Child CPR: Complete Guide to Infant & Pediatric Resuscitation

What Is CPR and Why Is It Different for Children?

CPR (cardiopulmonary resuscitation) is an emergency procedure combining rescue breaths and chest compressions to maintain blood circulation and oxygen delivery when the heart stops. For children, CPR differs from adult CPR because pediatric cardiac arrest is usually caused by respiratory failure rather than heart problems, making rescue breaths essential.

Cardiopulmonary resuscitation, commonly known as CPR, is a fundamental life-saving technique that everyone should learn, especially parents, caregivers, and those who work with children. When a child's heart stops beating (cardiac arrest), their brain and vital organs begin to suffer damage within minutes due to lack of oxygen. CPR serves as a bridge, maintaining minimal but crucial blood flow to these organs until professional medical help arrives and can provide advanced care.

The physiology behind pediatric cardiac arrest differs significantly from that of adults. In adults, cardiac arrest typically results from primary heart problems such as heart attacks or arrhythmias, where the heart itself malfunctions. However, in infants and children, the sequence is usually reversed. Most pediatric cardiac arrests are secondary events that follow respiratory problems - choking, drowning, severe asthma attacks, respiratory infections, or suffocation. This means the child's blood is already depleted of oxygen by the time the heart stops, making rescue breaths an absolutely critical component of pediatric CPR.

Understanding this fundamental difference explains why the approach to child CPR emphasizes both ventilation (rescue breaths) and circulation (chest compressions) equally. While compression-only CPR may be acceptable for witnessed adult cardiac arrest where oxygen levels in the blood are initially adequate, children require the full combination of compressions and breaths to maximize their chances of survival and neurological recovery.

The Two Components of CPR

CPR consists of two essential components that work together to sustain life. Rescue breaths (also called mouth-to-mouth resuscitation) deliver oxygen directly into the lungs, where it can be absorbed into the bloodstream. Chest compressions create artificial circulation by rhythmically pressing on the breastbone, which squeezes the heart between the sternum and spine, pushing blood through the body. Together, these actions deliver oxygenated blood to the brain and other vital organs, preventing irreversible damage while awaiting definitive medical treatment.

When Should You Perform CPR on a Child?

You should perform CPR on a child who is unresponsive and not breathing normally. Signs include no response to shaking or calling their name, no visible chest movement, no breath sounds, and no air felt against your cheek. Occasional gasping breaths are not normal breathing and require immediate CPR.

Recognizing when a child needs CPR is the first critical step in saving their life. The decision to start CPR must be made quickly and confidently, as every second of delay reduces the chances of survival. You should begin CPR when a child shows two key signs: unresponsiveness and absence of normal breathing.

Unresponsiveness means the child does not react to external stimuli. When you speak loudly to the child, gently shake their shoulders (or tap the soles of an infant's feet), they show no response - no eye opening, no movement, no vocalization. This unconscious state indicates the brain is not receiving adequate blood flow and oxygen.

Absence of normal breathing is assessed using the "look, listen, feel" technique. You look for chest and abdominal movement, listen for breath sounds near the mouth and nose, and feel for air movement against your cheek. This assessment should take no more than 10 seconds. If there is no breathing or only occasional gasping breaths (agonal respirations), the child requires immediate CPR.

What Are Agonal Breaths?

Agonal breathing is a pattern of irregular, gasping breaths that can occur in the early stages of cardiac arrest. These breaths may sound like snoring, sighing, or labored gasping. They do not provide effective oxygenation and should not be mistaken for normal breathing. If you observe agonal breathing in an unresponsive child, you must begin CPR immediately. Many bystanders hesitate to start CPR because they see these occasional gasps and assume the child is breathing - this is a dangerous mistake that costs lives.

Common Causes of Pediatric Cardiac Arrest

Understanding the common causes of cardiac arrest in children helps explain why respiratory support is so crucial in pediatric resuscitation. The most frequent causes include:

• Choking/Airway obstruction: Foreign objects blocking the airway, especially in young children who explore with their mouths
• Drowning: Submersion incidents where water prevents breathing
• Respiratory infections: Severe pneumonia, bronchiolitis, or croup that overwhelms breathing capacity
• Asthma: Severe asthma attacks causing respiratory failure
• Trauma: Injuries affecting breathing or causing blood loss
• Sudden Infant Death Syndrome (SIDS): Unexplained death in infants during sleep
• Congenital heart conditions: Heart defects present from birth that may cause arrhythmias

How Do You Perform CPR on a Child?

To perform child CPR: Check responsiveness, open the airway by tilting the head back and lifting the chin, give 5 rescue breaths watching for chest rise, then alternate 15 chest compressions with 2 breaths. For infants use 2 fingers for compressions at 4cm depth; for children use 1-2 hands at 5-6cm depth. Compress at 100-120 per minute.

Performing CPR on a child requires a systematic approach that prioritizes both ventilation and circulation. The following step-by-step guide is based on international resuscitation guidelines from ILCOR, the American Heart Association, and the European Resuscitation Council. While this information provides essential knowledge, hands-on training with CPR manikins is strongly recommended to develop proper technique and confidence.

Step 1: Check for Responsiveness

Your first action is to determine whether the child is conscious and responsive. Approach the child safely, ensuring there are no hazards to yourself or the child. Speak loudly and clearly, calling the child's name if known, or saying "Are you okay?" While speaking, gently shake the child's shoulders. For infants, you can tap the soles of their feet. If the child does not respond with any movement, sound, or eye opening, they are unresponsive and require immediate action.

If others are nearby, call out for help immediately. Having additional people allows one person to call emergency services while another begins resuscitation. If you are alone, you will call for help after delivering the initial rescue breaths.

Step 2: Open the Airway

Place the child on their back on a firm, flat surface. The floor is ideal if safe to use. Opening the airway is essential because when a child is unconscious, the tongue can fall backward and block the throat, preventing breathing.

To open the airway, place one hand on the child's forehead and gently tilt the head backward. With your other hand, place one or two fingertips under the bony part of the chin and lift the jaw upward. Be careful not to press on the soft tissue under the chin, as this can actually close the airway.

For infants under 1 year: Use a neutral head position - the head should not be tilted back as much as for older children. Infants have proportionally larger heads and more flexible airways, so only minimal extension is needed. Imagine placing the infant's nose pointing straight toward the ceiling.

Step 3: Check for Breathing

While maintaining the open airway, assess the child's breathing for no more than 10 seconds using the "look, listen, and feel" method:

• Look: Watch for chest and abdominal movement rising and falling
• Listen: Put your ear near the child's mouth and nose to hear any breath sounds
• Feel: With your cheek near the child's mouth, feel for air movement

If the child is breathing normally but remains unconscious, place them in the recovery position (stable side position) and call emergency services. Continue to monitor their breathing until help arrives.

If the child is not breathing or only gasping, you must begin rescue breaths immediately.

Step 4: Give 5 Initial Rescue Breaths

The first step in pediatric resuscitation is to deliver 5 rescue breaths. This addresses the respiratory cause of most pediatric cardiac arrests by providing oxygen to the depleted blood. Maintain the open airway position throughout.

For infants (under 1 year): Create an airtight seal by placing your mouth over both the infant's mouth AND nose together. The infant's face is small enough that you can cover both openings with your mouth.

For children (1-18 years): Pinch the child's nose closed with the hand that's on their forehead, then seal your mouth completely over the child's mouth.

Deliver 5 slow, gentle breaths, each lasting about 1 second. Watch for the chest to rise with each breath - this confirms the air is entering the lungs. The amount of air should be proportional to the child's size; small children and infants need much less volume than adults. Think of giving just enough air to make the chest rise slightly.

If the chest does not rise, reposition the head and chin to ensure the airway is open, and try again. If air still doesn't enter, suspect a foreign body obstruction and follow choking protocols.

Step 5: Call Emergency Services

After delivering the 5 initial rescue breaths, you must get professional help on the way. Call your local emergency number immediately:

• United States/Canada: 911
• European Union: 112
• United Kingdom: 999
• Australia: 000
• Other countries: Find your emergency number

Use the speakerphone function on your mobile phone so you can continue CPR while speaking to the emergency dispatcher. They will provide guidance and can walk you through the resuscitation process if needed.

If you are with another person, have them call emergency services while you continue providing CPR. They should also retrieve an automated external defibrillator (AED) if one is available nearby.

If you are alone with no phone available, perform CPR for approximately 1 minute before leaving briefly to call for help, then return immediately to continue resuscitation.

Step 6: Begin Chest Compressions

If the child shows no signs of life (no movement, no normal breathing, no coughing) after the initial rescue breaths, begin chest compressions. The goal is to press hard and fast on the lower half of the breastbone, creating artificial circulation.

For infants (under 1 year):

• Place two fingertips (index and middle finger) on the center of the chest, just below the nipple line
• Compress straight down approximately 4 centimeters (about 1.5 inches), which is roughly one-third of the chest depth
• Release completely between compressions to allow the heart to refill
• Compress at a rate of 100-120 compressions per minute

For children (1-18 years):

• Place the heel of one hand on the lower half of the breastbone (sternum), in the center of the chest
• For larger children, you may place your second hand on top of the first, interlacing your fingers
• Position your shoulders directly above your hands with arms straight
• Compress straight down approximately 5-6 centimeters (about 2-2.4 inches), one-third of chest depth
• Allow full chest recoil between compressions
• Compress at a rate of 100-120 compressions per minute

Step 7: Continue the CPR Cycle

After 15 chest compressions, give 2 rescue breaths. Then immediately resume compressions. This 15:2 ratio (15 compressions to 2 breaths) should be maintained continuously without unnecessary pauses.

Try to minimize interruptions between compressions and breaths. The transition should be smooth and quick. Do not stop to check for signs of life between cycles - this wastes valuable time. Continue the 15:2 cycle until:

• Emergency medical services arrive and take over care
• The child shows obvious signs of life (starts breathing normally, moving, or coughing)
• You become too exhausted to continue effectively
• A medical professional advises you to stop

CPR is physically demanding. If another trained person is present, switch roles every 2 minutes to prevent fatigue and maintain high-quality compressions. The switch should be done as quickly as possible - within 5-10 seconds.

Step 8: Use an AED If Available

An automated external defibrillator (AED) can analyze the child's heart rhythm and deliver an electrical shock if needed to restore a normal heartbeat. AEDs are safe and designed for use by untrained bystanders - the device provides voice instructions.

If an AED is available:

• Turn on the AED and follow the voice prompts
• Apply pediatric pads (for children under 8 years or less than 25 kg) if available
• If only adult pads are available, place one on the center of the chest and one on the back between the shoulder blades to prevent overlap
• Ensure no one is touching the child when the AED analyzes and when delivering a shock
• The AED will only deliver a shock if it detects a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia)
• Resume CPR immediately after a shock is delivered (or if no shock is advised)

What About Special Situations?

Special CPR situations include drowning (start with 5 rescue breaths before calling for help), choking (attempt to clear the airway first), and trauma (maintain spinal alignment). For newborns, use different techniques with smaller breaths and encircling hand chest compression. Always prioritize oxygen delivery in children.

Drowning

Drowning is a leading cause of death in children, and the resuscitation approach has specific considerations. Because drowning causes respiratory arrest before cardiac arrest, oxygenation is the primary concern. Remove the child from the water safely, ensuring your own safety first. Begin rescue breaths as soon as possible, even while still in shallow water if safe to do so. Give 5 initial rescue breaths, then call for emergency help, then continue with the standard 15:2 CPR cycle.

Do not attempt to drain water from the lungs - this wastes time and is ineffective. The priority is to deliver oxygen through rescue breaths and maintain circulation through compressions. Hypothermia may complicate drowning; children can sometimes survive prolonged submersion in cold water, so resuscitation should continue until professional help arrives.

Choking With Loss of Consciousness

If a choking child becomes unresponsive, lower them to the ground and begin CPR. Before giving rescue breaths, look inside the mouth and remove any visible obstruction with a finger sweep (only if you can clearly see an object - blind finger sweeps can push objects deeper). If you can deliver effective breaths with chest rise, continue standard CPR. If breaths do not go in, reposition the airway and try again. The chest compressions during CPR may help dislodge the foreign body.

Trauma

If cardiac arrest follows trauma (car accident, fall, injury), spinal injury may be present. Try to maintain the head and neck in alignment with the body during resuscitation. If the airway cannot be opened with the chin lift alone, use a jaw thrust maneuver instead of tilting the head back. However, never withhold CPR due to concerns about spinal injury - the priority is survival.

Newborns

Newborn resuscitation (first minutes after birth) differs from infant CPR and typically occurs in medical settings. If you witness a newborn emergency, call for professional help immediately. For newborns, breaths are given more gently, and the encircling hands technique may be used for compressions where both thumbs press on the lower sternum while the hands wrap around the chest.

What Happens After CPR?

After successful CPR, the child needs immediate hospital care for monitoring, treatment of the underlying cause, and management of potential complications. If the child regains consciousness, place them in the recovery position while awaiting emergency services. The child and family may need psychological support to process the traumatic event.

If CPR is successful and the child shows signs of life - regular breathing, movement, coughing, or regaining consciousness - they still require immediate medical attention. Continue to monitor their breathing and be prepared to restart CPR if they deteriorate. Place a breathing but unconscious child in the recovery position (lying on their side with the head tilted to allow any fluids to drain).

When emergency services arrive, they will provide advanced care including potential medication, advanced airway management, and transport to a hospital. Even after successful resuscitation, children typically need intensive care monitoring to address the underlying cause of the arrest and manage any complications from the period without circulation.

Psychological Impact

Cardiac arrest is a traumatic event for the child, the family, and often for bystanders who provided CPR. Children who survive may have no memory of the event itself but may experience anxiety, sleep disturbances, or fear related to what happened. Professional psychological support should be offered to the child and family. Those who performed CPR may also experience emotional reactions - seeking support from counselors or crisis services is appropriate and encouraged.

How Can You Learn Child CPR?

The best way to learn child CPR is through hands-on training courses offered by organizations like the American Heart Association, Red Cross, or local healthcare providers. Courses typically last 2-4 hours and include practice on manikins. Refresher training every 1-2 years is recommended to maintain skills.

While reading about CPR provides important knowledge, hands-on practice is essential for developing the muscle memory and confidence needed to perform effective resuscitation in an emergency. CPR courses provide the opportunity to practice on realistic manikins, receive feedback on technique, and ask questions from certified instructors.

Many organizations offer pediatric CPR training, including:

• American Heart Association (AHA)
• American Red Cross
• European Resuscitation Council member organizations
• St. John Ambulance
• Local hospitals and community centers
• Workplace safety training providers

Specialized courses for parents of high-risk infants (premature babies, children with heart conditions) may be available through hospitals. Some courses combine CPR training with first aid, including choking management, which is particularly valuable for caregivers.

Skills deteriorate over time, so refresher training every 1-2 years is recommended. Many organizations now offer blended learning options combining online study with shorter in-person skills practice sessions.