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Pediatric basic life support

Pediatric basic life support (PBLS) is the essential set of non-invasive emergency procedures aimed at recognizing and treating cardiac arrest, respiratory failure, and foreign-body airway obstruction in infants and children, with the primary goal of restoring effective oxygenation, circulation, and ventilation to prevent irreversible organ damage.^[1] These interventions form the foundation of the pediatric chain of survival, emphasizing immediate action by lay rescuers or healthcare providers in community, prehospital, or hospital settings to improve outcomes in out-of-hospital and in-hospital cardiac arrests. In the United States, over 20,000 pediatric in-hospital cardiac arrests occur annually, with out-of-hospital survival rates of approximately 6.6% for infants and 14.7% for children.^[1] PBLS guidelines, co-developed by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP), were updated in 2025 based on systematic reviews of resuscitation science from the International Liaison Committee on Resuscitation (ILCOR).^[1] PBLS applies specifically to infants (younger than 1 year of age, excluding newborns) and children (from 1 year to puberty, typically marked by breast development in females or axillary hair in males), with adult protocols used for pubertal adolescents and beyond.^[1] Unlike adult cardiac arrests, which often stem from primary cardiac issues, pediatric arrests are predominantly due to hypoxia or asphyxia from respiratory causes, underscoring the importance of early recognition of abnormal breathing (such as gasping or agonal gasps) and unresponsiveness.^[1] Key steps include immediate activation of emergency medical services, confirmation of absent or ineffective breathing and pulse (if trained), and prompt initiation of high-quality CPR consisting of chest compressions integrated with ventilations at age-appropriate ratios.^[1] The 2025 guidelines introduced refinements, including preferred compression techniques for infants (one-hand or two-thumb encircling hands methods) and reinforcement of a unified chain of survival integrating prevention, education, and recovery to address disparities in pediatric resuscitation outcomes.^[2]

Introduction

Definition and Scope

Pediatric basic life support (PBLS) is defined as the foundational set of interventions aimed at recognizing pediatric cardiac arrest and providing immediate, high-quality chest compressions combined with basic airway management and ventilation support, without the use of advanced medical equipment or interventions.^[1] This approach targets infants younger than 1 year and children from 1 year to the onset of puberty, excluding newborns, and emphasizes rapid response to unresponsiveness and absent or abnormal breathing, such as gasping, to initiate care.^[1] The scope of PBLS is primarily intended for use by lay rescuers and healthcare providers in out-of-hospital settings, though it also applies in-hospital when advanced resources are unavailable or during initial response phases.^[1] It deliberately excludes advanced life support measures, such as administration of medications or invasive airway procedures, focusing instead on manual techniques including automated external defibrillator (AED) use to maintain circulation and oxygenation until professional help arrives.^[1] In pediatric cases, PBLS addresses the predominance of asphyxial arrests, where the initial rhythms are typically nonshockable, such as asystole or pulseless electrical activity (PEA), which account for approximately 82-85% of incidents, in contrast to the rarer shockable rhythms like ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).^[3]^[4] Central to PBLS is the pediatric chain of survival, a conceptual framework that outlines coordinated steps to improve outcomes: prevention and preparedness to mitigate risks; early recognition and activation of emergency response; high-quality CPR with early defibrillation for applicable shockable rhythms; advanced resuscitation and post-cardiac arrest care; and recovery support for survivors.^[1]^[5] This chain underscores the critical role of immediate bystander action in pediatric arrests, where delays significantly worsen prognosis due to the underlying respiratory etiology in most cases.^[1]

Importance and Epidemiology

Pediatric cardiac arrest remains a leading cause of mortality in children, with an estimated 27,000 cases occurring annually in the United States, including more than 7,000 out-of-hospital cardiac arrests (OHCA) and approximately 20,000 in-hospital cardiac arrests (IHCA).^[1] Unlike adults, where cardiac etiologies predominate due to ischemic events, pediatric arrests are primarily driven by respiratory failure in 70% to 80% of cases, often progressing to non-shockable rhythms such as asystole or pulseless electrical activity (PEA).^[6] This distinction underscores the critical role of basic life support (BLS) in addressing reversible airway and breathing compromises to prevent progression to full arrest.^[1] The most common precipitants of pediatric cardiac arrest include airway obstruction from choking or foreign body aspiration, trauma, drowning, and sudden infant death syndrome (SIDS), which collectively account for a significant proportion of events, particularly in younger children.^[6] These causes highlight the preventable nature of many incidents, with early bystander intervention serving as a key modifiable factor; prompt recognition and BLS by laypersons can substantially mitigate outcomes by stabilizing oxygenation and circulation before professional help arrives.^[1] Survival rates for pediatric OHCA are low overall, ranging from 6.6% in infants to 17.3% in adolescents, but bystander cardiopulmonary resuscitation (CPR) increases these to approximately 9% compared to less than 5% without it, while also enhancing neurologically intact survival by 2 to 3 times.^[1] For IHCA, survival to hospital discharge has improved to around 40% to 44% as of 2022 with prompt BLS, reflecting advances in hospital-based response systems.^[1] These disparities emphasize BLS as a foundational intervention, particularly since most pediatric arrests involve non-shockable rhythms amenable to high-quality compressions and ventilations.^[7] The 2025 International Liaison Committee on Resuscitation (ILCOR) updates reinforce the urgency of immediate BLS, with evidence indicating that early CPR improves survival odds in pediatric cardiac arrest, based on systematic reviews of resuscitation science.^[7] This guidance prioritizes both compression-first (CAB) and ventilation-first (ABC) approaches, with a strong emphasis on bystander involvement to bridge the gap until emergency medical services arrive.^[7]

Guidelines and Standards

International Consensus

The International Liaison Committee on Resuscitation (ILCOR) serves as the global authority coordinating evidence-based reviews for resuscitation guidelines, including pediatric basic life support (BLS), through its Consensus on Science with Treatment Recommendations (CoSTR). Established to harmonize international efforts, ILCOR convenes experts from major organizations to conduct systematic reviews and scoping reviews, culminating in the 2025 CoSTR for pediatric life support, which emphasizes updated evidence from clinical trials and observational data to inform worldwide standards. Central to the 2025 consensus is the adoption of the compressions-airway-breathing (CAB) sequence for initiating BLS across all pediatric ages, prioritizing immediate chest compressions to improve survival outcomes by reducing delays in circulation support. High-quality cardiopulmonary resuscitation (CPR) remains a cornerstone, with recommendations for a compression rate of 100-120 per minute and depth of approximately one-third the anteroposterior chest diameter to ensure effective perfusion without causing injury. These parameters are derived from systematic reviews assessing CPR mechanics and hemodynamic effects, maintaining consistency with prior guidelines to facilitate training and implementation.^[1] For shockable rhythms such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), the consensus upholds the single-shock strategy followed immediately by CPR, unchanged from the 2020 recommendations due to insufficient new evidence from systematic reviews to alter the approach, which aims to minimize rhythm analysis time and preserve coronary perfusion. Evidence levels for these elements are generally low to moderate certainty, based on observational studies and expert consensus, highlighting the need for ongoing research. Globally, ILCOR's unified core principles, including limiting CPR interruptions to less than 10 seconds, allow for local adaptations by national bodies while ensuring foundational consistency in pediatric BLS delivery.^[7]^[1]

Key Organizations and Updates

The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) jointly developed the 2025 guidelines for Pediatric Basic Life Support, detailed in Part 6 of the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.^[1] These guidelines emphasize dispatcher-assisted CPR as a critical intervention for out-of-hospital cardiac arrest in children, noting its role in improving survival outcomes through guided compressions and breaths.^[1] Regarding persistent bradycardia, the guidelines reinforce the unchanged recommendation for timely epinephrine administration after initial ventilation and CPR efforts, with evidence supporting earlier use to enhance response rates.^[1] The European Resuscitation Council (ERC) published its 2025 Guidelines for Paediatric Life Support, which integrate the Chain of Survival framework applicable to all ages from birth to 18 years, encompassing prevention, early recognition, basic and advanced support, and post-resuscitation care.^[8] A new emphasis is placed on systems of care, including mandatory school-based training programs to equip children and teachers with recognition skills for critical illness and basic resuscitation techniques.^[8] Across both sets of 2025 guidelines, compression-only CPR is reinforced as a viable option for untrained lay rescuers, particularly when ventilation is not feasible, to encourage bystander intervention over inaction.^[1]^[8] No major alterations were made to compression-ventilation ratios. The AHA/AAP guidelines maintain 30:2 for single rescuers and 15:2 for two rescuers, while the ERC guidelines recommend 15:2 for trained single rescuers and 30:2 for untrained lay rescuers, based on evidence of optimal hemodynamic support.^[1]^[8] New data underscore the importance of ventilation quality, recommending a respiratory rate of 20–30 breaths per minute during CPR with advanced airways and monitoring end-tidal CO2 to avoid hyperventilation, which can compromise outcomes.^[1]^[8] The AHA/AAP guidelines incorporate U.S.-specific metrics, such as out-of-hospital cardiac arrest survival rates of 17.3% for adolescents, 14.7% for children, and 6.6% for infants, to contextualize implementation needs.^[1] In contrast, the ERC guidelines highlight European epidemiology, where out-of-hospital pediatric arrests often stem from hypoxia and exhibit low survival rates, prompting tailored emphases on prevention in community settings like schools.^[8] These organizational updates build on the foundational 2025 International Liaison Committee on Resuscitation (ILCOR) consensus, which synthesizes global evidence through systematic reviews to inform pediatric life support recommendations.^[9]

Age-Specific Considerations

Infants (1 Month to 1 Year)

Infants from 1 month to 1 year old present unique anatomical and physiological challenges that necessitate tailored approaches in basic life support (BLS) to optimize outcomes during cardiac arrest or respiratory compromise. Their proportionally larger head size, including a prominent occiput, can cause flexion of the neck when placed on a flat surface, potentially obstructing the airway if not properly managed. Additionally, the relatively larger tongue in proportion to the oral cavity increases the risk of upper airway obstruction, while the compliant, cartilaginous rib cage offers less structural support, heightening vulnerability to injury from excessive force during interventions. These anatomical features contribute to a higher incidence of respiratory arrest as the primary cause of cardiac arrest in this age group, often preceding circulatory failure.^[10] Physiologically, infants exhibit a higher metabolic rate and oxygen consumption compared to older children and adults, leading to faster desaturation during apnea or inadequate ventilation; their functional residual capacity is limited, allowing oxygen reserves to deplete within seconds to minutes. Normal heart rates for awake infants in this age range typically fall between 100 and 160 beats per minute, with resuscitation efforts focusing on detecting rates below 60 beats per minute in the context of poor perfusion. This elevated oxygen demand and rapid desaturation underscore the critical need for prompt airway and breathing support to prevent hypoxic injury.^[10]^[11] In BLS application, these differences inform specific modifications: the brachial artery is the preferred site for pulse checks due to its accessibility on the upper arm, allowing quick assessment without compromising other maneuvers. For airway management, a neutral position is maintained using a slight head-tilt chin-lift to counteract the larger occiput and avoid overextension, which could collapse the airway. Chest compressions target the lower half of the sternum, with the 2025 guidelines eliminating the traditional two-finger technique in favor of the one-hand (heel) method or two-thumbs encircling hands technique for single rescuers, as evidence shows improved depth and quality; for two rescuers, the two-thumbs encircling technique is preferred. The compression-to-ventilation ratio remains 30:2 for single rescuers and 15:2 for two, unchanged from prior iterations, with strong emphasis on using gentle pressure to achieve adequate depth (approximately 4 cm) while minimizing rib fractures given the compliant chest structure.^[1]^[12]^[10]

Children (1 Year to Onset of Puberty)

Basic life support (BLS) for children, defined as those approximately 1 year of age until the onset of puberty, requires adaptations that account for ongoing anatomical and physiological development, distinguishing this group from both infants and adolescents. Puberty is identified for BLS purposes by the presence of breast development in females or axillary hair in males, marking the transition to adult guidelines.^[1] In this age range, the airway becomes straighter and less cephalad compared to infants, with the larynx positioned more anteriorly at the level of C3-C4 and a narrower, funnel-shaped subglottic region that remains the narrowest point until adolescence.^[13] The chest wall gains rigidity with growth, transitioning from the high compliance seen in infancy to a structure that demands greater compression force to achieve adequate depth, while the rib cage remains more cartilaginous and flexible than in adults.^[14] Physiologically, children in this age group exhibit a cardiac output profile that increasingly resembles adults, relying more on heart rate than stroke volume, though arrests predominantly stem from respiratory failure, shock, or trauma rather than primary cardiac events.^[1] Common precipitants include asphyxia from foreign body aspiration, suffocation, or drowning, alongside medical conditions like sepsis and trauma-related injuries, which shift from the overwhelming respiratory dominance in infancy.^[1] This etiology underscores the need for BLS to prioritize oxygenation and ventilation alongside circulation support, as untreated hypoxia rapidly progresses to bradycardia and asystole. BLS techniques for children emphasize scalable interventions to match body size variations. Chest compressions use the heel of one or two hands placed on the lower half of the sternum, aiming for a depth of approximately 5 cm or one-third the anterior-posterior chest diameter at a rate of 100 to 120 per minute, allowing full recoil to optimize venous return.^[1] Pulse checks, if performed, target the carotid or femoral arteries due to their accessibility in larger necks and limbs, though rescuers are advised against delaying compressions for uncertain palpation.^[1] Ventilation employs a head tilt-chin lift maneuver to align the straighter airway, delivering breaths that produce visible chest rise, with compression-to-ventilation ratios of 30:2 for single rescuers or 15:2 for two rescuers to balance circulation and oxygenation needs.^[1] The 2025 American Heart Association and American Academy of Pediatrics guidelines reinforce these elements, emphasizing compression depths of 4 to 5 cm to ensure efficacy across growth stages and maintaining consistent ratios with infants for simplicity in training, while highlighting the importance of immediate automated external defibrillator application with pediatric pads to address the rare but increasing incidence of shockable rhythms from trauma.^[1]

Initial Assessment

Scene Safety and Responsiveness Check

Upon encountering a potential pediatric emergency, the rescuer must first verify scene safety to protect themselves, bystanders, and the child or infant from hazards such as traffic, electrical wires, chemicals, water, fire, or unstable structures.^[15] If the scene is unsafe, the rescuer should not approach until hazards are mitigated, such as by calling for professional assistance to secure the area or using barriers like traffic cones or turning off power sources. This initial safety assessment ensures that resuscitation efforts can proceed without additional risks to the rescuer, which is critical in pediatric settings where emergencies often occur in home or community environments.^[15] Once the scene is deemed safe, the rescuer checks for responsiveness by stimulating the child or infant and observing for any reaction. For children aged 1 year to the onset of puberty, the rescuer taps the child's shoulders firmly and shouts, "Are you okay?" while watching for movement, eye opening, or verbal response.^[16] For infants younger than 1 year of age (excluding the immediate newborn period), the approach is gentler: the rescuer flicks the sole of the infant's foot or taps the chest and shouts to elicit a cry, movement, or other signs of awareness, adapting to the infant's smaller size and fragility.^[15] These age-specific techniques minimize injury risk while effectively gauging consciousness. Unresponsiveness is indicated by the absence of any purposeful response to these stimuli, coupled with no normal breathing or only abnormal patterns like gasping or agonal breaths, which signal the need for immediate intervention.^[15] The entire responsiveness and breathing assessment should take no more than 10 seconds to avoid delays in initiating basic life support. In the 2025 International Liaison Committee on Resuscitation (ILCOR) consensus, this rapid evaluation is emphasized to transition quickly to the circulation-airway-breathing (CAB) sequence, prioritizing high-quality compressions in pediatric cardiac arrest, which often stems from respiratory or circulatory failure rather than primary cardiac events.^[17]

Activation of Emergency Response

Activation of the emergency response system is essential in pediatric basic life support to summon advanced medical care rapidly following the initial assessment of unresponsiveness. Rescuers should dial the local emergency number—such as 911 in the United States or 112 in Europe—immediately after confirming the child or infant does not respond and exhibits abnormal breathing, including gasping or apnea.^[1]^[8] When calling, provide clear details about the incident location, the victim's approximate age (infant or child), and the condition, stating that the victim is unresponsive and not breathing normally, to enable efficient dispatch of appropriate resources.^[18] Timing of the call varies based on the number of rescuers and the circumstances of the collapse. For a solo rescuer, if a mobile phone is available, activate the emergency response system first after the responsiveness check, then proceed to assess breathing (and pulse if trained as a healthcare provider) while following dispatcher instructions; this applies uniformly to both infants and children. In cases of unwitnessed collapse without immediate access to a phone, perform approximately 2 minutes of basic life support before leaving the victim to call for help and retrieve an automated external defibrillator if available. With multiple rescuers present, one should call immediately while the other initiates basic life support.^[1]^[19] Emergency dispatchers play a vital role by providing real-time guidance on basic life support techniques tailored to pediatric victims, such as compression depth and ventilation rates, to support rescuers until professional help arrives. The 2025 American Heart Association guidelines emphasize dispatcher-assisted interventions, noting that automated external dispatch systems—incorporating scripted protocols and technology-assisted prompts—improve bystander compliance with high-quality compressions and overall resuscitation initiation rates.^[1]^[16] If a phone is accessible, place it on speaker mode to receive continuous instructions without interrupting care delivery.^[8]

Airway Management

Opening the Airway

Opening the airway is a critical initial step in pediatric basic life support (BLS) for unresponsive victims, as obstruction can prevent effective breathing support and oxygenation. The primary technique recommended is the head-tilt chin-lift maneuver, which relieves upper airway obstruction by displacing the tongue and soft tissues from the posterior pharynx. This method is suitable for non-trauma scenarios and is performed after confirming unresponsiveness and calling for emergency help.^[8] To execute the head-tilt chin-lift, the rescuer places one hand on the victim's forehead to gently tilt the head backward while using the fingers of the other hand to lift the chin forward, thereby opening the mouth slightly without compressing the soft tissues under the chin. For children aged 1 year to puberty, this creates a "sniffing position" with moderate head extension to align the oral, pharyngeal, and tracheal axes for optimal airflow. The maneuver should be maintained during subsequent assessments and ventilations to ensure patency. In cases of suspected cervical spine injury, an alternative jaw-thrust technique is preferred, as detailed in modifications for trauma.^[8] Infants (younger than 1 year of age, excluding newborns) require modifications due to anatomical differences, including a relatively larger occiput, which can cause passive neck flexion and potential airway obstruction when supine. The 2025 European Resuscitation Council (ERC) guidelines emphasize a neutral head position with only slight extension—achieved by lifting the chin with the index and middle fingers—rather than full tilting, to avoid hyperextension that could compress the airway. Placing a small towel or rolled cloth under the shoulders can further support neutral alignment by counteracting the occiput's effect. Over-tilting must be avoided in infants, as it risks airway compromise from the prominent occiput.^[8] Following airway opening, rescuers assess breathing using the look-listen-feel method for no more than 10 seconds to minimize delays in CPR if needed. This involves looking for chest rise, listening for breath sounds at the nose and mouth, and feeling for air movement against the cheek. If no breathing or only gasping is detected, the rescuer proceeds to ventilations while maintaining the open airway position. If visible foreign body obstruction is present, it should be removed only if easily accessible, without blind finger sweeps.^[8]

Modifications for Trauma

In pediatric basic life support, modifications to airway management are essential when trauma is suspected, particularly involving potential cervical spine (C-spine) injury, to minimize further neurological damage while ensuring airway patency. The primary adaptation is the use of the jaw thrust maneuver instead of the standard head-tilt–chin lift, as the latter risks exacerbating spinal instability through neck extension. This approach is recommended in scenarios such as falls or motor vehicle collisions where C-spine injury is likely.^[1]^[8] The jaw thrust maneuver involves placing the fingers behind the angles of the child's mandible and lifting the jaw forward toward the tip of the nose, without tilting or rotating the head, to displace the tongue and soft tissues away from the posterior pharynx. This technique is preferred in trauma settings because it maintains neutral alignment of the C-spine. In infants and young children, anatomical differences pose unique challenges: the relatively smaller mandible and larger tongue increase the risk of airway obstruction, while the more flexible pediatric spine heightens vulnerability to upper cervical injuries, making precise execution critical. Rescuers should use the jaw thrust only if trained, or as a solo provider when no assistance is available for manual in-line stabilization. If the jaw thrust fails to open the airway adequately, a cautious head-tilt–chin lift may be employed as a fallback.^[20]^[21]^[22] According to the 2025 International Liaison Committee on Resuscitation (ILCOR) consensus, reflected in American Heart Association (AHA) and European Resuscitation Council (ERC) guidelines, the jaw thrust is the initial maneuver for suspected C-spine injury in pediatric victims during basic life support. Evidence supports its use, as it generates significantly less motion at unstable C1–C2 segments compared to head-tilt–chin lift, thereby reducing the risk of secondary spinal cord injury. Studies indicate jaw thrust is widely accepted as effective for maintaining airway patency without extension, with biomechanical analyses showing reduced displacement in trauma models.^[1]^[8]^[23]

Breathing Support

Rescue Breathing Technique

Rescue breathing in pediatric basic life support involves delivering controlled ventilations to an infant or child who has a palpable pulse but is not breathing or has inadequate respirations, aiming to provide adequate oxygenation without causing harm.^[1] For infants (younger than 1 year of age, excluding newborns), the technique uses mouth-to-mouth-and-nose ventilation: the rescuer seals their mouth over the infant's mouth and nose, creating a tight seal with puffed cheeks, and delivers a gentle breath over 1 second while observing for visible chest rise.^[1] In children (1 year to onset of puberty), mouth-to-mouth ventilation is performed by tilting the head back and lifting the chin to open the airway, pinching the child's nostrils closed, sealing the rescuer's mouth over the child's mouth, and delivering a breath over 1 second sufficient to cause the chest to rise visibly.^[1] A barrier device such as a resuscitation mask may be used to facilitate the seal and reduce infection risk if available.^[1] The volume of each breath should be tidal, approximately 6 to 7 mL/kg of body weight, adjusted to produce a visible but not excessive chest rise to ensure effective gas exchange while minimizing risks.^[1] For example, this equates to roughly 30 to 50 mL for infants and 150 to 240 mL for older children, though the primary guide is chest rise rather than a fixed volume.^[1] Breaths lasting about 1 second each are delivered at a rate of 20 to 30 per minute (1 breath every 2 to 3 seconds) for both infants and children when a pulse is present, continuing until the child resumes spontaneous breathing or advanced care arrives.^[24] If the chest does not rise with a breath, the rescuer should immediately reposition the head to ensure the airway is open and attempt another breath, as obstruction or improper positioning may prevent effective ventilation.^[1] Complications such as gastric distension can occur from excessive volume or pressure, potentially leading to vomiting and aspiration; rescuers must avoid overinflation by delivering only enough air for chest rise and monitoring for abdominal distention.^[1] In cases of vomiting during rescue breathing, the rescuer should turn the child's head to the side, clear the airway if necessary, and resume ventilations promptly.^[1]

Breath-to-Compression Ratios

In pediatric basic life support (BLS), the compression-to-ventilation ratio refers to the number of chest compressions delivered followed by rescue breaths during cardiopulmonary resuscitation (CPR), designed to balance circulatory support with oxygenation while minimizing interruptions in compressions. For a single rescuer performing CPR on infants (younger than 1 year of age, excluding newborns) or children (1 year to onset of puberty), the recommended ratio is 30 compressions to 2 breaths (30:2).^[1] This ratio applies uniformly across both age groups to simplify training and application in emergencies.^[1] For two-rescuer CPR, the ratio shifts to 15 compressions to 2 breaths (15:2) for both infants and children, allowing one rescuer to focus on compressions while the other provides ventilations more frequently.^[1] These ratios remain unchanged from the 2020 guidelines, reflecting ongoing consensus on their efficacy in pediatric cardiac arrest scenarios where respiratory causes predominate.^[1] Rescuers must minimize pauses for breath delivery to less than 10 seconds, ensuring a chest compression fraction exceeding 70% to maintain effective circulation.^[1] If an advanced airway (e.g., endotracheal tube) is placed—though not part of basic BLS—continuous chest compressions are performed without pauses, with asynchronous ventilations delivered at a rate of 20 to 30 breaths per minute (approximately one breath every 2 to 3 seconds).^[1] Basic pediatric BLS prioritizes conventional ratios over advanced techniques to avoid delays in lay or single-rescuer settings.^[1] The 2025 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR) supports the 30:2 ratio for single rescuers, citing evidence that lower ventilation frequencies during CPR preserve coronary perfusion pressure compared to higher ventilation rates, which can impede venous return and reduce cardiac output.^[17] Observational studies, such as those by Kitamura et al. (2010) and Naim et al. (2017), further demonstrate improved survival outcomes with these ratios over compression-only CPR in pediatric out-of-hospital arrests, emphasizing the need for ventilations in hypoxic etiologies common to children.

Circulation Management

Pulse Assessment

In pediatric basic life support, pulse assessment determines whether a palpable pulse is present to guide the initiation of chest compressions, with central pulses preferred for reliability in detecting cardiac output. For infants (under 1 year), the brachial pulse, located on the medial aspect of the upper arm between the biceps and triceps muscles, is the recommended site. For children (1 year to puberty), the carotid pulse in the neck lateral to the larynx or the femoral pulse in the groin crease are preferred central sites, as peripheral pulses may be less accurate during circulatory compromise. The technique requires using the index and middle fingers to palpate the selected site gently but firmly, avoiding the thumb due to its own pulse, and limiting the assessment to no more than 10 seconds to prevent delays in resuscitation. A pulse is deemed present if it is palpable at a rate exceeding 60 beats per minute with signs of adequate perfusion, such as pink skin color, warm extremities, and capillary refill under 2 seconds; rates below 60 beats per minute with poor perfusion warrant starting CPR. The 2025 American Heart Association and American Academy of Pediatrics guidelines recommend pulse checks only for trained healthcare providers, emphasizing high inaccuracy rates (sensitivity 76%-100%, specificity 64%-79%) that can lead to false positives or negatives. Lay rescuers should assume no pulse if the child is unresponsive and has absent or abnormal breathing, proceeding directly to CPR without assessment to prioritize rapid intervention. Common errors include false positives from rescuer panic or motion artifact, which occur in up to 50% of assessments, and any check causing delay beyond 10 seconds, as pauses averaging 5-18 seconds reduce CPR effectiveness; thus, training stresses minimizing or omitting checks when expertise is lacking.

Chest Compression Delivery

Chest compressions in pediatric basic life support (BLS) are critical for maintaining circulation and oxygenation during cardiac arrest, aiming to generate sufficient cardiac output through rhythmic pressure on the sternum. Effective delivery requires precise hand positioning, adequate depth, and an appropriate rate to optimize coronary and cerebral perfusion, as emphasized in the 2025 American Heart Association (AHA) guidelines. These techniques differ between infants (under 1 year) and children (1 year to puberty) to account for anatomical variations.^[1] For infants, the recommended hand positioning involves either the one-hand technique, using the heel of one hand on the lower half of the sternum, or the two-thumbs encircling hands technique, where the rescuer encircles the infant's chest with both hands and compresses using the thumbs. The two-finger technique has been eliminated in the 2025 guidelines due to its ineffectiveness in achieving adequate depth. Compressions should reach a depth of approximately 1.5 inches (4 cm), or one-third of the anteroposterior chest diameter, at a rate of 100 to 120 per minute.^[1]^[1] In children, compressions are performed using the heel of one hand placed on the lower half of the sternum, with the option to use two hands stacked for larger children to ensure greater force if needed; the one-hand method may allow better rate compliance. Depth targets about 2 inches (5 cm), or one-third of the anteroposterior chest diameter, while maintaining the same rate of 100 to 120 compressions per minute. After confirming pulselessness in the brachial artery for infants or femoral/carotid for children, compressions begin immediately without delay.^[1]^[1]^[1] To ensure high-quality compressions, rescuers must allow complete chest recoil by lifting the hands fully off the chest between each compression, avoiding leaning, which improves venous return and cardiac filling. Quality metrics include achieving the targeted depth and rate with minimal interruptions, though full chest expansion is primarily assessed during ventilations; incomplete recoil reduces cardiac output by up to 20-30% in studies. The 2025 AHA guidelines recommend the use of feedback devices during training to provide real-time guidance on depth, rate, and recoil, enhancing skill acquisition and retention.^[1]^[1]^[1]

CPR Integration

Solo Rescuer Procedure

The solo rescuer procedure in pediatric basic life support (BLS) integrates the core elements of circulation, airway, and breathing management into a streamlined algorithm designed for a single provider responding to an unresponsive child or infant. This approach follows the CAB sequence—prioritizing chest compressions to restore circulation—while minimizing interruptions to maintain high-quality CPR. According to the 2025 American Heart Association (AHA) and American Academy of Pediatrics (AAP) guidelines, the procedure begins with ensuring scene safety, assessing responsiveness by tapping the child and shouting for a response, and immediately activating the emergency response system (e.g., calling 911) while retrieving an automated external defibrillator (AED) if available.^[1]^[25] If the child or infant shows no signs of life, the rescuer checks for a pulse at the carotid (children) or brachial (infants) artery for no more than 10 seconds, simultaneously assessing for normal breathing or only gasping (agonal breaths). If no pulse is detected or the heart rate is less than 60 beats per minute with poor perfusion despite adequate oxygenation, CPR commences with 30 chest compressions followed by 2 breaths, repeating in cycles. For children aged 1 year to puberty, compressions use the heel of one or two hands on the lower half of the sternum, achieving a depth of approximately 5 cm (one-third the anteroposterior chest diameter) at a rate of 100–120 per minute, allowing full chest recoil between compressions. Infants under 1 year receive compressions using either the heel of one hand or the two-thumb encircling hands technique (preferred for depth), placed just below the nipple line, achieving a depth of approximately 4 cm (one-third the anteroposterior chest diameter) at the same rate; the two-finger method has been eliminated due to insufficient depth and force.^[1]^[5]^[2] The victim must be positioned supine on a firm, flat surface, such as the ground or a backboard, to optimize compression effectiveness; for infants in a solo scenario, placement on the rescuer's lap or forearm (with the head slightly lower than the torso) may be necessary if a surface is unavailable, ensuring the body remains stable. Breaths are delivered after opening the airway (using head-tilt chin-lift for non-trauma cases), aiming for visible chest rise without excessive volume to avoid gastric inflation. An AED is applied as soon as possible, with pediatric pads or a pediatric attenuator used if the victim is under 8 years or less than 25 kg (55 lb); if a shockable rhythm is detected, deliver the shock and immediately resume CPR for 2 minutes before reassessing. Cycles continue with a focus on prioritizing compressions, targeting at least 80% of the CPR cycle time on compressions to enhance outcomes, as emphasized in the 2025 updates.^[1]^[25]^[5] To manage fatigue, the solo rescuer should self-monitor compression quality and mentally aim to "switch" roles every 2 minutes (aligning with AED rhythm checks), though physical switching is impossible; rescuers are advised to rest briefly if exhaustion impairs performance, prioritizing sustained high-quality compressions over prolonged suboptimal efforts. The procedure terminates upon signs of recovery (e.g., normal breathing, movement, or palpable pulse), arrival of professional rescuers who assume care, successful AED shock followed by return of spontaneous circulation, or when the rescuer is physically unable to continue despite best efforts.^[1]^[25]

Two-Rescuer Procedure

In the two-rescuer pediatric basic life support (BLS) procedure, the victim is positioned supine on a firm surface between the rescuers to facilitate coordinated actions, with one rescuer located at the head for airway management and ventilation, and the other at the side for chest compressions.^[26] This setup allows for immediate activation of the emergency response system by the second rescuer upon arrival, while the first continues initial 30:2 compressions-to-breaths if started alone, transitioning to a 15:2 ratio once both are in place.^[1] Compressions are delivered at a rate of 100-120 per minute, achieving a depth of at least one-third the anteroposterior chest diameter (approximately 4 cm for infants and 5 cm for children), with full chest recoil between compressions to optimize cardiac output.^[8] The compressor performs 15 chest compressions using the two-thumb encircling technique for infants or the two-hand method for children, while the ventilator delivers two breaths of 1 second each (visible chest rise) using a bag-mask or mouth-to-mouth/mouth-to-nose technique, signaling coordination to minimize interruptions.^[1] Breaths are timed to occur during the compressor's pause at the end of the compression cycle, ensuring ventilations do not overlap with compressions in basic scenarios.^[8] If an advanced airway is later established, the compressor continues uninterrupted at 100-120 per minute while the ventilator provides asynchronous breaths at 20-30 per minute, though this remains outside standard basic support.^[1] Roles switch every 2 minutes, ideally during a pulse check or AED rhythm analysis, to prevent fatigue and maintain compression quality.^[26] This approach offers advantages over solo rescuer efforts by dividing tasks, enabling the 15:2 ratio for improved ventilation frequency without sacrificing compression consistency.^[1] Simulations demonstrate that two-rescuer CPR achieves superior compression depth, rate, and recoil compared to single-rescuer techniques, such as two-finger compressions, potentially enhancing hemodynamic efficiency and survival outcomes.^[27] In contrast to the solo procedure's 30:2 ratio, the two-rescuer method prioritizes teamwork for sustained high-quality BLS until advanced care arrives.^[8]

Special Scenarios

Choking Management

Choking in pediatric patients, also known as foreign body airway obstruction (FBAO), requires rapid recognition to distinguish between partial and complete obstruction, as delays can lead to respiratory arrest or cardiac complications. Signs of partial FBAO include sudden onset of coughing, wheezing, or stridor with the child able to cry, speak, or make sounds, indicating some airflow. In contrast, complete FBAO is indicated by a weak or absent cough, inability to vocalize or cry, high-pitched breathing noises, cyanosis, or altered mental status, signaling severe compromise that demands immediate intervention.^[28]^[1] For conscious infants (under 1 year) with severe FBAO, rescuers should support the head and neck while positioning the infant face-down along the forearm, with the head lower than the body, and deliver 5 firm back blows between the shoulder blades using the heel of the hand. If the object is not expelled, turn the infant face-up on the rescuer's thigh and perform 5 chest thrusts using the heel of one hand on the sternum, to a depth similar to compressions in CPR, repeating cycles until the object is dislodged or the infant becomes unresponsive. The 2025 guidelines recommend alternating 5 back blows with 5 chest thrusts for infants. For conscious children over 1 year, lean the child forward and administer 5 back blows with the heel of the hand between the shoulder blades, followed by 5 abdominal thrusts using the Heimlich maneuver (fist placed above the navel, grasped by the other hand, with upward thrusts), continuing cycles as needed. These techniques aim to create pressure gradients to expel the foreign body without causing injury.^[29]^[28]^[1] If the child becomes unconscious during choking management, lower them to a firm surface, call for emergency help if not already done, and begin CPR immediately, starting with chest compressions rather than breaths. Before attempting rescue breaths, open the mouth and remove any visible foreign body with a finger sweep only if seen, avoiding blind finger sweeps to prevent pushing the object deeper. Continue CPR cycles, checking the mouth after each set of compressions for visible objects to remove, integrating this with standard pediatric BLS protocols.^[1]^[30] The 2025 International Liaison Committee on Resuscitation (ILCOR) guidelines emphasize alternating back blows and thrusts for both infants and children to enhance effectiveness, with back slaps recommended initially for those with ineffective coughs based on very low-certainty evidence from observational studies. Prompt action in conscious victims can often achieve successful removal when performed correctly by trained bystanders, though multiple cycles are often required. ILCOR strongly discourages blind finger sweeps due to risks of further obstruction, prioritizing visible object removal only.^[30]^[31]

Drowning and Environmental Emergencies

In pediatric basic life support (BLS) for drowning, the primary mechanism of cardiac arrest is hypoxia rather than a primary cardiac event, necessitating modifications to standard protocols that prioritize ventilation to address hypoxemia. Rescue breaths should be initiated immediately after securing the airway, even in pulseless victims, as oxygenation is critical for potential recovery. For trained rescuers such as lifeguards, in-water CPR may be performed if the victim is unresponsive and safe extraction is not immediately possible, using a ratio of 30 compressions to 2 breaths while towing the child to shore; however, untrained bystanders should focus on rapid removal from water before starting CPR. Upon reaching dry land, wet clothing should be removed promptly to prevent further heat loss and facilitate effective compressions and warming. Bystander-initiated CPR in drowning incidents has been shown to double or triple survival chances to hospital discharge with favorable neurological outcomes in children.^[32]^[33]^[34] Hypothermia frequently complicates pediatric drowning, particularly in cold water submersion, and requires extended BLS efforts due to the protective effects of low body temperature on vital organs during prolonged hypoxia. CPR should be continued longer than in normothermic arrests, with no predetermined time limit for termination, as viable rhythms may return after extended efforts; concurrent rewarming using passive methods like removing wet clothes and insulating blankets, or active techniques such as warmed intravenous fluids if available, is essential during resuscitation. The 2025 American Heart Association (AHA) guidelines emphasize ventilating hypothermic pulseless children, as the safe window for effective oxygenation is prolonged compared to standard arrests, potentially yielding good neurological outcomes even after 30-60 minutes of CPR. In severe cases associated with drowning, extracorporeal membrane oxygenation (ECMO) for rewarming during CPR has demonstrated up to a 41% survival benefit in pediatric patients.^[32]^[33] For electrocution in children, which often occurs in environmental settings like lightning strikes or household accidents, BLS begins only after ensuring scene safety to prevent rescuer injury, such as turning off power sources or moving the victim from conductive areas using non-conductive materials. Once safe, standard pediatric CPR protocols are applied without specific modifications, focusing on high-quality compressions and breaths, as injuries may include internal trauma but do not alter the basic sequence. Immediate drying of wet victims from environmental exposure enhances compression efficacy and reduces hypothermia risk.^[32] Anaphylaxis in pediatric environmental emergencies, such as bee stings or exposure to allergens outdoors, primarily requires BLS airway management and CPR if cardiac arrest occurs, with epinephrine administration (intramuscular if auto-injector available) as an adjunct rather than a core BLS element. High-quality CPR remains the focus to support circulation until advanced care arrives, as hypoxia from airway swelling can lead to arrest; ventilations are prioritized to counter respiratory compromise.^[32]

Post-Resuscitation Care

Recognition of Recovery

Recognition of recovery in pediatric basic life support involves identifying signs of return of spontaneous circulation (ROSC), which indicates successful restoration of effective cardiac output and guides decisions on continuing or halting resuscitation efforts. Key clinical signs include the return of a palpable central pulse (such as carotid or femoral in children, or brachial in infants), spontaneous normal breathing, improvement in skin color to a pinker tone, and purposeful movement or responsiveness in the child.^[10] These signs must be assessed carefully, as they confirm adequate perfusion and oxygenation without reliance on advanced equipment.^[1] During CPR cycles, rescuers should monitor for these recovery signs by checking the pulse and breathing approximately every 2 minutes, limiting the assessment to no more than 10 seconds to minimize interruptions in compressions. According to the 2025 American Heart Association guidelines, if signs of recovery appear but subsequently deteriorate—such as loss of pulse or return to abnormal breathing—resuscitation should resume immediately to prevent re-arrest.^[19] This periodic evaluation aligns with the solo or two-rescuer CPR procedures, ensuring ongoing assessment without extending pauses.^[1] Rescuers must distinguish true recovery from false positives, such as agonal gasps, which are irregular, ineffective breathing patterns often seen in the initial phases of cardiac arrest and do not indicate ROSC; CPR should continue in these cases to support circulation until definitive signs emerge.^[1] Similarly, isolated weak pulses without accompanying signs like improved color or movement should not prompt cessation of efforts.^[10] In pediatric patients, recovery nuances vary by age, with infants (under 1 year) having lower survival rates from out-of-hospital cardiac arrest (approximately 6-10%) compared to older children (around 14%), necessitating avoidance of premature stopping to allow adequate time for stabilization.^[35]^[36] Children aged 1 year to puberty may show quicker overt signs like movement, but all age groups require vigilant monitoring to confirm sustained recovery.^[10]

Transition to Advanced Support

Upon recognition of return of spontaneous circulation or arrival of emergency medical services (EMS), rescuers should provide a concise handover report to advanced providers, including the duration of basic life support efforts, specific interventions performed such as compressions and ventilations, and any notable events like witnessed arrest or response to defibrillation if applicable.^[8] To minimize interruptions, chest compressions should continue without pause during the verbal report, ideally limiting the handover to under 10 seconds while one rescuer briefs the team.^[37] Post-ROSC, aim for oxygen saturation of 94-98% using basic monitoring if available, avoiding hyperoxia.^[8] For a pediatric victim who is unresponsive but demonstrating effective breathing, place the child in the recovery position—a side-lying posture with the head tilted backward to maintain an open airway—provided there is no suspicion of trauma or cervical spine injury.^[8] Continuously monitor airway, breathing, and circulation (ABC) every minute, checking for any deterioration that may necessitate resuming compressions.^[37] According to the 2025 European Resuscitation Council (ERC) guidelines, following handover, EMS teams should debrief lay or trained rescuers to review the event and provide emotional support, while transporting the child to a facility equipped for pediatric care, such as a pediatric intensive care unit or extracorporeal life support center if indicated.^[8] Post-event care includes offering psychological support to bystanders and family members, such as referral to counseling services to address potential trauma from the resuscitation.^[37] Additionally, document the quality of basic life support delivery, including compression depth, rate, and recoil, using standardized protocols to facilitate quality improvement and legal records.^[8]

References

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Error: Could not load webpage.<|control11|><|separator|>
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