Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Pediatric basic life support for healthcare providers

Authors Section Editor Deputy Editor

Pamela Bailey, MD Gary R Fleisher, MD James F Wiley, II, MD, MPH
Susan B Torrey, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2016. | This topic last updated: Jan 04, 2016.

INTRODUCTION Early recognition and treatment of sudden cardiac arrest improve survival for children
and adults [1-3]. Basic life support (BLS) involves a systematic approach to initial patient assessment,
activation of emergency medical services, and the initiation of cardiopulmonary resuscitation (CPR),
including defibrillation. Key components of effective CPR include adequate ventilation and chest
compressions.

BLS can be performed by trained laypersons, as well as by healthcare providers. This topic will review BLS
principles for healthcare providers. Basic airway management for children, neonatal resuscitation, and BLS
for adults is discussed separately. (See "Basic airway management in children" and "Neonatal resuscitation
in the delivery room" and "Basic life support (BLS) in adults".)

EPIDEMIOLOGY AND SURVIVAL Cardiopulmonary arrest among infants and children is typically
caused by progressive tissue hypoxia and acidosis as the result of respiratory failure and/or shock [4].
Causes of respiratory failure and shock leading to cardiopulmonary arrest in these age groups include
trauma, sudden infant death syndrome, respiratory distress, and sepsis [1,5-8]. This is in contrast to adults,
for whom the most common cause of cardiac arrest is ischemic cardiovascular disease. (See "Basic life
support (BLS) in adults", section on 'Epidemiology and survival'.)

Survival following pediatric cardiac arrest varies according to the site of arrest:

Out-of-hospital arrest Out-of-hospital pediatric arrests often occur at or near home and are
frequently unwitnessed [8,9]. Based upon observational studies, survival to discharge is approximately
3 to 4 percent for infants younger than one year of age [6,7], 9 to 11 percent for children 1 to 11 years
of age [8,10] and 9 to 16 percent for adolescents [8,10].

Increased survival occurs in pediatric patients who receive early cardiopulmonary resuscitation (CPR)
after a witnessed arrest and who have an initial cardiac arrest rhythm of ventricular fibrillation (VF) or
pulseless ventricular tachycardia (pVT) [1,10-12].

Sudden cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)
occurs in up to 18 percent of all pediatric prehospital cardiac arrests, but is less commonly the
presenting rhythm in younger children between the ages of one and eight years (8 percent) and infants
[11,13]. Predisposing conditions or causes of ventricular rhythms in pediatric patients with pulseless
arrest include hypertrophic cardiomyopathy, anomalous coronary artery (from the pulmonary artery),
long QT syndrome, myocarditis, drug intoxication (eg, tricyclic antidepressants, digoxin, cocaine), and
commotio cordis (ie, sharp blow to chest). (See appropriate topic reviews.)

In-hospital arrest Among children with in-hospital cardiopulmonary arrest, acute resuscitation
survival approaches 78 percent and survival to discharge occurs in 39 to 65 percent of patients who
receive CPR [14-16]. As an example, in one multicenter observational study of 1031 children with in-
hospital cardiopulmonary arrests occurring in academic pediatric hospitals over a 10-year period (2000
to 2009), adjusted survival to discharge increased from 14 to 43 percent while the rates of significant

 neurologic disability remained stable [15]. This improvement in survival occurred despite a high
prevalence of asystole and pulseless electrical activity (PEA) found as the initial arrest rhythm (up to
85 percent of patients) and was similar regardless of the initial cardiac arrest rhythm (ventricular
fibrillation, pulseless ventricular tachycardia, asystole or PEA) although improved adjusted survival was
seen in patients with an initial rhythm of pulseless VT or pulseless electrical activity when compared to
asystole (risk ratio [RR] 1.6 and 1.2, respectively) [15]. The use of extracorporeal membrane
oxygenation during resuscitation and postresuscitation care (ECPR) significantly increased from 8 to
14 percent of patients during the study but was not associated with overall survival to discharge.

Thus, rates of survival from cardiopulmonary arrest are higher for in-hospital pediatric cardiopulmonary
arrests than for out-of-hospital arrests and improved survival among children with in-hospital arrests cannot
be attributed to differences in initial cardiac arrest rhythm or ability to perform ECPR.

By contrast, if promptly treated, children with a respiratory arrest are much more likely to recover than those
with a cardiopulmonary arrest [1,17]. As an example, in an observational study of 95 children with out-of-
hospital arrest, 82 percent of children with respiratory arrest were alive at one year compared with 14
percent of patients with a cardiopulmonary arrest [1]. Thus, the best outcomes in critically ill children occur if
cardiac arrest is avoided altogether.

INTERNATIONAL RESUSCITATION GUIDELINES Based upon extensive review of clinical and

laboratory evidence, the American Heart Association (AHA) and the International Liaison Committee on
Resuscitation (ILCOR) published updated guidelines for pediatric basic life support (BLS) in 2015 [18,19].
For the purposes of these guidelines, a newborn is defined as from birth to hospital discharge, an infant is
younger than one year of age, and a child is from one year to the start of puberty (axillary hair in males and
breast development in females).

The approved international BLS algorithms are available here (single rescuer) and here (two or more
rescuers).

The 2015 guidelines reaffirm that the circulation-airway-breathing (C-A-B) sequence is still preferred for
pediatric cardiopulmonary resuscitation (CPR) and that conventional CPR has better outcomes in children
and is strongly preferred to compression-only CPR [18,19].

The sequence for neonatal resuscitation is described separately. (See "Neonatal resuscitation in the
delivery room", section on 'Overview of resuscitative steps'.)

However, not all individual councils have adopted the 2015 pediatric basic life support updates. As an
example, for a single healthcare professional rescuer, ABC starting with the five stair step breaths and a
15:2 compression to breath ratio are still advocated by the Resuscitation Council of the United Kingdom
instead of C-A-B [20].

BASIC LIFE SUPPORT ALGORITHMS The recommended approach for basic life support (BLS) for one
or two healthcare providers is provided in the algorithms available here (single rescuer) and here (two or
more rescuers) [18,19].

The key actions are as follows [18,19]:

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

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

If the patient is responsive, the healthcare provider should determine additional medical needs and
need for activation of the emergency medical response system based upon the patient's condition.

Assess breathing and pulse The provider should determine if the patient is breathing or only
gasping while simultaneously checking for a pulse.

This assessment guides further actions as follows:

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

- Single rescuer If this is not a witnessed sudden collapse then the provider should start
cardiopulmonary resuscitation (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.)

If this is a witnessed sudden collapse, then the provider should activate EMS (if not already
done) and retrieve an AED or, for advanced life support providers, defibrillator. The single
rescuer should then use the AED or, for advanced life support providers, defibrillator as
soon as it is available.

- Two or more rescuers The providers should start CPR (compressions-airway-breathing,

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 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.)

Substantial evidence indicates that healthcare providers are often unable to quickly determine
whether or not a pulse is present [21]. 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 1 breath every 3 to 5 seconds (12 to 20 breaths/min).

- Add compressions if pulse remains 60/min with poor perfusion.
- Activate EMS, if not already done.
- Continue rescue breathing. Check pulse every 2 minutes. If no pulse, start CPR
(compressions-airway-breathing, 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 emergency responders arrive.

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

The sequence in which the actions of CPR for infants and children should be performed by healthcare
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 compressions BEFORE performing airway or breathing maneuvers (C-A-B).

After 30 compressions (15 compressions if two rescuers), open the airway and give 2 breaths.
(See 'Ventilation' below.)

If the pulse is 60 beats per minute (bpm) after about 2 minutes of CPR, continue ventilation.

Apply the AED or defibrillator according to the algorithms:

- Single rescuer For a witnessed collapse, retrieve the AED or, for advanced life support
providers, the defibrillator and use it as soon as possible. For an unwitnessed collapse,
perform about 2 minutes of CPR and then activate EMS (if not already done) and retrieve
the AED or, for advanced life support providers, the defibrillator.

- Two or more rescuers One rescuer initiates CPR while the other rescuer activates EMS
and retrieves the AED or, for advanced life support providers, the defibrillator. The AED or
defibrillator is then used as soon as it is available. (See "Defibrillation and cardioversion in
children (including automated external defibrillation)", section on 'Procedure' and
"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 1 shock and resume CPR immediately for about 2 minutes or
until prompted by the AED. Continue until advanced life support providers take over or the
victim starts to move.

- No shockable rhythm Resume CPR immediately for about 2 minutes or until prompted
by the AED. Continue until advanced life support providers take over or the victim starts to
move.

High-quality CPR focuses on the effective delivery of chest compressions with limited interruptions and
avoidance of excessive ventilation. (See 'Chest compressions' below.)

The algorithms for a single and two or more rescuers are designed so that CPR is performed for
approximately 2 minutes (five cycles) 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 "Basic
life support (BLS) in adults", section on 'Phases of resuscitation'.)

CHEST COMPRESSIONS The 2015 international resuscitation guidelines continue to emphasize the
importance of proper technique when performing chest compression, with full chest recoil and minimal
interruptions [18,19]. Evidence in adults and animals suggest that these are the essential elements for
effective chest compressions [22-24].

Chest compressions should be performed over the lower half of the sternum [18,19,25]. Compression of the
xiphoid process can cause trauma to the liver, spleen, or stomach, and must be avoided. The effectiveness
of compressions can be maximized by attention to the following:

The chest should be depressed at least one-third of its anterior-posterior diameter with each
compression (approximately 4 cm [1.5 inches] in most infants and 5 cm [2 inches] in most children).
Compressions in adolescents should attain the recommended adult depth of 5 to 6 cm, but should not
exceed 6 cm (2.4 inches).

The optimum rate of compressions is approximately 100 to 120 per minute. Each compression and
decompression phase should be of equal duration.

The use of a metronome is associated with a higher achievement of the optimal rate of compressions.
As an example, in a crossover trial of 155 medical personnel (medical students, pediatric residents and
fellows, and pediatric nurses) who performed compressions on a pediatric manikin with or without a
metronome, compressions occurred at the recommended rate significantly more often when a
metronome was used (72 versus 50 percent) [26]. In this study, rescuers tended to perform
compressions too fast when they did not use a metronome.

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

A smooth compression-decompression rhythm, with minimal interruption, should be developed.

Infants Chest compressions for infants (younger than one year) may be performed with either two fingers
or with the two thumb-encircling hands technique as described below. No outcome studies have compared
these two techniques in children with cardiac arrest [17-19,22,23].

Two fingers This technique is recommended by the American Heart Association (AHA) when there is
a single rescuer [17-19,27]. 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 [28].

Rescuer fatigue has been raised as a concern with this method and data are conflicting. In one randomized
study of cardiopulmonary resuscitation (CPR) on infant manikins by 16 experienced pediatric healthcare
providers, rescuer fatigue did not significantly differ between the two finger and thumb encirclement
techniques [29]. However, in a randomized crossover study of 20 healthcare providers that compared the
two fingers versus the two thumb technique, the two thumb technique was associated with better
compression depth, rate, and consistency than the two finger technique [30]. Providers also reported that
the two thumb technique was less tiring and that performing compressions on a table rather than on the
floor or in a radiant warmer was most comfortable. On the other hand, providers noted that the two finger
technique permitted easier transition from compressions to ventilation and allowed the provider to maintain
the head tilt during compressions which prevented the need for repositioning for ventilation when performing
one-person infant CPR.
 Two thumb-encircling hands The two thumb-encircling hands technique is suggested when there
are two rescuers [17-19]. The thorax is encircled with both hands and cardiac compressions are performed
with the thumbs (figure 2). The thumbs compress over the lower half of the sternum, avoiding the xiphoid
process, while the fingers are spread around the thorax.

The following evidence supports the recommendation of the two thumb-encircling hands technique:

In a pediatric animal model, arterial and coronary perfusion pressures were improved with
circumferential compression [31].

In a similar study using an infant mannequin, the two-thumb method provided higher blood and
perfusion pressures than the two-finger method [32].

A randomized trial compared the adequacy of compressions performed on an infant mannequin by

healthcare providers using either the two-thumb or two-finger method [33]. Although 71 percent of
participants failed to give a sufficient number of adequate compressions by either method, the depth of
compression was significantly better using the two-thumb method.

Children For children (from one year until the start of puberty), 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 [18,19,21].
Evidence to support using two hands to perform chest compressions for children is limited. In a small
randomized trial that compared the pressure generated by one and two handed compressions on a pediatric
mannequin, significantly higher pressures were generated using two hands [34]. The two-hand method for
CPR has not been associated with increased rescuer fatigue versus the one-hand method in randomized
studies that used manikins [29,35]. However, the rate of compression slowed significantly more among
emergency department staff who used the one-hand method versus the two-hand method (decrease of 7
versus 3 compressions per minute during 1 minute, respectively) [35].

COMPRESSION TO VENTILATION RATIO 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 [17-19,21,27,36]. However, every effort should be made to avoid excessive ventilation and to
limit interruptions of chest compressions to less than 10 seconds.

For lone rescuers, two ventilations should be delivered during a short pause at the end of every 30th
compression. For two rescuers, two ventilations should be delivered at the end of every 15th compression.

Once the trachea is intubated, ventilation and compression can be performed independently. For infants and
children, ventilations are given at a rate of 8 to 10 per minute. Compressions are delivered at a rate of 100
to 120 per minute without pauses.

Experimental evidence in animals indicates that coronary artery perfusion pressure declines with
interruptions in chest compressions [23,24]. Observational reports suggest that long interruptions in
cardiopulmonary resuscitation (CPR) occur commonly [37,38]. Compression to ventilation ratios of 30 to 2
and 15 to 2 are recommended to minimize interruption and for ease of teaching and retention [21,36].

Coordination of compression and ventilation may be facilitated by counting compressions aloud or using an
audio-prompted rate guide [39].

The compression to ventilation ratio for newborns is discussed separately. (See "Neonatal resuscitation in
the delivery room", section on 'Chest compressions'.)
Conventional versus compression-only CPR We recommend that rescuers provide conventional CPR
to infants and children with cardiac arrest, regardless of whether the arrest occurs within or outside of the
hospital [18,19,21,36].

Although compression-only CPR (CO-CPR) for bystanders is suggested in limited situations in adults with
cardiac arrest (see "Basic life support (BLS) in adults", section on 'Compression-only CPR (CO-CPR)'),
conventional CPR is recommended in infants and children because cardiac arrest in this population is more
commonly due to hypoxia when compared with adults [17,21,36]. (See 'Epidemiology and survival' above.)

One nationwide, observational study of 5158 children 17 years of age, who had an out-of-hospital arrest,
found that, among the children who suffered arrests from noncardiac causes, those who received
conventional CPR were significantly more likely to have favorable neurologic outcomes at one month than
those who received COO-CPR (7.2 versus 1.6 percent, odds ratio [OR] 5.5; 95% CI 2.5-17.0) [40].
Neurologic outcomes were similar between conventional CPR and CO-CPR for children who suffered
arrests from cardiac etiologies (10 versus 9 percent, OR 1.2; 95% CI 0.6-2.7). Favorable neurologic
outcome was more common in patients who received bystander CPR compared with no CPR (5.1 versus
1.5 percent, OR 4.17, 95% CI: 2.4-7.3). Infants had poor outcomes regardless of the type of CPR received.
Another observational study of 759 children sampled from the same national database also showed
significantly improved survival and neurologically favorable survival at one month in children who received
conventional CPR [41].

Since the cause of an arrest is not typically known in the out of hospital setting and the majority of pediatric
arrests are due to noncardiac causes, the available evidence supports conventional CPR as the method that
is associated with the best neurologic outcome in infants and children.

VENTILATION 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 'Ventilation'.)

Evidence in adults and animals suggest that hyperventilation is associated with increased intrathoracic
pressure and decreased coronary and cerebral perfusion (see "Basic life support (BLS) in adults", section
on 'Ventilations'). These data are the basis for the following recommendations [17,42]:

Each rescue breath should be delivered over 1 second.

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

A child with a pulse 60 bpm who is not breathing should receive 1 breath every 3 to 5 seconds (12 to
20 breaths per minute).

Infants and children who require chest compressions should receive 2 breaths per 30 chest
compressions for a lone rescuer and 2 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 8 to 10 breaths per minute without any
interruption of chest compressions. (See 'Compression to ventilation ratio' above.)

AUTOMATED EXTERNAL DEFIBRILLATOR The 2015 international resuscitation guidelines

recommend that, if a manual defibrillator is not available, an automated external defibrillator (AED) be used
as soon as possible for infants and children who experience a witnessed cardiac arrest [17-19,21,27,36].
For patients with an unwitnessed arrest, the algorithms for a single and two or more rescuers are designed
so that cardiopulmonary resuscitation (CPR) is performed for approximately 2 minutes (five cycles) before
using an AED. (See 'Basic life support algorithms' above.)
For infants and children <8 years of age, an AED with a pediatric dose attenuating system should be used
whenever possible. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is
not available, then use of an AED without a dose attenuator is advised [17,27]. (See "Defibrillation and
cardioversion in children (including automated external defibrillation)", section on 'Automated external
defibrillator use in infants and children'.)

AEDs are portable devices that have been used extensively to provide prompt defibrillation to adults in
cardiac arrest. They are designed to be used by untrained bystanders and are increasingly available in
public locations such as airports, athletic events, and the workplace. The device identifies 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. (See "Automated external defibrillators".)

In observational series, 6 to 19 percent of infants and children in cardiac arrest had ventricular fibrillation
(VF) as the initial rhythm, indicating that a substantial number of children in cardiac arrest might benefit from
early defibrillation [1,6,7,13,43]. Limited evidence suggests that AEDs can be appropriately and safely used
for infants and children [44-49]. 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 [50].

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 5th to 6th
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 10th to 12th 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 information: CPR for children (The Basics)")

SUMMARY AND RECOMMENDATIONS

Cardiopulmonary arrest among children is typically caused by progressive tissue hypoxia and acidosis
as the result of respiratory failure and/or shock. Survival rates for children with cardiac arrest depend
upon setting (outpatient versus inpatient arrest) and are improved by prompt initiation of
cardiopulmonary resuscitation (CPR). (See 'Epidemiology and survival' above.)

The American Heart Association (AHA) and the International Liaison Committee on Resuscitation
(ILCOR) published updated guidelines for basic life support (BLS) and advanced cardiac life support
(ACLS) in late 2015 (2010 guidelines). The most important elements of the BLS guidelines are
included in the summary below. We suggest the practices described in the 2015 guidelines and
summarized below be followed when providing BLS to patients (Grade 2C). Among the specific
elements of the BLS guidelines, we recommend that infants and children with cardiac arrest receive
conventional CPR rather than compression-only CPR (Grade 1B). (See 'Conventional versus
compression-only CPR' above.)

The approved international basic life support algorithms are available here (single rescuer) and here
(two or more rescuers). (See 'Basic life support algorithms' above.)
 CPR should be started in patients with no or abnormal breathing and no definite pulse after 10
seconds. Key components of CPR include:

Chest compressions should be initiated BEFORE ventilation in infants and children with cardiac
arrest. (See 'Basic life support algorithms' above.)

Each chest compression should depress the chest by a minimum of one-third of its anterior-
posterior diameter, at a rate of about 100 compressions per minute. 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 a metronome may help to optimize the rate of compressions. (See
'Chest compressions' above.)

Ventilations should be delivered over 1 second with enough volume to see the chest wall rise.
Excessive ventilation should be avoided. (See 'Ventilation' above.)

The compression to ventilation ratio varies depending on the circumstance (see 'Compression to
ventilation ratio' above):

- 30 compressions followed by 2 breaths for a lone rescuer

- 15 compressions followed by 2 breaths for two rescuers resuscitating an infant (<1 year of
age) or child (1 year to start of puberty)

- Intubated infants and children should be ventilated at a rate of 8 to 10 breaths per minute
without any interruption of chest compressions

If a manual defibrillator for use by an advanced life support provider is not available, an automated
defibrillator (AED) should be used as soon as possible for all infants and children with a witnessed
arrest. The algorithms for a single and two or more rescuers are designed so that CPR is performed for
approximately 2 minutes (five cycles) before using an AED in a patient with an unwitnessed arrest.
(See 'Automated external defibrillator' above.)

Recommendations for the resuscitation of newborns are reviewed separately. (See "Neonatal
resuscitation in the delivery room".)

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Topic 6384 Version 20.0

GRAPHICS

Chest compression for infant resuscitation: Two

finger technique

Chest compressions for infants (under one year) may be performed with
two fingers placed on the sternum just below the nipples. This picture
shows the site of compressions. When compressions are performed the
two fingers used should be perpendicular to the chest and straight.

Graphic 73038 Version 5.0

Chest compression for infant resuscitation: Two
thumb technique

The thorax is encircled with the hands and cardiac compressions are
performed with both thumbs. The compression site is approximately one
finger's breadth below the intermammary line. The area over the
xiphoid process should be avoided to prevent injury to the liver, spleen,
or stomach.

Graphic 77050 Version 2.0

One-handed chest compressions

For children (from one year until the start of puberty), chest
compressions may be performed with the heel of one hand placed over
the lower half of the sternum.

Graphic 62171 Version 2.0

 Two-handed chest compressions

For children (from one year until the start of puberty), chest
compressions may be performed with two hands placed over the lower
half of the sternum.

Graphic 59710 Version 2.0

Contributor Disclosures
Pamela Bailey, MD Nothing to disclose. Susan B Torrey, MD Nothing to disclose. Gary R Fleisher, MD
Nothing to disclose. James F Wiley, II, MD, MPH Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
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