If a baby or child is unresponsive with abnormal breathing (e.g., taking irregular or noisy breaths, or stopped breathing altogether) and has no signs of life, it indicates they are in cardiac arrest. When a baby or child is in cardiac arrest, their heart stops beating and cannot pump blood around their body. This means that vital organs, such as the brain, do not get enough oxygen and can start to deteriorate within minutes. While cardiac arrest occurs less frequently in babies and children compared to adults, it is still life-threatening. Typically, cardiac arrest in babies and children is the result of a breathing problem, whereas, in adults, it usually has to do with their heart suddenly stopping. The causes vary by age, setting and any underlying health problems of the baby or child; however, some common ones include choking, drowning and disease. Since the cause of cardiac arrest is likely to relate to their breathing, rescue breaths play a more critical role in CPR for babies or children. Survival to hospital discharge is primarily linked to the early initiation of CPR.
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NOTE
The techniques of CPR need to be adapted depending on the size of the unresponsive person and the size of the first aid provider. If the person looks like a baby (less than about one-year-old), treat them as a baby. If the person looks like they are a child, treat them as a child.
If the person looks like an adolescent, (they may have been through puberty) or an adult use the guidelines provided in Unresponsive and abnormal breathing (adolescent and adult).
It is most important to do something. In the case of someone needing CPR, it is unlikely a first aid provider can make the situation worse for the person.
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Guidelines
- First aid providers should use a response check and breathing check to ascertain whether a baby or child is unresponsive and breathing abnormally. Checking for a pulse is not needed. **
- CPR should be performed on a baby or child who is unresponsive with abnormal breathing (e.g. taking irregular or noisy breaths or have stopped breathing altogether). **
- Rescue breaths should be provided as part of CPR to a baby or child who is unresponsive with abnormal breathing. *
- Rescue breaths should be given to a baby or child before chest compressions. Two to five initial rescue breaths may be given. *
- For a baby, chest compressions can be performed with the two thumb-encircling hand method or with the two-finger In new-borns, the two thumb-encircling hand method is preferred. *
- For a child, chest compressions may be performed with one or two hands. (For example, if the first aid provider is small or the child is large the first aid provider may use two hands.) *
- A compression-to-rescue-breath ratio of 30:2 (30 compressions and 2 rescue breaths) may be used on a baby or child who is unresponsive with abnormal breathing. *
- For a baby, chest compression depth should be at least one-third of the chest’s depth or approximately 4 cm (1½ inches). *
- For a child, chest compression depth should be one-third of the depth of the chest or approximately 5 cm (2 inches). **
- The rate of chest compressions should be 100–120 per minute for babies and children (this is the same as for an adolescent or adult). **
- Chest compression may be performed on a firm surface when possible. *
- All emergency medical dispatchers should provide CPR instructions (referred to as dispatcher-assisted-CPR) to first aid providers who call regarding an unresponsive baby or child with abnormal breathing. **
Good practice points
- First aid providers who are unwilling, untrained or unable to perform rescue breaths for a baby or child should perform chest-compression-only CPR.
Chain of survival behaviours
Prevent and prepare
- Refer to your local or national health authority to identify the main causes of baby and child cardiac arrest in your region. Preventable and preparable causes include choking, drowning or disease.
- Follow recommended baby and child safety practices, such as supervision near water.
Early recognition
In the first few minutes after cardiac arrest, a baby or child may have agonal breathing (meaning they are barely breathing or gasping noisily and irregularly). This type of breathing is abnormal. If there is any doubt about whether breathing is normal, assume it is not.
Check for a response.
- Baby: Pick the baby up or tap on the sole of their foot. An unresponsive baby will be limp and abnormal colour.
- Child: Gently tap the child’s shoulders. Speaking loudly and clearly, ask a question such as, “Are you alright?”.
If the baby or child does not respond or not react:
- Open their airway: For a baby, tilt their head slightly to a neutral position and lift their chin. For a child, tilt their head back and lift their chin.
- Check for breathing: Look, listen and feel for normal breathing for up to ten seconds. Look for chest or abdominal movement; listen for breathing sounds; feel for breaths on your cheek. If you have any doubt whether breathing is normal, take action as though it is not.
First aid steps
If the baby or child’s breathing is abnormal (or they are not breathing):
1. Immediately ask a bystander to access EMS, or if you are alone, access EMS yourself. If using a phone, activate the speaker function.
2. Give two to five initial rescue breaths using a mouth-to-mouth-and-nose technique for a baby or a mouth-to-mouth technique for a child. Blow steadily for one second until you see their chest or abdomen rise.
3. Give 30 chest compressions without delay; push down on the centre of their chest at a fast and regular rate (100–120 compressions per minute).
4. Give two rescue breaths. Blow steadily into the mouth or mouth-and-nose for one second until you see the chest or abdomen rise.
5. Continue with cycles of 30 chest compressions and two rescue breaths until emergency help arrives or the baby or child shows signs of life (such as coughing, opening their eyes, speaking or moving purposefully) and starts to breathe normally.
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NOTE
- If an automated external defibrillator is available, ask a bystander to bring it as quickly as possible. Follow the voice prompts, interrupting CPR cycles as little as possible. (See Unresponsive and abnormal breathing when a defibrillator is available.)
- If you are unwilling or unable to give rescue breaths, give chest-compression-only CPR at a rate of 100–120 compressions per minute.
- If more than one first aid provider is present, change provider every one to two minutes to prevent fatigue. Ensure there is no interruption to CPR as the next person takes over.
- If you are alone and do not have a way to call EMS while performing CPR (e.g., no speakerphone), perform CPR for one minute before pausing to call for help.
- While performing rescue breaths, be alert to any signs of life such as movement or coughing.
- If the baby or child is unresponsive and breathing normally, maintain an open airway. See Unresponsive and breathing normally.
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Local adaptation
- In contexts that do not have an EMS or other higher level of care, if CPR has not been effective within the first 20 minutes, then (except in cases of drowning and hypothermia) the first aid provider could stop CPR as it is unlikely to be beneficial.
- If it is a child drowned or with hypothermia, there is a chance of saving them even with CPR alone.
- If transporting the baby or child from a remote area to medical care, continuous CPR on a firm surface must be provided during transit.
Access help
- When accessing EMS, very clearly explain that the baby or child is unresponsive and breathing abnormally; this will prompt EMS to prioritise your case appropriately.
- Ask bystanders for help accessing EMS and providing CPR, as well as bringing and using an automated external defibrillator.
- The survival of the baby or child depends upon immediate and effective CPR; when accessing help, keep any interruptions to chest compressions minimal.
Self-recovery
- Even if the first aid responder has performed CPR and defibrillation and the baby or child is now responsive and breathing normally, you must continue close monitoring until EMS attend to them as they may stop breathing again.
Education considerations
Context considerations
- Refer to and follow the guidance of regional resuscitation councils or other national protocols and tailor education accordingly.
- Consult local regulators to consider differences in regulation and liability protection for first aid providers.
- In some countries, specifically those with a high rate of tuberculosis, rescue breaths may be discouraged. Teach first aid providers chest compression-only CPR (or bag-valve-mask resuscitation if they are professional responders). See also Pandemic.
- In contexts where there is no EMS available or higher onward care, resuscitation for babies and children can still be attempted.
- Be familiar with local culture, resources and local expectations of healthcare ahead of developing an education programme and contextualise it accordingly (Anderson et al., 2018).
- Programme designers could define within programmes two or five initial rescue breaths to be given depending on what is most commonly advocated in the context.
Learner considerations
- CPR training is an important intervention that can promote a sense of control and reduce the feelings of anxiety and burden experienced by parents with a baby at risk of cardiac arrest (Moser et al., 1999).
- Be aware and respect that some learners may not be comfortable practising with realistic manikins for psychological or emotional reasons. Arrange alternative practice options.
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These considerations are specific to emergency medical dispatchers.
- Emergency medical dispatchers can provide a critical role through the prompt recognition of cardiac arrest, provision of CPR instructions by phone and dispatch of the EMS with a defibrillator. Consider as part of the education for this role:
> The use of scripted protocols as a helpful way to confirm when a baby or child is in cardiac arrest.
> Additional training around the recognition of agonal breathing.
> How to provide CPR instructions for a baby or child (including rescue breaths and compressions).
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Facilitation tips
- Focus on prevention is critical for the survival of babies and children.
- Emphasise the importance of the first aid provider, other bystanders and EMS working together to provide care quickly and effectively.
- Explore the mechanics of the tongue and airway for the breathing check. Allow learners to understand that when the muscles relax the tongue can block the airway, (so the baby or child cannot breathe). Tilting the head back for a child or into neutral position for baby pulls the tongue forward, opening their airway. Sometimes, simply opening the airway will enable the baby or child to breathe.
- Consider providing both the two-finger and two-thumb techniques when facilitating baby CPR. When in a stressful situation, learners may choose the one with which they are most comfortable (Pellegrino et al., 2017).
- If using manikins, ensure they are realistic in terms of size, weight and features so learners can get a sense of how to perform the skill correctly (Gesicki & Longmore, 2019).
- Help learners understand the desired outcomes of CPR – to get oxygen into the lungs (rescue breaths) and to pump blood around the body (chest compressions) and to keep the brain and vital organs functioning until defibrillation can take place.
- Emphasise that learners should avoid excessively providing rescue breaths as the air will enter the baby or child’s stomach.
- Emphasise that the goal of resuscitation remains the same for all ages, only the approach is modified. However, first aid providers who know how to perform adult CPR, but do not know baby or child CPR, may use the same sequence as adults.
- Highlight that the decision to start CPR should be immediate and without delay. Time is critical to a positive outcome. Emphasise that rapid and continuous compressions are also critical for a positive outcome.
- Learners can gain knowledge and some basic skills through self-directed learning which might save time for practice in face-to-face-sessions. (Weiner et al., 2010).
Facilitation tools
- When instructing learners on how to perform chest compressions and rescue breaths, refer to the resource Facilitating CPR skills (baby or child).
- Refer to the General approach for tools which can help learners to sequence and prioritise their actions. Mnemonics such as DR ABCD can be of help to some learners to establish a clear course of action.
- Sequence the learning to include discussions about possible scenarios, role play, demonstration, practice with a peer, and feedback. Involve learners in deciding on the scene and encourage discussions about how they might access help.
- Discuss with learners the emotions and motivations that they might feel when helping a baby or child who is unresponsive and breathing abnormally. Encourage learners to express their fears and doubts and to share experiences to build confidence to help.
- Use alternatives to resuscitation manikins when they are not available, such as teddy bears or cushions.
Learning connections
- In contexts where a defibrillator is likely to be available, pair this topic with Unresponsive and breathing abnormally when a defibrillator is available.
- Pair this topic with Choking or Drowning.
- Some learners learning this topic may benefit from learning about how to provide first aid for Acute grief or Traumatic event.
Scientific foundation
Pulse check
An update was performed in 2020 by the Pediatric life support task force of the International Liaison Committee on Resuscitation (ILCOR) (Maconochie et al., 2020). New studies about the accuracy of pulse check versus assessment of signs of life were insufficient to identify cardiac arrest, and it was decided to keep the 2010 treatment recommendation. Palpation of a pulse (or its absence) is not reliable as the sole determinant of cardiac arrest and need for chest compressions.
The 2010 ILCOR evidence summary on the pulse check versus no pulse check found that many studies observed that neither first aid providers nor healthcare professionals were able to perform an accurate pulse check in healthy babies or children within ten seconds. Two studies blinded healthcare providers and had them assess children with no pulsatile circulation. The providers commonly misjudged the pulse status, and their assessment for signs of life often took longer than ten seconds. The average time to confirm the absence of a pulse was 30 seconds (de Caen et al., 2010).
The sequence of chest compressions and rescue breaths
We used the Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations and an ILCOR evidence summary from 2017 for this topic (Maconochie et al., 2020; Maconochie et al., 2017). In 2015, the consensus on science indicated that in adults and children if we compare CPR beginning with compressions to CPR beginning with rescue breaths, the confidence in effect estimates were so low that it was too speculative to make a recommendation. In 2020, for the same comparison, no new human paediatric evidence was identified. So, the recommendations for sequencing of CPR steps for babies and children in cardiac arrest remain unchanged from those published in 2015.
Chest compression-only CPR versus standard CPR
We used two evidence summaries from ILCOR from 2015 and 2017 (Maconochie et al., 2015; Olasveengen., 2017). One systematic review of two extensive observational cohort studies compared chest compression-only CPR to standard CPR with a ratio of 30:2 or 30:2 and 15:2. The review found that significantly fewer people (ages one to 17) experienced favourable neurological outcomes and survived to the one month mark after receiving compression-only CPR. The result was also significant with fewer people achieving the favourable outcome of the return of spontaneous circulation in the same age group. In babies, there was no demonstrable difference in the outcomes between chest compression-only CPR or standard CPR.
Dispatch-assisted cardiopulmonary resuscitation
An ILCOR evidence summary and a systematic review, both from 2019, explored the impact of dispatcher-assisted-CPR on the survival and neurological outcomes in babies after they experienced out-of-hospital-cardiac-arrest (Koster et al., 2010; Nikolaou et al., 2019).
In babies and children, studies reported a significantly higher rate of CPR in the cohorts that offered dispatcher-assisted-CPR. They also associated an earlier time to CPR initiation with systems that provided dispatcher-assisted-CPR compared with those that provided CPR without dispatch assistance. There were significantly higher rates of favourable neurological outcomes at one month and survival to one month associated with those who received dispatcher-assisted-CPR compared with those who received unassisted CPR. The same results are found for favourable neurological outcomes at hospital discharge and survival to hospital discharge.
When comparing babies and children who received dispatcher-assisted-CPR and those who received unassisted-CPR, one study found that the assisted CPR group reported lower rates of favourable neurological outcomes and survival at one month. However, another study found no difference between the two. The reason seems to be because the start of CPR was longer in the dispatcher-assisted-CPR compared to the unassisted bystander CPR cohort.
Chest compression technique
For chest compression technique used on a child, baby and new-born we used ILCOR evidence summaries from 2010 (de Caen et al., 2010; Wyllie et al., 2010). Several studies on this topic are published after 2010, but, until a new systematic review is done, the Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations propose to apply the 2010 treatment recommendation.
In 2010, we did not find any outcome studies comparing one versus two-hand chest compressions for children in cardiac arrest. The only evidence was for healthcare providers and studies using manikin children. This evidence found that healthcare workers generate higher chest compression pressure when using the two-hand technique and first aid provider fatigue increased when using one-hand compressions.
In new-borns, small case series published before 2010 support the current favoured practice of the two-thumb-encircling hand technique for chest compressions compared to the two-finger technique. The two-thumb-encircling method produces higher blood pressure and can sustain a consistent quality of compressions for a longer time. It is also perceived as easier and less tiring for the provider. In babies and new-borns, providers should centre compressions over the lower third of the sternum rather than the mid-sternum.
Compression-to-rescue-breath ratio
Two ILCOR evidence summaries from 2010 on the optimal ratio for chest compressions and rescue breaths for babies and children formed the basis of this scientific foundation (de Caen et al., 2010; Wyllie et al., 2010).
Five studies using a variety of manikin sizes, compared compression-to-rescue-breath ratios of 15:2 with 30:2. The studies found that a ratio of 30:2 yielded more chest compressions with no, or minimal, increase in rescuer fatigue. Another study found that we have less “no flow time ” and more chest compressions per minute with a ratio of 30:2 compared to 15:2.
With insufficient human data to identify an optimal compression-to-rescue-breath ratio for CPR in babies and children and ease of teaching and retention, the same compression–rescue breath as for adult (30:2) is proposed.
Chest compression depth
The scientific foundation for this topic includes an evidence summary from 2015, a scoping review from 2020 and the Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (Considine et al., 2020; Maconochie et al., 2020). All references are from ILCOR and examine the chest compression depth in children.
One study reported a statistically significant relationship between compression depth and the outcomes of one-day survival and the return of spontaneous circulation. Results demonstrated that when 60% or more of chest compressions had an average depth of greater than or equal to 51 mm (compared to less than 60% at this average depth), both outcomes improved. The study found no difference in compression depth for the outcome of survival to hospital discharge. The studies referenced did not document an association between specific chest compression depths and the outcomes of survival to hospital discharge or survival at the one-month mark.
In children with out-of-hospital-cardiac-arrest, one study found no differences regarding the return of spontaneous circulation when comparing CPR with a chest compression depth of 38 mm or more to a chest compression depth less than 38 mm.
Compression rate
As the scientific foundation for this topic, one evidence summary from ILCOR in 2015 and a 2020 ILCOR scoping review was used on the chest compression rate in children (Maconochie et al., 2015; Considine et al., 2020).
There was an inconsistent association between chest compression rate and the outcome of survival with a favourable neurological outcome. One in-hospital cardiac arrest study reported a correlation between a chest compression rate greater than 100/min, in children, compared to a compression rate of 100-120/min. Rates of 120-140/min or greater than 140/min made no difference to survival with a favourable neurological outcome.
In children who experienced cardiac arrest out-of-hospital, a compression rate of 100-120/min, less than 100/min or more than 120/min made no difference to the outcome of survival at the 24-hour mark.
For the outcome of achieving the return of spontaneous circulation following out-of-hospital cardiac arrest, the following comparisons were also made with regards to chest compression rates used on children. A chest compression rate of 100-120/min, compared to rates of less than 100/min, 120-140/min or greater than 140/min, made no impactful difference. A chest compression rate of 100-120/min compared to rates of less than 100/min or greater than 120/min made no difference.
New data is unlikely to lead to a change in recommendations.
Chest compression recoil
There were no studies reporting outcomes for chest compression recoil in baby or child cardiac arrest.
Interactions between CPR parameters
One 2020 ILCOR scoping review formed the basis of the interactions between CPR parameters (Considine et al., 2020).
One study reported no significant relationship between chest compression rates and chest compression depths. Chest compressions depths greater than 51 mm versus less than 51 mm were not associated with the CPR rate in children.
References
Systematic reviews
Considine, J., Gazmuri, R. J., Perkins, G. D., Kudenchuk, P. J., Olasveengen, T. M., Vaillancourt, C., … & EscalanteKanashiro, R. (2020). Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review. Resuscitation, 146, 188-202
de Caen, A. R., Kleinman, M. E., Chameides, L., Atkins, D. L., Berg, R. A., Berg, M. D., … & Hazinski, M. F. (2010). Part 10: Paediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 81(1), e213-e259.
de Caen AR, Maconochie IK, Aickin R, Atkins DL, Biarent D, … Guerguerian A-M. (2015). Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support. Pediatrics. American Academy of Pediatrics, 2015 Nov 1;136 (Supplement 2): S88–S119.
Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, et al. (2010). Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. pp. e48–70.
Maconochie, I. K., Aickin, R., Hazinski, M. F., Atkins, D. L., Bingham, R., Couto, T. B., … & Ong, G. Y. (2020). Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation, 142(16_suppl_1), S140-S184.
Maconochie, I. A., Atkins, R., Bingham, D., Chong, B., & Couto, K. C. (2017). CPR: Chest compression to ventilation ratio-bystander-pediatric consensus on science and treatment recommendation [Internet]. Brussels. Belgium: International Liaison Committee on Resuscitation (ILCOR), Pediatric Life Support Task Force; 2017. June 30. Available from: http://www.ilcor.org
Maconochie, I. K., de Caen, A. R., Aickin, R., Atkins, D. L., Biarent, D., Guerguerian, A. M., … & Ng, K. C. (2015). Part 6: pediatric basic life support and pediatric advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 95, e147-e168.
Nikolaou, N., Dainty, K. N., Couper, K., Morley, P., Tijssen, J., Vaillancourt, C., … & Nishiyama, C. (2019). A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children. Resuscitation, 138, 82-105.
Olasveengen, T. M., de Caen, A. R., Mancini, M. E., Maconochie, I. K., Aickin, R., Atkins, D. L., et al. (2017). 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Circulation, 136(23), III–5–17.
http://doi.org/10.1161/CIR.0000000000000541
Wyllie, J., Perlman, J. M., Kattwinkel, J., Atkins, D. L., Chameides, L., Goldsmith, J. P., … & Simon, W. M. (2010). Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 81(1), e260-e287.
Non-systematic reviews
Meert, K. L., Telford, R., Holubkov, R., Slomine, B. S., Christensen, J. R., Dean, J. M., & Moler, F. W. (2016). Pediatric out-of-hospital cardiac arrest characteristics and their association with survival and neurobehavioral outcome. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 17(12), e543.
DOI: 10.1097/PCC.0000000000000969
Education references
Anderson, C. R., & Taira, B. R. (2018). The train-the-trainer model for the propagation of resuscitation knowledge in limited-resource settings: A systematic review. Resuscitation, 127, 1-7.
Gesicki, A., & Longmore, S. (2019). Time to Reconsider the Straddle-Arm Technique: Providing Care for the Conscious Infant who is Choking. International Journal of First Aid Education, 2(2), 67.
http://dx.doi.org/10.21038/ijfa.2019.0008. International Journal of First Aid Education, Vol. 2 Issue 2
Moser, D. K., Dracup, K., & Doering, L. V. (1999). Effect of cardiopulmonary resuscitation training for parents of high-risk neonates on perceived anxiety, control, and burden. Heart & lung, 28(5), 326-333.
https://doi.org/10.1053/hl.1999.v28.a101053
Pellegrino, J. L., Bogumil, D., Epstein, J. L., & Burke, R. V. (2019). Two-thumb-encircling advantageous for lay responder infant CPR: a randomised manikin study. Archives of disease in childhood, 104(6), 530-534.
DOI:10.1136/archdischild-2018-314893
Weiner, G. M., Menghini, K., Zaichkin, J., Caid, A. E., Jacoby, C. J., & Simon, W. M. (2011). Self-directed versus traditional classroom training for neonatal resuscitation. Pediatrics, 127(4), 713-719.
DOI: https://doi.org/10.1542/peds.2010-2829
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