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Cardiopulmonary Resuscitation (CPR) in Infants and Children

By Robert E O’Connor, MD, MPH, Professor and Chair of Emergency Medicine, University of Virginia School of Medicine

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Despite the use of CPR, mortality rates for out-of-hospital cardiac arrest are 80 to 97% for infants and children. Mortality rates for in-hospital cardiac arrest for infants and children range between 40% and 65%. The mortality rate is 20 to 25% for respiratory arrest alone. Neurologic outcome is often severely compromised.

Pediatric resuscitation protocols apply to infants < 1 yr of age and children up to the age of puberty (defined as appearance of breasts in females and axillary hair in males) or children weighing < 55 kg. Adult resuscitation protocols apply to children past the age of puberty or children weighing > 55 kg. Neonatal resuscitation is discussed elsewhere.

About 50 to 65% of children requiring CPR are < 1 yr; of these, most are < 6 mo. About 6% of neonates require resuscitation at delivery; the incidence increases significantly if birth weight is < 1500 g.

Standardized outcome guidelines should be followed in reporting outcomes of CPR in children; eg, the modified Pittsburgh Outcome Categories Scale reflects cerebral and overall performance (see Table: Pediatric Cerebral Performance Category Scale*).

Pediatric Cerebral Performance Category Scale*

Score

Category

Description

1

Normal

Age-appropriate level of functioning

In preschool-aged children, appropriate development

In school-aged children, attendance in regular classes

2

Mild disability

Can interact at an age-appropriate level

Minor neurologic disease that is controlled and does not interfere with daily functioning (eg, seizure disorder)

In preschool-aged children, possibly minor developmental delays, but with > 75% of all daily living developmental milestones above the 10th percentile

In school-aged children, attendance in regular school but in a grade that is not appropriate for age or in the appropriate grade but failing because of cognitive difficulties

3

Moderate disability

Below age-appropriate functioning

Neurologic disease that is not controlled and severely limits activities

In preschool-aged children, most daily living developmental milestones below the 10th percentile

In school-aged children, can do activities of daily living but attend special classes because of cognitive difficulties or a learning deficit

4

Severe disability

In preschool-aged children, activities of daily living milestones below the 10th percentile and excessive dependence on others for activities of daily living

In school-aged children, possibly severe impairment that prevents school attendance and dependence on others for activities of daily living

In preschool-aged and school-aged children, possibly abnormal motor movements, including nonpurposeful, decorticate, or decerebrate responses to pain

5

Coma or vegetative state

Unawareness

6

Death

*Worst level of performance for any single criterion is used for categorizing. Deficits are scored only if they result from a neurologic disorder. Assessments are based on medical records or an interview with the caretaker.

From Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style; statement for health care professionals from the Task Force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council; Pediatrics96(4):765–779, 1995.

Standards and guidelines for CPR from the American Heart Association are followed (see Table: CPR Techniques for Health Care Practitioners). For protocol after an infant or child has collapsed with possible cardiac arrest, see Figure: Pediatric comprehensive emergency cardiac care.

CPR Techniques for Health Care Practitioners

Age Group

One-Rescuer CPR*

Two-Rescuer CPR

Breath Size

Adults and adolescents

2 breaths (1 sec each) after every 30 chest compressions at 100–120/min

2 breaths (1 sec each) after every 30 chest compressions at 100–120/min

Each breath about 500 mL (caution against hyperventilation)

Children (1 yr––puberty)

2 breaths (1 sec each) after every 30 chest compressions at 100–120/min

2 breaths (1 sec each) after every 15 chest compressions at 100–120/min

Smaller breaths than for adults (enough to make chest rise)

Infants (< 1 yr, excluding newborns)

2 breaths (1 sec each) after every 30 chest compressions at 100–120/min

2 breaths (1 sec each) after every 15 chest compressions at 100–120/min

Only small puffs from the rescuer’s cheeks

*For a single lay rescuer, compression-only CPR is recommended in adults and adolescents.

Breaths are given without stopping chest compressions.

Puberty is defined as the appearance of breasts in females and axillary hair in males.

After CPR has been started, defibrillation and identification of the underlying cardiac rhythm (see Cardiopulmonary Resuscitation (CPR) in Adults : Monitor and IV) are done.

Pediatric comprehensive emergency cardiac care.

*If an adequate number of trained personnel are available, patient assessment, CPR, and activation of the emergency response system should occur simultaneously.

Based on the Comprehensive Emergency Cardiac Care Algorithm from the American Heart Association.

Major Differences Between Pediatric and Adult CPR

Prearrest

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

Chest compressions

During chest compressions in infants and children (below the age of puberty or < 55 kg), the chest should be depressed one third of the anteroposterior diameter. This is about 1.5 in (4 cm) to 2 in (5 cm). In adolescents or children > 55 kg, the recommended compression depth is the same as in adults, ie, 2 in (5 cm) to 2.4 in (6 cm).

Method of chest compression is also different in infants and children and is illustrated below. The rate of compression in infants and children is similar to that of adults at 100 to 120 compressions/min.

Chest compression.

A: Side-by-side thumb placement for chest compressions is preferred for neonates and small infants whose chest can be encircled. Thumbs should overlap if used in very small neonates.

B: Two fingers are used for infants. Fingers should be maintained in the upright position during compression. For neonates, this technique results in too low a position, ie, at or below the xiphoid; the correct position is just below the nipple line.

C: Hand position for chest compression for a child.

(Adapted from American Heart Association: Standards and guidelines for CPR. Journal of the American Medical Association 268:2251–2281,1992. Copyright 1992, American Medical Association.)

Drugs

After adequate oxygenation and ventilation, epinephrine is the drug of choice (see First-line drugs). Epinephrine dose is 0.01 mg/kg IV, which can be repeated q 3 to 5 min.

Amiodarone 5 mg/kg IV bolus can be given if defibrillation is unsuccessful after epinephrine. It may be repeated up to 2 times for refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). If amiodarone is not available, lidocaine may be given at a loading dose of 1 mg/kg IV followed by a maintenance infusion of 20 to 50 mcg/kg/min. Neither amiodarone nor lidocaine have been shown to improve survival to hospital discharge.

Blood pressure

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

Because BP varies with age, an easy guideline to remember the lower limits of normal for systolic BP (< 5th percentile) by age is as follows:

  • < 1 mo: 60 mm Hg

  • 1 mo to 1 yr: 70 mm Hg

  • > 1 yr: 70 + (2 × age in yr)

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

Equipment and environment

Equipment size, drug dosage, and CPR parameters vary with patient age and weight (see Table: CPR Techniques for Health Care Practitioners, see Table: Drugs for Resuscitation*, and see Table: Guide to Pediatric Resuscitation—Mechanical Measures). Size-variable equipment includes defibrillator paddles or electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal tubes, and suction catheters. Weight should be measured rather than guessed; alternatively, commercially available measuring tapes that are calibrated to read standard patient weight based on body length can be used. Some tapes are printed with the recommended drug dose and equipment size for each weight. Dosages should be rounded down; eg, a 2 ½-yr-old child should receive the dose for a 2-yr-old child.

Drugs for Resuscitation*

Drug

Adult Dose

Pediatric Dose

Comments

Adenosine

6 mg initially, then 12 mg × 2

0.1 mg/kg initially, then 0.2 mg/kg × 2

Rapid IV push is followed by flush (maximum single dose 12 mg).

Amiodarone

For VF/pulseless VT: 300 mg

For VF/pulseless VT: 5 mg/kg

For VF/pulseless VT: Give as IV push over 2 min.

For perfusing VT: Loading dose: 150 mg

Infusion (drip): 1 mg/min × 6 h, then 0.5 mg/min × 24 h

For perfusing VT: 5 mg/kg over 20–60 min, repeated to a maximum of 15 mg/kg/day

For perfusing VT: Give initial dose as IV push over 10 min.

Amrinone

Loading dose: 0.75 mg/kg over 2–3 min

Infusion (drip): 5–10 mcg/kg/min

Loading dose: 0.75–1 mg/kg over 5 min (may be repeated up to 3 mg/kg)

Infusion: 5–10 mcg/kg/min

500 mg in 250 mL 0.9% saline gives 2 mg/mL.

Atropine

0.5–1 mg

0.02 mg/kg

Repeat q 3–5 min to effect or total dose of 0.04 mg/kg (minimum dose 0.1 mg).

Calcium chloride

1 g

20 mg/kg

10% solution contains 100 mg/mL.

Calcium gluceptate

0.66 g

N/A

22% solution contains 220 mg/mL.

Calcium gluconate

0.6 g

60–100 mg/kg

10% solution contains 100 mg/mL.

Dobutamine

2–20 mcg/kg/min (starting at 2–5 mcg/kg/min)

Same as adult dose

500 mg in 250 mL 5% D/W gives 2000 mcg/mL.

Dopamine

2–20 mcg/kg/min (starting at 2–5 mcg/kg/min)

Same as adult dose

400 mg in 250 mL 5% D/W gives 1600 mcg/mL.

Epinephrine

Bolus: 1 mg

Infusion: 2–10 mcg/min

Bolus: 0.01 mg/kg

Infusion: 0.1–1.0 mcg/kg/min

Repeat q 3 to 5 min as needed.

8 mg in 250 mL 5% D/W gives 32 mcg/mL.

Glucose

25 g 50% D/W

0.5–1 g/kg

Avoid high concentrations in infants and young children.

5% D/W: Give 10–20 mL/kg.

10% D/W: Give 5–10 mL/kg.

25% D/W: Give 2–4 mL/kg.

For older children, use a large vein.

Lidocaine

1–1.5 mg/kg; repeat q 5–10 min to a maximum of 3 mg/kg

1 mg/kg loading dose, then 20–50 mcg/kg/min infusion

In adults, lidocaine may be considered after ROSC for VF/VT.

In children, lidocaine may be used instead of amiodarone for refractory VF/VT.

Magnesium sulfate

1–2 g

25–50 mg/kg to a maximum of 2 g

Give over 2–5 min.

Milrinone

Loading dose: 50 mcg/kg over 10 min

Infusion: 0.5 mcg/kg/min

Loading dose: 50–75 mcg/kg over 10 min

Infusion: 0.5–0.75 mcg/kg/min

50 mg in 250 mL 5% D/W gives 200 mcg/mL.

Naloxone

2 mg intranasal or 0.4 mg IM

0.1 mg/kg if patients are < 20 kg or <5 yr

Repeat as needed.

Norepinephrine

Infusion: 2–16 mcg/min

Infusion: Starting with 0.05–0.1 mcg/kg/min (maximum dose 2 mcg/kg/min)

8 mg in 250 mL 5% D/W gives 32 mcg/mL.

Phenylephrine

Infusion: 0.1–1.5 mcg/kg/min

Infusion: 0.1–0.5 mcg/kg/min

10 mg in 250 mL 5% D/W gives 40 mcg/mL.

Procainamide

30 mg/min to effect or a maximum of 17 mg/kg

Same as adult dose

Procainamide is not recommended for pulseless arrest in children.

Sodium bicarbonate (NaHCO3)

50 mEq

1 mEq/kg

Infuse slowly and only when ventilation is adequate.

4.2% contains 0.5 mEq/mL; 8.4% contains 1 mEq/mL.

Vasopressin

No longer recommended

Not recommended

Vasopressin is no more effective than epinephrine.

*For indications and use, see text.

IV or intraosseous.

ROSC = restoration of spontaneous circulation; VF = ventricular fibrillation; VT = ventricular tachycardia.

Guide to Pediatric Resuscitation—Mechanical Measures

Age (yr)

Term neonate

< 12 mo

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Weight, typical (kg)

3.5

< 10

10

12

14

16

18

20

22

25

28

30

35

40

45

50

55

60

Compression techniques

Thumb compression, hands around chest (preferred) or 2 fingers

1 hand

2 hands

Airway size (Portex) in cm

000

00

00

0

0

7

7

7

7

7

7

7

7

7

8

8

8

8

3.5

5

5

6

6

Masks in Laerdal sizes or equivalent

Circular 0/1

Rendell- Baker type # 1

Rendell-Baker type # 2

Dome cuff mask # 3

Dome cuff mask # 4

Ventilation bag with reservoir for 100% O2 delivery

Infant 240 mL

Child 400–500 mL

Adult 1600 mL

Laryngoscope blade size

Miller 0

Straight blade

1

1

1

2

2

2

2

2

2

2

3

3

3

3

3

3

3

Straight blade (preferred) or curved blade

Curved or straight blade

ETT size (Portex) in mm

3

3.5

4

4.5

4.5

5

5

5.5

5.5

6

6

6

6

6.5

6.5

6.5

6.5

7

Uncuffed

Uncuffed

Cuffed

Suction catheter

Direct oropharyngeal

Through ETT

10 F

Pediatric tonsil suction

8 Fr

Adult tonsil suction

10 Fr

*Pause for ventilation.

ETT =endotracheal tube; Fr = French.

Courtesy of Dr. B. Paes and Dr. M. Sullivan, the Departments of Pediatrics and Medicine, St. Joseph’s Hospital, The Children’s Hospital, Hamilton Health Sciences Corporation, McMaster University, Hamilton, Ontario, Canada.

Temperature management

Susceptibility to heat loss is greater in infants and children because of a large surface area relative to body mass and less subcutaneous tissue. A neutral external thermal environment is crucial during CPR and postresuscitation. Hypothermia with core temperature < 35° C makes resuscitation more difficult.

For comatose children resuscitated from in-hospital and out-of-hospital cardiac arrest, there is no evidence that therapeutic hypothermia is beneficial. In comatose children resuscitated from cardiac arrest, therapeutic normothermia (36° C to 37.5° C) should be pursued (1, 2) and fever should be treated aggressively.

Airway and ventilation

Upper airway anatomy is different in children. The head is large with a small face, mandible, and external nares, and the neck is relatively short. The tongue is large relative to the mouth, and the larynx lies higher in the neck and is angled more anteriorly. The epiglottis is long, and the narrowest portion of the trachea is inferior to the vocal cords at the cricoid ring, allowing the use of uncuffed endotracheal tubes. In younger children, a straight laryngoscope blade generally allows better visualization of the vocal cords than a curved blade because the larynx is more anterior and the epiglottis is more floppy and redundant.

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

With an advanced airway in place, 1 breath is given q 6 sec (10 breaths/min) for infants, children, and adults.

Defibrillation

In asystole, atropine and pacing are not used.

VF and pulseless VT occur in only about 15 to 20% of cardiac arrests. Vasopressin is not indicated. When defibrillation is used, the absolute energy dose is less than that for adults; waveform can be biphasic (preferred) or monophasic. For either waveform, the recommended energy dose is 2 joules/kg for the first shock, increasing to 4 joules/kg for subsequent attempts (if necessary—see defibrillation in adults). The maximum recommended dose is 10 joules/kg or the maximum adult dose (200 joules for a biphasic defibrillator and 360 joules for a monophasic defibrillator).

Automated external defibrillators (AEDs) with adult cables may be used for children as young as 1 yr, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for children between 1 yr and 8 yr. There is insufficient evidence to recommend for or against the use of AEDs in children < 1 yr. For pad placement, see defibrillation in adults.

Treatment references

More Information

  • American Heart Association's guidelines for CPR and emergency cardiovascular care

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ATROPEN
  • EVZIO
  • No US brand name
  • XYLOCAINE
  • ADRENALIN
  • ADENOCARD
  • LEVOPHED
  • VASOSTRICT
  • CORDARONE