Cardiopulmonary Resuscitation (CPR) in Infants and Children

Bradycardia in a distressed child is a sign of impending cardiac arrest. Neonates, infants, and young children are more likely to develop bradycardia caused by hypoxemia, whereas older children initially tend to have tachycardia. An infant or child with a heart rate < 60/minute and signs of poor perfusion that do not rise with ventilatory support should have cardiac compressions (see figure Chest Compression in Infants and Children). Bradycardia secondary to heart block is unusual.

During chest compressions in infants and children (below the age of puberty or < 55 kg), the chest should be depressed one-third of the anteroposterior diameter. This is approximately 4 to 5 cm. In adolescents or children > 55 kg, the recommended compression depth is the same as in adults, ie, 5 to 6 cm (see also chest compressions in adults).

The method of chest compression is also different in infants and children (see figure Chest Compression in Infants and Children). The rate of compression in infants and children is similar to that of adults at 100 to 120 compressions/minute.

Chest Compression in Infants and Children

A: When 2 rescuers are present, side-by-side thumb placement for chest compressions is preferred for neonates and small infants whose chest can be encircled. Thumbs should overlap if used in very small neonates. B: Lone rescuers can use 2 fingers for infant compressions. Fingers should be maintained in the upright position during compression. For neonates, this technique results in too low a position, ie, at or below the xiphoid; the correct position is just below the nipple line. C: Hand position for chest compression for a child. (Adapted from American Heart Association: Standards and guidelines for CPR. Journal of the American Medical Association 268:2251–2281,1992. Copyright 1992, American Medical Association.)

First-line medications1).

For shockable rhythms (ventricular fibrillation [VF] or pulseless ventricular tachycardiaventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). If amiodaroneamiodarone nor lidocaine have been shown to improve survival to hospital discharge.

Blood pressure (BP) should be measured with an appropriate-sized cuff, but direct invasive arterial BP monitoring is mandatory in severely compromised children.

Because BP varies with age, an easy guideline to remember the lower limits of normal for systolic BP (< fifth percentile) by age is as follows:

• < 1 month: 60 mm Hg

• 1 month to 1 year: 70 mm Hg

• > 1 year: 70 + (2 × age in year)

Thus, in a 5-year-old child, hypotension would be defined by a BP of < 80 mm Hg (70 + [2 × 5]). Of significant importance is that children maintain BP longer because of stronger compensatory mechanisms (increased heart rate, increased systemic vascular resistance). Once hypotension occurs, cardiorespiratory arrest may rapidly follow. All effort should be made to start treatment when compensatory signs of shock (eg, increased heart rate, cool extremities, capillary refill > 2 seconds, poor peripheral pulses) are present but before hypotension develops.

Equipment size, medication dosage, and CPR parameters vary with patient age and weight (see tables CPR Techniques for Health Care Professionals, Medications Commonly Used for Resuscitation, and Guide to Pediatric Resuscitation). Size-variable equipment includes defibrillator paddles or electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal tubes, and suction catheters.

Weight should be measured rather than guessed; alternatively, commercially available measuring tapes that are calibrated to read standard patient weight based on body length can be used. Some tapes are printed with the recommended medication dose and equipment size for each weight. Dosages should be rounded down; eg, a 2 ½-year-old child should receive the dose for a 2-year-old child.

Susceptibility to heat loss is greater in infants and children because of a large surface area relative to body mass and less subcutaneous tissue. A neutral external thermal environment (maintaining the infant's body temperature and a stable metabolic state with minimal oxygen and energy use) is crucial during CPR and postresuscitation. Hypothermia with core temperature < 35° C makes resuscitation more difficult.

For comatose children resuscitated from in-hospital and out-of-hospital cardiac arrest, American Heart Association and American Association of Pediatrics guidelines advise therapeutic hypothermia (32 to 36° C) or normothermia (36 to 37.5° C—2, 3 ). Fever should be treated aggressively.

Upper airway anatomy in children differs from that of adults. The head is large with a small face, mandible, and external nares, and the neck is relatively short. The tongue is large relative to the mouth, and the larynx lies higher in the neck and is angled more anteriorly. The epiglottis is long, and the narrowest portion of the trachea is inferior to the vocal cords at the cricoid ring, allowing the use of uncuffed endotracheal tubes. In younger children, a straight laryngoscope blade generally allows better visualization of the vocal cords than a curved blade because the larynx is more anterior and the epiglottis is more floppy and redundant. Available evidence does not support improved patient outcomes in infants and children who have out-of-hospital cardiac arrest with the use of advanced airway interventions as compared to bag-valve-mask ventilation (4).

If only a single rescuer is present and if there is no advanced airway in place in infants and children undergoing resuscitation, the recommended compression:ventilation ratio is 30:2 ; if more than one rescuer is present, the ratio is 15:2. This recommendation is in contrast to that for adults where the compression:ventilation ratio is always 30:2 and is independent of the number of rescuers.

With an advanced airway in place, the 2020 International Liaison Committee on Resuscitation (ILCOR) guidelines for pediatric cardiac arrest resuscitation advise a ventilation rate of 20 to 30 breaths per minute (with the faster rate in infants) (3). However, this revised recommendation is based on a study of hospitalized patients and remains controversial in prehospital care (5). Many researchers of pediatric prehospital care continue to advise a ventilation rate of 10-breaths per minute.

Clinical Calculators

Endotracheal tube size for children (Age 1 to 8 years)

Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) occur in approximately 15 to 20% of pediatric cardiac arrests (6see defibrillation in adults). The maximum recommended dose is 10 joules/kg or the maximum adult dose (200 joules for a biphasic defibrillator and 360 joules for a monophasic defibrillator).

Automated external defibrillators (AEDs) with adult cables may be used for children, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for pediatric patients up to 8 years of age. Current guidelines recommend manual defibrillation if possible for pediatric patients, but an AED (with or without pediatric cables) can be used if a manual defibrillator is not immediately available (3). For pad placement, see defibrillation in adults.

1. 1. Topjian AA, Raymond TT, Atkins D, et al: Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 142(16_suppl_2):S469–S523, 2020. doi:10.1161/CIR.0000000000000901

2. 2. Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW; International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force: Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 167:160–172, 2021. doi:10.1016/j.resuscitation.2021.08.040

3. 3. Maconochie IK, Aickin R, Hazinski MF, et al: Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 156:A120–A155, 2020. doi:10.1016/j.resuscitation.2020.09.013

4. 4. Jarvis JL, Panchal AR, Lyng JW, et al: Evidence-Based Guideline for Prehospital Airway Management. Prehosp Emerg Care 28(4):545–557, 2024. doi:10.1080/10903127.2023.2281363

5. 5. Sutton RM, Reeder RW, Landis WP, et al: Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med 47(11):1627–1636, 2019. doi:10.1097/CCM.0000000000003898

6. 6. López-Herce J, García C, Domínguez P, et al: Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation 63(3):311–320, 2004. doi:10.1016/j.resuscitation.2004.06.008