessed arrest. This approach is based upon limited evidence in adults that, even for prolonged arrest from ventricular fibrillation (VF), an initial period of CPR improves the likelihood of successful defibrillation. (See "Adult basic life support (BLS) for health care providers", section on 'Phases of resuscitation'.)

CHEST COMPRESSIONS — The 2020 American Heart Association (AHA) cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines [44] reaffirm the 2017 treatment recommendation summary [45] and continue to emphasize the importance of proper technique when performing chest compressions based on evidence in adults and animals [42,60-62]. Chest compressions should be performed over the lower half of the sternum [42,43,63]. Compression of the xiphoid process can cause trauma to the liver, spleen, or stomach and must be avoided.

The effectiveness of chest compressions can be maximized by attention to the following essential elements:

●The chest should be depressed at least one-third of its anterior-posterior diameter with each compression [64-67]:

•Infants: approximately 4 cm (1.5 inches)

•Children: 5 cm (2 inches)

•Adolescents: 5 to 6 cm, but should not exceed 6 cm (2.4 inches) per adult recommendations

●The optimum rate of compressions is approximately 100 to 120 per minute [68,69]. Each compression and decompression phase should be of equal duration.

●The sternum should return briefly to its normal position at the end of each compression, allowing the chest to recoil fully [70].

●A smooth compression-decompression rhythm, with minimal interruption, should be developed [27,71].

●Perform chest compressions on a firm surface [72-78]. During in-hospital cardiopulmonary arrest (IHCA), use a backboard to improve chest compression depth [72,74,75,79-82], and when available, activate the "CPR mode" of the bed to increase mattress stiffness [72,83-85].

Use of coaching, audio-visual feedback, and frequent training improves provider adherence to these recommendations. (See 'CPR coaching, feedback devices, and refresher training' below.)

Infants — The 2020 AHA CPR and ECC guidelines reaffirm that chest compressions for infants may be performed with either the two-fingers technique or the two-thumb encircling hands technique as described below [44]. If the rescuer is unable to compress at least one-third of the anterior-posterior diameter of the chest with either of these techniques, it is reasonable to use the heel of one hand.

Two fingers — This technique is suggested by the AHA when there is a single rescuer [13,42,43,63,86-89]. The two-fingers technique during single-rescuer infant CPR permits both easier transition from compressions to ventilation and maintenance of the head tilt maneuver during compressions, thereby avoiding head repositioning for ventilation [90].

Chest compressions are performed with index and middle fingers, placed on the sternum just below the nipples (figure 1). Because of the infant's large occiput, slight neck extension and the placement of a hand or rolled towel beneath the upper thorax and shoulders may be necessary to ensure that the work of compression is focused on the heart [91].

Rescuer fatigue — Rescuer fatigue has been raised as a concern with the two-fingers technique, and infant manikin data comparing the two-fingers and two-thumb encircling hands techniques are conflicting. Two randomized crossover studies reported less rescuer fatigue with the two-thumb technique [90,92]. However, in one randomized study, rescuer fatigue did not significantly differ between the two techniques [93].

Two-thumb encircling hands — For infants undergoing two-rescuer CPR, we suggest that compressions be performed using the two-thumb encircling hands technique [13,42,43,94-98].

The thorax is encircled with both hands, and chest compressions are performed with the thumbs (figure 2). The thumbs compress the lower half of the sternum, avoiding the xiphoid process, while the hands are spread around the thorax.

This suggestion is supported by studies showing superior performance of the two-thumb encircling hands technique compared with the two-fingers technique, specifically improved:

●Arterial and coronary perfusion pressures (animal model) [99]

●Blood and perfusion pressures (infant manikin) [100]

●Compression depth, rate, and consistency (infant manikin) [90,92,101]

Children — For children, chest compressions should be performed over the lower half of the sternum with either the heel of one hand or with two hands (picture 1 and picture 2).

No outcome studies have compared these two techniques in children with cardiac arrest [42,43,55]. In pediatric manikin studies, the two-hand technique has been associated with improved compression depth [102], improved compression force [103], and less rescuer fatigue [104].

CPR coaching, feedback devices, and refresher training — For pediatric CPR, coaching, real-time feedback devices, and refresher training appear to improve the quality of chest compressions during pediatric resuscitation although evidence of improved clinical outcomes with the use of CPR coaching or feedback devices in children with cardiac arrest is lacking [105-116]:

●Coaching – Specific tasks of the CPR coach include [54]:

•Coordinates the start of CPR

•States the midrange compression and ventilation rate targets

•Provides device and visual feedback on quality of chest compressions to enhance performance

•Minimizes pauses during CPR with the goal of maintaining a cardiac compression fraction (CCF; proportion of time during cardiac arrest during which chest compressions are administered) at 80 percent

During pediatric resuscitation, the CPR coach may also act in the monitor/defibrillator role.

Compared with team performance without a CPR coach, the inclusion of a trained CPR coach during simulated pediatric cardiac arrest has been associated with decreased team member mental workload [113] and better team performance (improved verbalization before pauses in CPR, decreased pause duration, shorter pauses during intubation, and better coordination of key tasks during pauses) [114,117].

●Feedback devices – Mechanical feedback devices (audio and audio-visual) plus integration of a trained CPR coach into resuscitation teams has improved chest compression quality in randomized, simulation-based clinical trials [105-109,111,115,116]. Mechanical feedback device use alone has been associated with an increased likelihood of delivery of chest compressions compliant with excellent CPR (rate, depth, and CCF) during in-hospital cardiac arrest [112].

●Refresher training – Refresher CPR simulation training ("just-in-time" CPR training with use of a visual feedback device) provided prior to trial CPR performance combined with visual feedback during trial performance may improve CPR quality during simulated pediatric cardiac arrest more than either refresher training or visual feedback alone, especially when performed on a regular basis [106]. For example, CPR simulation training with real-time feedback occurring monthly significantly improved the proportion of health care providers able to perform "excellent CPR" (defined as 90 percent guideline compliance for compression depth, rate, and recoil) on an infant manikin compared with providers in the control group receiving only annual BLS training (72 versus 19.5 percent, respectively) [110]. In a prospective observational study, a high-frequency training program in pediatric CPR attended by ED providers in a children's hospital over a 15-month period resulted in improved performance of CPR skills during simulated and actual pediatric cardiac arrest [118].

COMPRESSION TO VENTILATION RATIO

No advanced airway — For infants and children who remain pulseless after the initial sequence of compressions, chest compressions should always be accompanied by ventilation [13,42,43,55,86,119]. However, every effort should be made to avoid excessive ventilation and to limit interruptions of chest compressions to less than 10 seconds.

Experimental evidence in animals indicates that coronary artery perfusion pressure declines with interruptions in chest compressions [61,62]. Observational reports suggest that long interruptions in cardiopulmonary resuscitation (CPR) occur commonly [120,121].

Compression to ventilation ratios of 30 to 2 and 15 to 2 are recommended to minimize interruption and for ease of teaching and retention [55,119].

●Single rescuer: Two ventilations should be delivered during a short pause at the end of every 30^th compression

●Two rescuers: Two ventilations should be delivered at the end of every 15^th compression

Advanced airway — Once the trachea is intubated, chest compressions and ventilations can be performed independently. For infants and children, chest compressions are delivered at a rate of 100 to 120 per minute without pauses, and ventilations are given at a rate of 20 to 30 breaths per minute (one breath every two to three seconds) [44]. The 2020 change in compression to ventilation rate in infants and children with an advanced airway is based upon a multicenter observational study of 47 children with in-hospital cardiopulmonary arrest (IHCA) that found that ventilation rates of at least 30 breaths per minute in infants and 25 breaths per minute in children were associated with increased rates of return of spontaneous circulation (ROSC) and survival [59].

Conventional versus compression-only CPR — We suggest that rescuers provide conventional CPR rather than compression-only CPR (CO-CPR) to infants and children with IHCA or out-of-hospital cardiac arrest (OHCA) [42,43,45,55,119,122-124]. For children with cardiac arrest who cannot be ventilated (eg, upper airway obstruction or severe lung disease), CO-CPR is warranted while oxygenation and ventilation are established. This recommendation is based upon observational studies of bystander CPR, which suggest the following [19,122,125,126]:

●The proportion of children with one-month survival with favorable neurologic outcomes after OHCA ranged widely among the studies but was higher in children receiving conventional CPR: conventional CPR (13 to 26 percent); CO-CPR (9 to 16 percent); no bystander CPR (2 to 7.5 percent).

●Both conventional and CO-CPR appear to have better one-month survival with favorable neurologic outcomes than no bystander CPR although the benefit of CO-CPR compared with no bystander CPR is inconsistent.

●Conventional CPR may increase one-month survival with favorable neurologic outcomes compared with CO-CPR for children 1 to 17 years of age whose arrest is due to noncardiac causes.

●Conventional CPR and CO-CPR appear to result in similar one-month survival with favorable neurologic outcomes for infants and children after cardiac arrest.

Because the cause of pediatric OHCA is not typically known and the majority of pediatric cardiac arrests are due to non-cardiac causes, the available evidence supports conventional CPR as the method that is associated with the best neurologic outcome in infants and children. However, either conventional CPR or CO-CPR is preferable to no CPR in children suffering OHCA.

AIRWAY — The airway should be opened with a head tilt-chin lift maneuver unless a cervical spine injury is suspected. In the setting of trauma in which cervical spine injury is suspected, use a jaw thrust maneuver without head tilt; however, if this action is unsuccessful, use the head tilt-chin lift maneuver. (See "Basic airway management in children", section on 'Noninvasive relief of obstruction'.)

BREATHING — Ventilations can be provided with mouth-to-mouth, mouth-to-nose, or with a bag and mask (see "Basic airway management in children", section on 'Assisted ventilation'). Bag-mask ventilation is often sufficient to achieve adequate ventilation during cardiopulmonary resuscitation (CPR). If adequate ventilation cannot be achieved with bag-mask ventilation, or the resuscitation is prolonged, an advanced airway (endotracheal tube or supraglottic device) may be required. Bag-mask ventilation is a reasonable alternative to an advanced airway (endotracheal intubation or supraglottic airway) in the prehospital management of pediatric cardiac arrest [36,127-129]. (See "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

Evidence in adults and animals suggest that hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion (see "Adult basic life support (BLS) for health care providers", section on 'Ventilations'). These data are the basis for the following recommendations [13,130]:

●Each rescue breath should be delivered over one second.

●The volume of each breath should be sufficient to see the chest wall rise.

●An infant or child with a heart rate ≥60/minute without normal breathing should receive one breath every two to three seconds (20 to 30 breaths per minute) [44,59].

●Infants and children who require chest compressions should receive two breaths per 30 chest compressions for a lone rescuer and two breaths per 15 chest compressions for two rescuers. (See 'Compression to ventilation ratio' above.)

●Intubated infants and children should be ventilated at a rate of 20 to 30 breaths per minute (one breath every two to three seconds) with a goal of 30 breaths per minute in infants and 20 to 25 breaths per minute in children without any interruption of chest compressions [44,59]. (See 'Compression to ventilation ratio' above.)

AUTOMATED EXTERNAL DEFIBRILLATOR — An automated external defibrillator (AED) is a portable device that identifies "shockable rhythms" that should be treated with defibrillation. It then instructs the operator how to use the device to deliver a standard shock to the patient. The device also identifies "non-shockable rhythms" and advises no shock followed by a prompt to resume cardiopulmonary resuscitation (CPR). (See "Automated external defibrillators" and "Technique of defibrillation and cardioversion in children (including automated external defibrillation)", section on 'Automated external defibrillator use in infants and children'.)

The 2020 American Heart Association (AHA) CPR and emergency cardiovascular care (ECC) guidelines reaffirm the following for infants and children with cardiac arrest [44]:

●Witnessed arrest – An AED should be used as soon as possible if a manual defibrillator is not available [13,42,43,55,86,119]. CPR should be performed until the AED (or manual defibrillator, if available) is ready to deliver a shock [131-135]. A single shock followed by immediate chest compressions is recommended for infants and children with a shockable rhythm [71,136]. The initial manual defibrillation dose is 2 J/kg (up to the adult maximum dose) with timing of additional defibrillation and escalation of defibrillation doses as indicated in the algorithm (algorithm 4).

●Unwitnessed arrest – The algorithms for a single rescuer and two or more rescuers are designed so that CPR is performed for approximately two minutes (five cycles for single rescuer and 10 cycles for two or more rescuers) before using an AED. (See 'Basic life support approach' above.)

●Age <8 years – An AED with a pediatric dose attenuating system should be used whenever possible [2,3,28,137-144]. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is not available, use of an AED without a dose attenuator is advised [13,86,139,140,142,145]. When affixing the self-adhering pads, use either anterior-lateral placement or anterior-posterior placement to maintain good separation between the pads [146,147]. (See "Technique of defibrillation and cardioversion in children (including automated external defibrillation)", section on 'Automated external defibrillator use in infants and children'.)

In observational series, up to 19 percent of infants and children in cardiac arrest outside of a hospital (OHCA) had a shockable rhythm as the initial rhythm. Thus, a substantial number of children in cardiac arrest might benefit from early defibrillation [1,7,8,26,148]. Limited evidence suggests that AEDs can be appropriately and safely used for infants and children [137-141,149].

The AED is designed to be used by untrained bystanders and is increasingly available in public locations such as airports, athletic events, shopping malls, and the workplace. The American Academy of Pediatrics (AAP) recommends that lay rescuer AED programs (such as in schools) be implemented as part of comprehensive emergency response plans, rather than as programs focused on a single piece of equipment.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: CPR for children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Prompt recognition – Pediatric cardiac arrest most often results from progressive tissue hypoxia and acidosis due to respiratory failure and/or shock. However, sudden arrest from a shockable rhythm (ie, ventricular fibrillation [VF] or pulseless ventricular tachycardia [pVT]) also occurs frequently. Survival rates for children with cardiac arrest are improved by prompt recognition and initiation of cardiopulmonary resuscitation (CPR). (See 'Epidemiology and survival' above.)

●Basic life support (BLS) algorithms – Indications for pediatric BLS include:

•Cardiac (pulseless) arrest

•Bradycardia (heart rate <60/minute) with a pulse and poor perfusion

BLS guidelines are provided for one rescuer here (algorithm 1) and for two rescuers here (algorithm 2) (see 'Basic life support approach' above). Guidance for the resuscitation of newborns is provided in the algorithm (algorithm 5) and reviewed separately. (See "Neonatal resuscitation in the delivery room".)

●Pulse checks – For infants and children with signs of cardiac arrest, check for a pulse (preferably the brachial pulse in infants and femoral or carotid pulse in children) for no longer than 10 seconds. After initiating CPR, perform subsequent pulse checks approximately every two minutes.

●Start CPR – Children with no or ineffective breathing and no definite pulse within 10 seconds require CPR with initiation of compressions before ventilation (airway and breathing), or C-A-B. In most cases, we suggest conventional CPR rather than compression-only CPR (CO-CPR) (Grade 2C). For children with cardiac arrest who cannot be ventilated (eg, upper airway obstruction or severe lung disease), CO- CPR is warranted while oxygenation and ventilation are established. (See 'Conventional versus compression-only CPR' above.)

●Chest compressions

•Each chest compression should depress the chest by a minimum of one-third of its anterior-posterior diameter, at a rate of about 100 to 120 compressions per minute. The technique and required depth of compressions depends upon patient age (see 'Chest compressions' above):

-Infants (<1 year) – For infants undergoing single-rescuer CPR, we suggest that compressions be performed using the two-fingers technique (figure 1) (Grade 2C) (see 'Two fingers' above). For infants undergoing two-rescuer CPR, we suggest that compressions be performed using the two-thumb encircling hands technique (figure 2) (Grade 2C) (see 'Two-thumb encircling hands' above). The required depth is approximately 4 cm (1.5 inches). If the rescuer is unable to achieve this depth with either of these techniques, it is reasonable to use the heel of one hand. (See 'Infants' above.)

-Children (≥1 year) – In children, perform chest compressions using either a one-hand or two-hand technique. The required depth is 5 cm (2 inches). (See 'Children' above.)

-Adolescents – In adolescents, perform chest compressions with two hands per adult recommendations. The required depth is 5 to 6 cm but should not exceed 6 cm (2.4 inches). (See "Adult basic life support (BLS) for health care providers", section on 'Chest compressions'.)

Chest compressions should be performed on a firm surface (eg, in health care facilities, use a backboard or activate "CPR mode" on the bed). The chest should fully recoil at the end of each compression. Interruptions in chest compressions should be minimal (less than 10 seconds). The use of CPR feedback devices (eg, metronome, visual feedback, and coaching) may help to optimize the rate of compressions.

●Airway - Open the airway with a head tilt-chin lift maneuver unless a cervical spine injury is suspected. In the setting of trauma in which cervical spine injury is suspected, use a jaw thrust maneuver without head tilt; however, if this action is unsuccessful, carefully use the head tilt-chin lift maneuver. (See "Basic airway management in children".)

●Breathing – Deliver each breath over one second with enough volume to see the chest wall rise. Avoid excessive ventilation. Bag-mask ventilation is often sufficient to achieve adequate ventilation during CPR. If adequate ventilation cannot be achieved with bag-mask ventilation or the resuscitation is prolonged, an advanced airway (endotracheal tube or supraglottic device) may be required. (See 'Breathing' above.)

•Compression-ventilation ratio: We suggest the following compression to ventilation ratios (Grade 2C) (see 'Compression to ventilation ratio' above):

-Single rescuer: 30 compressions followed by two breaths

-Two or more rescuers: 15 compressions followed by two breaths

-Advanced airway in place: 20 to 30 breaths per minute (one breath every two to three seconds) with a goal of 30 breaths per minute in infants and 20 to 25 breaths per minute in children without any interruption of chest compressions

•Rescue breathing in children without cardiac arrest – For infants and children who are not in cardiac arrest (ie, heart rate ≥60/minute) but who have absent or inadequate respiratory effort, rescue breaths should be provided at a rate of one breath every two to three seconds (20 to 30 breaths per minute). (See 'Breathing' above.)

●Defibrillation: All children in cardiac arrest require assessment for a shockable rhythm using an automated external defibrillator (AED) or, for advanced life support (ALS) providers, a manual defibrillator. When affixing the self-adhering pads, use either anterior-lateral placement or anterior-posterior placement to maintain good separation between the pads. Other important considerations include (see 'Automated external defibrillator' above):

•Witnessed arrest – For a witnessed arrest, the AED (or, for ALS providers, manual defibrillator) should be applied as soon as possible. Perform CPR until the AED (or manual defibrillator) is ready to deliver a shock; immediately start chest compressions after the shock is delivered.

•Unwitnessed arrest – For an unwitnessed arrest, we suggest performing CPR for approximately two minutes (five cycles for single rescuer and 10 cycles for two or more rescuers) before using an AED or manual defibrillator (Grade 2C).

•Age <8 years – For children <8 years of age, use an AED with a pediatric dose attenuating system, if available. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is not available, use of an AED without a dose attenuator is acceptable.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Pamela Bailey, MD, who contributed to earlier versions of this topic review.