2025+AHA心肺复苏与心血管急救指南-第6部分：儿童基本生命支持

PREAMBLE

More than 20 000 infants and children have an in-hospital cardiac arrest(IHCA) per year in the United States.1-5 In 2015, emergency medical service-documented OHCA occurred in>7000 infants and children.4 Pediatric OHCA patients' survival to hospital discharge varies by age, with survival rates of 17.3% in adolescents, 14.7% in children,and 6.6% in infants.6 Since 2000, pediatric IHCA has had an overall increase in survival to hospital discharge improving from 18.9% to 44.2% in 2022.5 Neurological outcomes remain difficult to assess across the pediat-ric age spectrum, with variability in reporting metrics and time to follow-up across studies of both OHCA and IHCA.Favorable neurological outcome has been reported in up to 47% of survivors to discharge.7 Despite increases in survival from IHCA, there is more to be done to improve both survival and neurological outcomes.8

These guidelines have recommendations for pedi-atic basic life support (BLS)-excluding the newborn infant-and are based on the best available resuscita-tion science. The Chain of Survival (see Major Concepts

<EndOfPara>section), including recovery from cardiac arrest, requires coordinated efforts from medical professionals in a vari-ety of disciplines and, in the case of OHCA, from lay responders, emergency dispatchers, and first respond-ers. In addition, specific recommendations for pediatric advanced life support are provided in “Part 8: Pediatric Advanced Life Support”9; recommendations for resus-citation training are provided in “Part 12: Resuscitation Education Science"10; recommendations about systems of care are provided in “Part 4: Systems of Care"11; rec-ommendations for special circumstances are provided in “Part 10: Adult and Pediatric Special Circumstances of Resuscitation"12; and ethical considerations related to pediatric resuscitation are discussed in “Part 3: Ethics."13

INTRODUCTION

Scope of Guidelines

These guidelines are intended to be a resource for lay responders and health care professionals to identify and treat infants and children in the prearrest, intra-arrest,and postarrest states. These apply to infants and children in multiple settings: the community, prehospital, and hos-pital environment. Prearrest, intra-arrest, and postarrest topics are reviewed, including cardiac arrest in special circumstances such as severe FBAO.

For pediatric BLS, guidelines apply as follows:

● Infant guidelines apply to infants younger than approx-imately 1 year of age (excluding newborn infants).

● Child guidelines apply to children approximately 1 year of age until puberty. For teaching purposes,puberty is defined as breast development in females and the presence of axillary hair in males.

● For those with signs of puberty and beyond, adult BLS guidelines should be followed.

Neither pediatric advanced nor basic life support guide-lines address the resuscitation of newborn infants, who are transitioning from a fluid-filled to an air-filled environment.Resuscitation of the newborn infant is addressed in "Part 5: Neonatal Resuscitation."14 Although pediatric basic and advanced life support guidelines may be applied to new-born infants <28 days old based on pathophysiology and institutional practice, neonatal guidelines should be fol-lowed at birth to address unique aspects of transitional physiology. ${ }^{15}$ Infancy is considered the first year of life.

Organization of the Pediatric Writing Committee

The Pediatric BLS Writing Group consisted of pediat-ric clinicians with representation from the American Heart Association(AHA) and the American Academy of Pediatrics(AAP), including intensivists, cardiac in-tensivists, emergency medicine physicians, respira-tory therapists, nurses, and nurse practitioners. A call for candidates was distributed to the AHA Emergency

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

Cardiovascular Care Committee and AAP subject mat-ter experts, and volunteers with recognized expertise in pediatric resuscitation were nominated by the writing

group co-chairs. Writing group members were selected by the AHA Emergency Cardiovascular Care Science Subcommittee and then

Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care(Updated December 2024)*

CLASS(STRENGTH) OF RECOMMENDATION

Class 1(STRONG)

Event >>> Risk

Suggested phrases for writing recommendations:

<EndOfPara>Is recommended

<BeginOfPara>Is indicated/useful/effective/beneficial

● Should be performed/administered/other

•Comparative-Effectiveness Phrases\dagger

- Treatment/strategy A is recommended/indicated in preference to treatment B

- Treatment A should be chosen over treatment B

Class 2a(MODERATE)

Benefit >> Risk

Suggested phrases for writing recommendations:

● Is reasonable

•Can be useful/effective/beneficial

•Comparative-Effectiveness Phrases$\dagger$

- Treatment/strategy A is probably recommended/indicated in preference to treatment B

It is reasonable to choose treatment A over treatment B

Class 2b (WEAK)

Benefit ≥ Risk

Suggested phrases for writing recommendations:

● May/might be reasonable

● May/might be considered

•Usefulness/effectiveness is unknown/unclear/uncertain or not well-established

Class 3: No Benefit(MODERATE)Benefit= Risk(Generally,LOE A or B use only)

Suggested phrases for writing recommendations:

● Is not recommended

<BeginOfPara>Is not indicated/useful/effective/beneficial

● Should not be performed/administered/other

Class 3: HARM(STRONG)

Risk> Benefit

Suggested phrases for writing recommendations:

· Potentially harmful

● Causes harm

● Associated with excess morbidity/mortality

$\quad$ Should not be performed/administered/other

LEVEL(QUALITY) OF EVIDENCE#

Level A

• High-quality evidence\# from more than 1 RCT

Meta-analyses of high-quality RCTs

•One or more RCTs corroborated by high-quality registry studies

Level B-R

(Randomized)

•Moderate-quality evidence\# from 1 or more RCTs

Meta-analyses of moderate-quality RCTs

Level B-NR

(Nonrandomized)

•Moderate-quality evidence $\pm$ from 1 or more well-designed, well-executed nonrandomized studies,observational studies, or registry studies

•Meta-analyses of such studies

(Limited Data)

Randomized or nonrandomized observational or registry studies with limitations of design or execution

•Meta-analyses of such studies

•Physiological or mechanistic studies in human subjects

Level C-EO

(Expert Opinion)

● Consensus of expert opinion based on clinical experience

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

+For comparative-effectiveness recommendations(COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

$\ddagger$ The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion;LD,limited data; LOE, Level of Evidence; NR, nonrandomized;R,randomized; and RCT,randomized controlled trial.

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approved by the AHA Manuscript Oversight Committee.The AHA and AAP have rigorous conflict of interest poli-cies and procedures to minimize the risk of bias or im-proper influence during development of the guidelines.16 Prior to appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential(including intellectual) conflicts. Writing group members whose research led to changes in guidelines were required to declare those conflicts during discus-sions and abstain from voting on those specific recom-mendations. This process is described more fully in“Part 2:Evidence Evaluation and Guidelines Development"17 Com-prehensive disclosure information for writing group mem-bers and peer reviewers is listed in Appendixes 1 and 2.

METHODOLOGY AND EVIDENCE REVIEW

These pediatric guidelines are based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation and affiliated International Liaison Committee on Resuscita-tion member councils. Three types of evidence reviews(systematic reviews, scoping reviews, and evidence up-dates) were used in the 2025 process.18,19 This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development."17

Class of Recommendation and Level of Evidence

The writing group reviewed all relevant and current AHA Guidelines for CPR and Emergency Cardiovascular Care and all relevant International Liaison Committee on Re-suscitation Consensus on CPR and Emergency Cardio-vascular Care Science With Treatment Recommendations from 2020, 2022, 2023, and 2024.20-23 Evidence and recommendations were reviewed to determine if current guidelines should be reaffirmed, revised or retired, or if new recommendations were needed. The writing group then drafted, reviewed, and approved recommendations,assigning a Class of Recommendation (COR; ie, strength)and Level of Evidence (LOE; ie, quality, certainty) to each.Criteria for each COR and LOE are described in Table 1.

Guidelines Structure

The 2025 guidelines are organized in discrete modules of information on specific topics or management is-sues.24 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. Recommendations are presented in order of COR: most potential benefit (Class 1), followed by lesser certainty of benefit (Class 2), and finally po-tential for harm or no benefit (Class 3). Following the COR, recommendations are ordered by the certainty of

supporting LOE: Level A (high-quality randomized con-trolled trials) to Level C-EO (expert opinion). This order does not reflect the order in which care should be provided.

In addition to the table of recommendations, the knowledge chunk includes a brief synopsis to put the recommendations into context with important back-ground information and overarching management or treatment concepts. Recommendation-specific sup-portive text clarifies the rationale and key study data supporting the recommendations. When appropriate,illustrations are included. Hyperlinked references are provided to facilitate quick access and review.

Document Review and Approval

The guideline was submitted for blinded peer review to 8 subject matter experts nominated by the AHA and AAP Before appointment, all peer reviewers were required to disclose relationships with industry and any other con-flicts of interest, and all disclosures were reviewed by AHA staff. The guideline was also reviewed and approved for publication by the AHA Science Advisory and Coor-dinating Committee, the AHA Executive Committee, and the AAP Board of Directors. Comprehensive disclosure information for peer reviewers is listed in Appendixes 1 and 2. These recommendations supersede the last full set of AHA recommendations for pediatric advanced life support, made in 2020.25 The writing group consisting of AHA and AAP representatives voted on and approved all guideline recommendations.

REFERENCES

1. Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J,Grossestruer AV, Yankama T, Donnino MW, Andersen LW; on behalf of the American Heart Association's Get With The Guidelines-Resuscitation In-vestigators. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ. Cardiovasc Qual Outcomes.2019;12:e005580.

2.Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH,Warden CR, Berg RA; and the Resuscitation Outcomes Consor-tium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consor-tium Epity-Cardiac Arrest. Circulation. 2009;119:1484-1491. doi: 10.1161/CIRCULATIONAHA.108.802678

3.Knudson JD,Neish SR,Cabrera AG,Lowry AW,Shamszad P,Morales DL,Graves DE,Williams EA,Rossano JW.Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids' Inpatient Database. Crit Care Med.2012;40:2940-2944. doi:10.1097/CCM.0b013e31825feb3f

4.Vrani SS,Alonso A,Benjamin EJ,Bittencourt MS,Callaway CW,Carson AP,Chamberain AM,Chang AR,Cheng S,Delling FN,et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Sta-tistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke.2020 at:141:e139-e596.doi:10.1161/CIR00000000000000757

5. Martin SS, Aday AW, Almarozoo ZI, Anderson CAM, Arora P, Avery CL,Baker-Smith CM, Baron Gibbs B, Beaton AZ, Boehme AK, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.2024 heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. 2024;149:e347-e913. doi:10.1161/CIR.0000000000000000.613. doi:10.1161/CIR.00000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613. doi:10.1161/CIR.0000000000000.613.

6.CARES: Centers for Disease Control and Prevention and Emory University School of Medicine. Cardiac Arrest Registry to Enhance Survival (CARES).MyCARES. Accessed April 1,2023. https://mycares.net

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7. Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL,BenRs RJ, Praestgaard A, Weissfeld L, et al: on behalf of the Ameri-can Heart Association's Get With The Guidelines-Resuscitation(Formerly the National Registry of Dopplanmonary Resuscitation) Investigators. Du orration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac rats. Circulation.2013;127:442-451; doi:1011/CIRCirculationNAHA-112:152652

8. Girotra S, Spertus JA, Li Y, Berg A, Radnakari VM, Chan PS; on behalf of the American Heart Association Get With the Guidelines-Resuscitation Observations. Survival trends in pediatric in-spatial hospital cardiac arrest: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes.2013;6:42-49. doi:10.1161/CIRCOUTCOMES.112.967986

Jaa. L99, Lia DH, Scott US, Guff HP, Jayes K., Kamath-Rayne BD, Levy, Mahgoub M, Morgan RW, McCormick R, Roberts JS, Ross CE, Schexneyner SM,Sweberg T, Valdes SO, Topian AA Part: 8 Pediatr Advanced Life Support 2025 American Heart Association Guidelines for cardiopulmonary Resus-citation and Emergency Cardiovascular Care. Circulation. 2025;152(2:15957-2) S479-S537, doi:10.1161/CIR/0000000000001368

10. Donoghue A, Auerbach M, Banerjee A, Blewer A, Cheng A, Kadlec K, Lin Y,Diederich E, Sawyer T, Stallings D, Toft L, Dorman W, Dijk, SJchexander S,Dainty KN. Part 12: Resclutation Education Science: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation for Cardiopulmonary Resuscitation for Cardiopulmonary Resuscitation for Cardiopulmonary Resuscitation for Cardiopulmonary Resuscitation for Cardi_10.1161/CIR/000000000000001374

11. Dezifulian C, Cabanas JG, Buckley J, Cash RE, Crowe RP, Drennan IR,Mahgoub M, Mannarino CN, May T, Salico DD, Uzende AL, et al. Part 4:Systems of Care: 2025 American Heart Association Guidelines for Cardio-

12. Cao D,Arens AM,Chow SL,Easter SR,Hoffman RS,Lagina AT,Lavona EJ,Patil KD,Sutherland LD,Tsissen JA,et Par al. Part 10: adult and pediat-ric special circumstances of resuscitation: 2025 American Heart Asso-ciation Guidelines for Cardioplmonary Resuscitation and Emergency Cardiovascular Care. Circulation: 2025/1525(suppl 2):10.1161/CIR/00000000000001378

13.Emerl J,Atkins DL,Dayra MR,Del Rios M,Fry JT,Henderson CM,Lewis-Newty M,Modrid WA, Marc Oato, IR公司 JP et al. Part 3: ethics: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S33-S325. doi:10.1161/CIR/0000000000001371

14. Lee HC, Strand ML, Finan E, Illuzzi Z, Kamath-Rayne BD, Kapadia V,Mahgoub M,Niemeyer S,Schexneyander S,Schexneyander S,Boan et al. Sneonal reuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2025;152(Suppl 2):neonal reuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Energy Cardiovascular Care. Circulation, 2025;152(Suppl 2):S385-S423. doi: 10.1161/CIR.00000000000001367

15. Sawyer T, McBride ME, Ades A, Kapadia VS, Leone TA, Lakshminrushima,S,Ali N, Marshall S, Schmolzer GM, Kadlec KD, et al. Considerations on the use of neonatal and pediatric resuscitation guidelines for hospitalized neonates and infants; on behalf of American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics.2024;153e2023064681. doi:10.1542/peds.2023-064681

16. American Heart Association. Conflict of interest Policy Accessed December 31, 2019. https://www.heart.org/enabout-us/stations-and-policies/cffect-of-interest-policy

17. Panchal AR, Bartos JA, Wyckoff MH, Drennan IR, Mahgshen A, Schneydray SM, Rodriguez AJ, Asson S, Cnight, JROsles SC, et al. Part 2: evi-dence evaluation and guidelines development: 2025 American Heart As-sociation Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S313-S322. doi:10.1161/C00000000000001373

18. International Liaison Committee on Resuscitation(ILCOR). Continuous evi-dence evaluation guidance and templates: 2020 evidence update process final. Accsued December 31, 2019. https://www.lcohorg.org/documents/continuous-evidence-evaluation-guidance-and-templates

19. Institute of Medicine (US) Committee of Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care:Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S,eds.Washington,DC:The National Academies Press;2011.

20:Wyckhoff MH, Greir R, Morley PT, Ng KC, Oslaevengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Car-diovascular Care Science With Treatment Recommendations: sum-mary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and

Teams; and First Aid Task Forces.Circulation.2022;146:e483-e557. doi:10.1161/CIR.000000000000001095

21. Greif R, Bray JE, Djar T, Drennan IR, Liley HG, Ng K-C, Cheng A, Douma MJ, Scholefield BR, Smyth M, et al. 2024 International consensus on car-diopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Edu-cation, Implementation, and Teams; and First Aid Task Forces. Circulation.2024;150:e580-e687. doi: 10.1161/CIR.0000000000001288

22.Maconohe IK, Acidin R, Hazinski MF, Atkins DL, Bingham R, Couto TB,Guerguerian AM,Nadkarmi VM, Ng KC, Nuthall GA, et al; on behalf of the Pe-diatric Life Support Collaborators. Pediatric life support: 2020 International Consensus on cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation.2020;142(16\underline{\underline{\Sigma}}\underline{\underline{\Sigma}}\underline{\underline{\Sigma}})$

23. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson Jin, Morley PT,Drennan IR, Smyth M, Schildle field BR,et al. 2023 International Consensus on cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Holefield BR,et al. 2023 International Consensus on cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Holefield BR,et al. 2023 International Consensus on cardiopulmonary Resuscitation and Emergency Services with Treatment Model; Pediatric Life Support; Neonatal Life Sup-port;Education,Implementation,and Teams; and First Aid Task Forces.Cir-culation.2023;148:e187-e280.doi:10.1161/CIR.00000000000001179

24. Levine G N.GarsQT,Beckman JA,Al-Khatib SM,Birtcher KK,Cigararro JE,and de Las Fuentes L, Deswalter A, Fleisher LA, Gentile F,et al.Recent innovations,modifications, and evolution of ACC/AHA Clinical Practice Guidelines: an update for our constituencies: a report of the American College of Cardiol-ogy/American Heart Association Task Force on Clinical Practice Guidelines.Circulation.2019;139:e879-e886.doi:10.1161/CIR.0000000000000651

25. Topjan AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, Lasa JJ,Lavones J EJ, Levy A, Mahgoub M, et al; on behalf of the Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support:2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation:2020;142(16 suppil.2)[1011/CIR.200000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

MAJOR CONCEPTS

The epidemiology, pathophysiology, and common etiolo-gies of pediatric cardiac arrest are distinct from adult and neonatal cardiac arrest. Cardiac arrest in infants and children does not usually result from a primary cardiac cause; rather, it is the result of progressive respiratory failure or shock. In these patients, cardiac arrest is pre-ceded by a variable period of deterioration, which even-tually results in cardiopulmonary failure, bradycardia, and cardiac arrest. In children with congenital heart disease,cardiac arrest is often due to a primary cardiac cause,although the etiology is distinct from that in adults.

Outcomes for pediatric IHCA have improved over the past 20 years, in part because of early recognition, high-quality CPR, postarest care, and extracorporeal CPR.1-3 In a recent analysis of the AHA Get With The Guidelines-resuscitation Registry, a large multicenter, hospital-based cardiac arrest registry, a large multicenter, hospital-based cardiac arrest registry, pediatric IHCA survival to hospital discharge was 19% in 2000 and 44% in 2022. Survival has improved for pediat-ric events requiring CPR in the United States, with a 19% absolute increase in survival for in-hospital pulseless cardiac arrests and a 9% absolute increase in sur-vival for nonpulseless events(eg, bradycardia with hemody-namic compromise) between 2000 and 2018. However,survival from pulseless cardiac arrests has reached a pla-teau following 20102°New directions of research and ther-apy may be required to improve cardiac arrest survival. More IHCA IHCA events now occur in an intensive care unit setting,

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Figure 1. Cardiac arrest Chain of Survival.

CPR indicates cardiopulmonary resuscitation.

suggesting that patients at risk for cardiac arrest are being identified sooner and transferred to a higher level of care.4,5

Survival rates from OHCA remain less encouraging.Most pediatric OHCA are respiratory/asphyxial events leading to asystole or PEA and thus are nonshockable rhythms. While AEDs may be more prevalent in schools and sporting events over recent years, AEDs can deliver shocks only if a shockable rhythm (VF/pVT) is detected.AEDs save lives in the minority of pediatric arrests with shockable rhythms, but because those cases are rare,widespread AED deployment has not yet resulted in large overall improvements in pediatric OHCA survival at the population level. ${ }^{6-8}$ In a recent analysis of the Car-diac Arrest Registry to Enhance Survival from 2022, a multicenter OHCA registry, annual survival to hospital discharge of pediatric OHCA ranged from 6.6% to 17.3%depending on region and patient age, demonstrating gains for some populations over the last decade. 9 There was no significant change in these rates over time, con-sistent with other national registries. ${ }^{10,11}$ In the Resus-citation Outcomes Consortium Cardiac Epidemiological Registry, survival after OHCA was higher in regions with more arrests that were witnessed by emergency medi-cal services and with higher lay responder CPR rates,stressing the importance of early recognition and treat-ment of these patients.${ }^{4}$

As survival rates from pediatric cardiac arrest increase,there has been a shift with more focus on neurodevelop-mental, physical, and emotional outcomes of survivors.Recent studies demonstrate that one quarter of patients with favorable outcomes have global cognitive impair-ment and that 85% of older children who were reported to have favorable outcomes have selective neuropsychro-logical deficits. ${ }^{12}$

The Pediatric Chain of Survival

<BeginOfPara>Historically, cardiac arrest care has focused on the man-agement of the cardiac arrest itself, highlighting high-quality CPR, early defibrillation, and effective teamwork.However, there are aspects of prerearest and postarrest care that are critical to improve outcomes. As pediatric cardiac arrest survival rates have plateaued for lessuse

<EndOfPara>cardiac arrest, the prevention of cardiac arrest becomes even more important. In the out-of-hospital environment,this includes safety initiatives(eg, bike helmet laws), sud-den infant death syndrome prevention, lay rescuer CPR training, early recognition of the critically ill infant or child by the caregiver, and timely access to emergency care. When OHCA occurs, early lay responder CPR is critical in improv-ing outcomes, as well as the availability of AEDs for shock-able rhythms. In the in-hospital environment, cardiac arrest prevention focuses on the early recognition and treatment of patients at high risk, such as children undergoing cardiac surgery or children with acute fulminant myocarditis, acute decompensated heart failure, or pulmonary hypertension.Following resuscitation from cardiac arrest, management of the post-cardiac arrest syndrome(which may include brain dysfunction, myocardial dysfunction with low cardiac output, and ischemia or reperfusion injury) is important to avoid known contributors to secondary injury, such as hypo-tension. ${ }^{13,14}$ Accurate neuroprognostication is important to guide caregiver discussions and decision-making. Finally,given the elevated risk of neurodevelopmental impairment in cardiac arrest survivors, early referral for rehabilitation assessment and intervention is key.

A single Chain of Survival that supports the paradigm of early recognition through recovery after cardiac arrest has now been standardized across infants, children, and adults(outside of neonatal care; Figure 1).

REFERENCES

1.$\text{Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS; on behalf}$of the American Heart Association Get With The Guidelines-Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With The Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes.2013;6:42-49. doi: 10.1161/CIRCOUTCOMES.112.967968

2.Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK,Donnino MW, Andersen LW. Trends in survival after pediatric in-hospital cardiac arrest in the United States. Circulation. 2019;140:1398-1408. doi:10.1161/CIRCULATIONHAHA.119.04.1667

3.Berg RA, Sutton RM, Holubkov R, Nicholson CE, Dean JM, Harrison R,Heidemann S,Meert K,Newth C,Moler F,et al; on behalf of the Eunice Ken-nedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network and for the Ameri-can Heart Association's Get With The Guidelines-Resuscitation(formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Ratio of PICU versus cardiculmonary resuscitation events is increasing. Crit Care Med.2013;41:2292-2297. doi:10.1097/CCM.0b013e31828cf0c0

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

4.Fink EL,Prince DK, Kaltman JR,Atkins DL, Austin M, Warden C, Hutchison J, Daya M, Goldberg S, Herren H, et al; on behalf of the Resuscitation Out-comes Consortium. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Re-suscitation.2016;107:121-128.10:1016/j.resuscitation.2016.07.244

5.Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T; on behalf of the Japanese Circulation Society Resuscitation Science Study Group. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation.2012;126:2834-2843. doi:10.1161/CIRCULATIONAHA.112:109496

6. Jayaram N,et al."Epidemiology of pediatric out-of-hospital cardiac arrest in the United States." Resuscitation: 2015;90:19-25.

7. Hansen M,et al."Association of bystander and first-sponder interven-tion with survival after pediatric out-of-hospital cardiac arrest in the United States."JAMA Netw Open 2020;3:e204283.

8. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA; and the Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children:the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation.2009/11:1484-1491. doi:10.1161/CIRCULATIONAHA.108.802678

9.Cardiac Arrest.\ Thister of Enhance Survival. Accessed April 1,2023.https://mycares.net

10.Tham LP,Wah W,Phillips R,Shahidah N,Ng YY,Shin SD,Nishiuchi T,Wong KD,Ko PC,Khunklau N,et al.Epidemiology and outcome of paediatric out-of-hospital cardiac arrest: a paediatric sub-study of the Pan-Asian Resus-citation Outcomes Study(PAROS). Resuscitation: 2018:125:111-117. doi:1016.1017/jresg.2018.01.040

11. Straney LD, Schlapbach LJ, Yong G, Bray JE, Millar J, Slater A, Alexander J,Finn J; on behalf of the Australian and New Zealand Intensive Care Society Paediatric Study Group. Trends in PICU admission and survival rates in chil-dren in Australia and New Zealand following cardiac arrest: Pediatr Crit Care Med.2015;16:613-620. doi: 10.1097/PCC.000000000000425

12.$\_$Slomine BS, Silverstein FS,Christensen JR, Page K, Holubkov R, Dean JM,Moler F, Neuropsychological outcomes of children 1 year after pediatric cardiac arrest: secondary analysis of 2 randomized clinical trials. JAMA Neu-rol.2018;75:1502-1510. doi: 10.1001/jamaneurol.2018.26282

13.Topian AA, de Caen A: Winwright MS, Abella BS, Abend NS, Atkins DL,Bembea MM, Fink EL, Guerguerian AM, Haskell SE, et al. Pediatric post-cardiac arrest care: a scientific statement from the American Heart Association.Circulation.2019;140:e194-e233.doi:10.1161/CIR.0000000000000697

14. Laveriere EK,Polansky M,French B,Nadkami VM,Berg RA,Topjian AA.Associa-tion of duration of hypotension with survival after pediatric cardiac arrest. Pediatr Pediatr Care Med.2020;21:143-149. doi:10.1097/PCC.000000000000002119

TREATMENT OF RESPIRATORY FAILURE

Respiratory failure occurs when a patient's breathing be-comes inadequate and results in ineffective oxygenation and ventilation. This can occur due to disordered control of breathing, upper airway obstruction, lower airway ob-struction, respiratory muscle failure, or parenchymal lung disease. Providing assisted ventilation when breathing is absent or inadequate, relieving FBAO, and administering naloxone in opioid overdose can be lifesaving.

Opening the Airway

|Recommendations for Opening the Airway||| |---|---|---| |COR|LOE|Recommendations| |1|C-LD|1. Unless a cervical spine injury is suspected, use a head tilt-chin lift maneuver to open the airway in infants and children.| |1|C-EO|2. For infants and children with suspected cervical spinal injury, use a jaw thrust without head tilt to open the airway.| |1|C-EO|3. For infants and children with suspected cervical spinal injury, if the jaw thrust does not open the airway, use a head tilt-chin lift maneuver.|

 Figure 2. Head tilt-chin lift maneuver to open the airway in infants while providing breaths.

Synopsis

Ensuring a patent airway is crucial for effective ventilation and oxygenation. Although there is no definitive evidence favoring a particular technique related to creating/main-taining patency of the airway, it is important for rescuers to understand the benefits and limitations of each method and to remain skilled in their application. Multiple approach-es may be necessary to open an airway, and continuous monitoring of the pediatric patient is essential to confirm and maintain airway patency to ensure sufficient ventilation and oxygenation. Research comparing airway management strategies in pediatric cardiac arrest patients is lacking,with most available data derived from radiographic stud-ies obtained during effective surgeries. As observed in the 2020 Guidelines, there continues to be a lack of pediatric-specific clinical studies. Figure 2 demonstrates the head tilt-chin lift maneuver to open the airway in infants.

Recommendation-Specific Supportive Text

1.No data directly address the ideal method to achieve or maintain pediatric airway patency. One retrospective cohort study evaluated various head-tilt angles in neonates and young infants under-going diagnostic magnetic resonance imaging and found that the highest proportion of patent airways was at a head-tilt angle of 144° to 150° based on a regression analysis.1

2.While no pediatric studies evaluate jaw thrust ver-sus head tilt to open the airway, jaw thrust is widely accepted as an effective way to open the airway,and this maneuver theoretically limits cervical motion compared with the chin lift.

3.There are no pediatric studies evaluating the impact of a head tilt-itch in lift maneuver to open the airway in a trauma patient with suspected cervi-cal spine injury. However, if rescuers are unable to open the airway and deliver effective ventila-tions using a jaw thrust, given the importance of a

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patent airway, using a head tilt-chin lift maneuver is recommended.

REFERENCES

1. Bhalala US, Hemani M, Shah M, Kim B, Gu B, Cruz A, Arunachalam P, Tian E,Yu C,Punnoose J,et al.Defining optimal head-tilt position of resuscitation in neonates and young infants using magnetic resonance imaging data.PLoS One.2016;11:e0151789.doi:10.1371/journal.pone.0151789

Treatment of Inadequate Breathing With a Pulse

|Recommendations for Treatment of Inadequate Breathing With a Pulse|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-EO|1. For infants and children with a pulse but absent or inadequate respiratory effort, breaths should be provided.|| |2a|C-EO|2. For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 s(20-30 breaths/min).||

Synopsis

The priority in managing a seriously ill or injured child who is not in cardiac arrest is evaluating the airway and breathing. If the child demonstrates signs of inadequate or absent breathing, breaths should be initiated to restore adequate oxygenation and ventilation. Because respirato-ry conditions are a major cause of cardiac arrest in infants and children, it is important to begin appropriate interven-tions to support ventilation and oxygenation quickly.

Recommendation-Specific Supportive Text

<BeginOfPara>1 and 2. Pediatric-specific clinical studies evaluating the effect of different ventilation rates on outcomes in patients who have inadequate breathing with a pulse are lacking. In 2020, the guidelines were updated to reflect new data from a multicenter observational study that found that ventilation rates of at least 30/min in infants and at least

 Figure 3. Chest thrusts in an infant with severe foreign-body airway obstruction.

<EndOfPara>25/min in children >1 year of age during CPR with an advanced airway in place were associated with improved return of spontaneous circulation(ROSC), survival to discharge, and survival with favorable neurological outcome. Excessive ven-tilation rates were associated with lower systolic blood pressures in older children, so care must be taken to avoid higher rates that could compromise hemodynamic's.1 For the ease of training, the rec-ommended respiratory rate for the pediatric patient with inadequate breathing and a pulse continues to be 1 breath every 2 to 3 seconds.

REFERENCES

1. Sutton RM, Reeder RW, Landis WP, Meert KL, Yates AR, Morgan RW,Berger JT, Newth CJ, Carcillo JA, McQuillen PS, et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes. Crit Care Med.2019;47:1627-1636. doi: 10.1097/CCM.0000000000003898

Foreign-Body Airway Obstruction

|Recommendations for FBAO|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-LD|1. Infants or children with mild FBAO should be al- lowed to clear the airway by coughing while being observed for signs of severe FBAO.|| |1|C-LD|2. For infants with severe FBAO, repeated cycles of 5 back blows alternating with 5 chest thrust should be performed until the object is expelled or the infant becomes unresponsive.|| |1|C-LD|3. For children with severe FBAO, repeated cycles of 5 back blows alternating with 5 abdominal thrust should be performed until the object is expelled or the child becomes unresponsive.|| |1|C-LD|4. If infants or children with severe FBAO become unresponsive, rescuers should start CPR, begin- ing with chest compressions (rescuers should not perform pulse check).||

 Figure 4. Back blows in an infant with severe foreign-body airway obstruction.

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 Figure 5. Abdominal thrusts in a child with severe foreign-body airway obstruction.

|Recommendations for FBAO(Continued)|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-LD|5. For infants or children with FBAO receiving CPR, rescuers should remove any visible foreign body when opening the airway to provide breaths.|| |2B|C-LD|6. Effectiveness and safety of suction-based airway clearance devices have not been established in in- fans and children. There is insufficient evidence to make a recommendation for infants and children.|| |3|Harm C-LD|7. Blind finger sweeps should not be performed for infants and children with FBAO.||

Synopsis

Suffocation(eg, FBAO) is a leading cause of death in in-fants and children. Balloons, certain foods(eg, hot dogs,nuts, grapes), and small household objects are the most common causes of FBAO in children, ${}^{1-3}$ while liquids are common among infants.4 It is important to differentiate between mild FBAO(the patient is coughing and mak-ing sounds) and severe FBAO(the patient cannot make sounds). Patients with mild FBAO can attempt to clear the obstruction by coughing, but intervention is required in se-vere obstruction. There are no high-quality data to support recommendations regarding FBAO in children. Figures 3 and 4 demonstrate chest thrusts and back blows in an infant with severe FBAO, and Figure 5 demonstrates ab-dominal thrusts in a child with severe FBAO. Figures 6 and 7 are the algorithms for infant and child FBAO.

Recommendation-Specific Supportive Text

1 and 3. Many FBAOs are relieved by allowing the patient to cough or, if severe, are treated by bystanders using chest thrusts or abdominal thrusts.4-8 A recent observational study of adult and pediatric FBAO suggests improved clearance of a foreign body with the use of back blows over abdominal thrusts.8 To create consistency for instructional purposes, and in the absence of inferiority from pediatric data, management of severe FBAO in children now starts with a series of back blows instead of abdominal thrusts. Repeated cycles of


Figure 6. Infant FBAO.

BLS indicates basic life support; CPR,cardiopulmonary resuscitation; and FBAO,foreign-body airway obstruction.

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Figure 7. Child FBAO.

BLS indicates basic life support; CPR,cardiopulmonary resuscitation; and FBAO,foreign-body airway obstruction.

<BeginOfPara>5 back blows followed by 5 abdominal thrusts are performed until the obstruction is cleared or the child becomes unresponsive.

2.Observational data primarily from case series support the use of back blows 4,5,9-11 or chest thrusts 7-9,12 for infants. Abdominal thrusts are not recommended for infants, given the poten-tial to cause abdominal organ injury.13 The heel-of-hand technique for chest thrusts is now recommended for infants with severe FBAO, as current CPR literature suggests that it gener-ates greater compression depth than the previ-ously recommended 2-finger technique.14 While the heel-of-hand technique for chest thrusts resembles chest compressions that are used as part of CPR, there is no focus on the other components of high-quality CPR chest com-pressions(eg, rate, recoil), so the term chest compression is not used. If infants and children develop severe FBAO, emergency medical ser-vices should be promptly activated as they can rapidly deteriorate into cardiac arrest.

4.Once the infant or child is unconscious, obser-vational data support immediate CPR with pro-vision of chest compressions(do not perform a pulse check), followed by ventilations.8,12 Note that these compressions are delivered with attention to the provision of high-quality chest compressions as part of CPR.

5 and 7. Observational data suggest that the risk of blind finger sweeps outweighs any potential benefit in the management of FBAO. ${}^{7,15-17}$

6. A solitary case series describes the use of por-table nonpowered suction devices for infants and children with severe FBAO.18 As the avail-able evidence comes from voluntary reporting to an industry-sponsored registry, there is potential for significant confounding and bias, as well as incomplete case descriptions and patient out-comes reporting. The limited reported evidence also does not suggest superiority of these devices over standard techniques such as back blows or abdominal thrusts.

REFERENCES

1. Rimell FL, Thome A, Jr, Stool S, Reilly JS, Rider G, Stool D, Wilson CL. Char-acteristics of objects that cause choking in children. JAMA.1995;274:1763-1766.

2. Harris CS,Baker SP,Smith GA,Harris RM.Childhood asphyxiation by food.a national analysis and overview. JAMA 1984;251:2231-2235.

3.Morley RE,Ludemann JP, Moxham JP, Kozak FK, Riding KH. Foreign body aspiration in infants and toddlers: recent trends in British Columbia. J Oto-laryngol. 2004;33:37-41. doi: 10.2310/7070.2004.00310

4. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Airway obstruc-tion in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care.2004;8:196-199. doi:10.1016/j.prehos.2003.12.014

5.Heimlich H.J. A life-saving maneuver to prevent food-choking. JAMA.1975;234:398-401.

6.Sternbach G., Kiskadton RT. Henry Heimlich: a life-saving ma-neveru for food choking.J Emerg Med. 1985;3:143-148.doi:10.1016/0736-479(85)90047-2

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7. Couper K, Abu Hassan, A ohri V, Patterson E, Tang HT, Bingham R,Osliavengen T, Perkins God; on behalf of the International Liaison Com-mittee on Resuscitation Basic and Paediatric Life Support Task Force Collaborators. Removal of foreign body airway obstruction: a system-atic review of interventions. Resuscitation. 2020;156:174-181. doi:10.1016/j.resuscitation.2020.09.007

8.Dunne CL, Cirone J, Blanchard IE, Holroyd-Leduc J, Wilson TA, Sauro K, McRae AD. Evaluation of basic life support interventions for foreign body airway obstructions: a population-based cohort study. Resuscitation.2024;2011:110258.doi:10.1016/j.resuscitation.2024.110258

9.Redding JS.The choking controversy: critique of evidence on the Heimlich maneuver. Crit Care Med. 1979;7:475-479.

10. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Air-way obstruction in children aged less than 5 years: the prehos-pital experience. Prehosp Emerg. Care 2004;8:196-199. doi: 10.1016/j.prehos.2003.12.014

11. Sternbach G, Kiskadton RT. Henry Heimlich: a life-saving ma-neuer for food choking. J Emerg Med.1985;3:143-148. doi: 10.1016/0736-4679(85)90047-2

12. Kinoshita K, Azuhata T, Kawano D, Kawahara Y. Relationships between pre-hospital characteristics and outcome in victims of foreign body


Act fast and get help.

● If the child or infant is unresponsive,shout for help.

• Call 911.

● Ask someone to get an AED.

● If the child or infant is not breathing normally, immediately start CPR.

2.Give compressions and breaths


Children and infants need compressions and breaths!

● Start CPR. Use the heel of 1 hand(for infants) or 2 hands(for children) to push hard and fast in the center of the chest.

● After 30 compressions, give 2 breaths.

● Continue giving 30 compressions and 2 breaths until the AED or medical help arrives.

3. Use the AED


When that AED arrives, use it immediately!

● Turn on the AED and follow the prompts.

● Use child or infant pads, if available;if using adult pads, make sure the pads do not touch each other.

● Continue CPR and breaths until medical help arrives.

airway obstruction during meals. Resuscitation. 2015;88:63-67. doi:10.1016/j.resuscitation.2014.12.018

13. Lee SL, Kim SS, Shekherdimian S, Ledbetter DJ. Complications as a result of the Heinich maneuver. J Trauma. 2009;66:E34-E35. doi:10.1097/01.ta0000219291.27245.90

14.O'Connell KJ, Sandler A, Dutta A, Ahmed R, Neubrand T, Myers S, Kerrey B, Donoghue A. The effect of hand position on chest compression quality during CPR in young children: findings from the Videography in Pediatric Resuscitation(VIPER) collaborative. Resuscitation. 2023;185:109741. doi:10.1016/j.resuscitation.2023.109741

15. Abder-Rahman HA. Infants choking following blind finger sweep. J Pediatr(RoJ.2009;85:273-275. doi: 10.2223/JPED.1892

16. Hartrey R, Bingham RM. Pharyngeal trauma as a result of blind finger sweeps in the choking child. J Accid Emerg Med. 1995;12:52-54. doi:10.1136/emj.12.152

17. Kabmbi M, Goodwin SR. Traumatic epiglottis following blind finger sweep to remove a pharyngeal foreign body. Clin Pediatr (Phila). 1995;34:495-497. doi:10.1177/000992289503400908

18.Dunne CL, Osman S, Viguers K, Queirog AC, Szpilman D, Peden AE. Phase one of a global evaluation of suction-based airway clear-ance devices in foreign body airway obstructions: a retrospective

Figure 8. Pediatric BLS (Infants to Puberty) for Lay Rescuers.

AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation.

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

 Figure 9. Pediatric BLS Algorithm(Infants to Puberty) for Health Care Professionals-Single Rescuer.

AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; HR, heart rate; and PALS, pediatric advanced life support.

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

 Figure 10. Pediatric BLS Algorithm(Infants to Puberty) for Health Care Professionals-2 or More Rescuers.

AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; HR, heart rate; and PALS, pediatric advanced life support.

descriptive analysis. Int J Environ Res Public Health.2022;19:3846. doi:10.3390/ijerph19073846

SEQUENCE OF RESUSCITATION

The sequence of resuscitation events is displayed in Figures 8,9, and 10. Figure 8 is an infographic showing the critical actions for lay rescuers(ie, without medical

<EndOfPara>knowledge or experience). Figures 9 and 10 are algo-rithms showing the critical sequences for those with a basic level of medical knowledge and experience. The use of opioid antagonists(eg,naloxone) during respirato-ry or cardiac arrest is incorporated into the Pediatric BLS algorithms(Figures 9 and 10), with more detailed infor-mation provided in "Part 10: Adult and Pediatric Special Circumstances in Resuscitation."12

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Initiation of CPR

|Recommendations for Initiation of CPR|||| |---|---|---|---| |COR|LOE|Recommendations|COR| |1|C-LD|1. Lay rescers should begin CPR immediately for any infant or child who is unresponsive, not breath-ing normally, and does not have signs of life; they should not check for a pulse.|1. Lay rescers should begin CPR immediately for any infant or child who is unresponsive, not breath-ing normally, and does not have signs of life; they should not check for a pulse.| |2a|C-LD|2. In infants and children with no signs of life, it is reasonable for health care professionals to check for a pulse for up to 10 s and begin compressions unless a definite pulse is felt.|1.2. In infants and children with no signs of life, it is reasonable for health care professionals to check for a pulse for up to 10 s and begin compressions unless a definite pulse is felt.| |2b|C-LD|3. It may be reasonable to initiate CPR with compressions-airway-breathing over airway- breathing-compressions.|1. It may be reasonable to initiate CPR with a pressure-airway-breathing over airway- breathing-compressions.|

Synopsis

Rapid recognition of cardiac arrest, immediate initiation of high-quality chest compressions, and delivery of effective ventilations are critical to improve outcomes from pediatric cardiac arrest. Lay rescers should not delay starting CPR in a child with no "signs of life" Palpation for the presence or absence of a pulse is not reliable as the sole determi-nant of cardiac arrest and the need for chest compres-sions. In infants and children, asphyxial cardiac arrest is more common than cardiac arrest from a primary cardiac event; therefore, effective ventilation is paramount dur-ing resuscitation of children. When CPR is initiated, the compressions-airway-breathing sequence mirrors the adult sequence to enhance educational simplicity in training.

Recommendation-Specific Supportive Text

1.Lay rescuers are unable to reliably determine the presence or absence of a pulse and should not delay the initiation of CPR for any victim without signs of life. ${ }^{1-15}$

2.No clinical trials have compared manual pulse checks with observations of“signs of life.” However, adult and pediatric studies have identified a high error rate, and harmful CPR pauses during manual pulse checks by health care professionals.16-19 In one study, health care professionals' pulse palpation accuracy was 78%16 compared with lay rescue pulper pulsation accuracy of 47% at 5 seconds and 73% at 10 seconds.1

3.One pediatric study demonstrated only a small delay (5.74 seconds) in commencement of breaths with compressions-airway-breathing compared with airway-breathing-compressions.20 Although the supporting evidence is minimal, continuing to recommend compressions-airway-breathing likely results in minimal delays in giving breaths and allows for a consistent approach to cardiac arrest treatment in adults and children.

REFERENCES

1. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid airly-breathing. Resuscitation. 1997;35:23-26. doi:10.1016/s0300-9572(96)01092-1

2. Brearley S, Shearman CP, Simms MH. Peripheral pulse palpation: an unreli-able physical sign. Ann R Coll Surg Engl. 1992;74:169-171.

3.Cavallaro DL, Melker RJ. Comparison of two techniques for detect-ing cardiac activity in infants. Crit Care Med. 1983;11:189-190. doi: 10.1097/00003246-198303000-00009

4.Inagawa G,Morimura N,Miwa T,Okuda K,Hirata M,Hiroki K.A comparison of five techniques for detecting cardiac activity in infants. Paediatr Anaesth.2003;13:141-146. doi: 10.0146/j.1460-9592.2003.00970.x

5. Kamlin CO, O'Donnell CP, Everest NJ, Davis PG, Morley CJ. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation.2006;71:319-321. doi: 10.1016/j.resuscitation.2006.04.015

6. Lee CJ, Bullock LJ. Determining the pulse for infant CPR: time for a change? Mil Med. 1991;1:56:190-193.

7. Mather C, O'Kelly S. The palpation of pulses. Anaesthesia. 1996;51:189-191. doi: 10.1111/j.1365-2044.1996.tb07713.x

8. Ochoa F, Ramalle-Góma E, Cariproto JM, Garcia A, Saralegui I. Com-petence of health professionals to check the carotid pulse. Resuscitation.1998;37:175-175. doi:10.1016/s0300-9572(98)00055-0

9.Owen CJ,Wyllie JP. Determination of heart rate in the baby at birth. Resus-citation.2004;60:213-217. doi: 10.1016/j.resuscitation.2003.10.002

10.Sarti A, Savron F, Casotto V, Cuttini M. Heartbeat assessment in infants: a comparison of four clinical methods. Pediatr Crit Care Med.2005;6:212-215. doi: 10.1097/01.PCC.0000154952.59176.E0

11. Sarti A, Savron F, Ronfana L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth.2006;16:394-398.108.doi:10.1111/j.1460-9592.2005.01803.x

12. Tanner M, Nagy S, Peat J. K. Detection of infant's heart beat/pulse by care-givers: a comparison of 4 methods. J Pediatr. 2000;137:429-430. doi: 10.1067/mpd.2000.107188

13. Whitelaw CC, Goldsmith Li. Comparison of two techniques for determining the presence of a pulse in an infant. Acad Emerg Med. 1997;4:153-154. doi: 10.10111/1.1553-2712.1997.tb03725.x

14. Dick WF, Eberle B, Wissen G, Schneider T. The carotid pulse check revisited:what if there is no pulse? Crit Care Med.2000;28(suppl):N183-N185. doi: 10.1097/00003246-200011001-00002

15. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch T, Szanova I. Check-ing the carid pulse check; diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107-116. doi:10.1016/s0300-9572(96)01016-7

16. Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009;80:61-64. doi:10.1016/j.resuscitation.2008.10.002

17. Tibballs J, Weeranatna C. The influence of time on the accuracy of health-care personnel to diagnose paediatric cardiac arrest by pulse palpation. Re-suscitation.2010;81:671-675. doi: 10.1016/j.resuscitation.2010.01.030

18.O'Connell KJ,Keane RR,Cochrane NH,Sandler AB,Donoghue AJ,Kerrey BT,Myers SR, Vizafiedan T, Mullan PC. Pauses in compressions dur-ing pediatric CPR: opportunities for improving CPR quality. Resuscitation 2019;145:158-165. doi: 10.1016/j.resuscitation.2019.08.015

19.Taeb M, Schwartz JM, Spaeder MC, Levin AB. Pediatric cardiopulmo-nary resuscitation tasks and hands-off time: a descriptive analysis us-ing video review. Pediatr Crit Care Med. 2020;21:e804-e809. doi:10.1097/PCC.00000000000000000000000000000000000000000000

20.Lubrano R, Cecchetti C, Belleli E, Gentile I, Loayza Levano H, Orsini F,Bertazzoni G, Messi G, Rugolotto S, Pirozzi N, et al. Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial. Resuscitation. 2012;83:1473-1477. doi:10.1016/j.resuscitation.2012.04.011

SEQUENCE OF RESUSCITATION

Components of High-Quality CPR

|Recommendations for Components of High-Quality CPR|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|B-NR|1. Conventional CPR(chest compressions with breaths/ventilations) should be provided to infants and children in cardiac arrest.|| |1|B-NR|2. For infants and children in cardiac arrest, interrupt- cations in CPR should be minimized, and pauses in chest compressions should be<10 s.||

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|Recommendations for Components of High-Quality CPR(Continued)||| |---|---|---| |COR|LOE|Recommendations| |1|C-EO|3. Rescuers should allow the chest to recoil com- pletely after each compression.| |2a|B-NR|4. If lay rescuers are unable or unwilling to deliver breaths to an infant or child in cardiac arrest, it is reasonable to provide compression-only CPR.| |2a|C-LD|5. It is reasonable to use a chest compression rate of 100 to 120/min for infants and children.| |2a|C-LD|6. For infants and children, it is reasonable for rescu- ers to provide chest compressions that depress the chest at least one-third the anteroposterior diameter of the chest, which equates to approxi- mately 1.5 in (4 cm) in infants and 2 in (5 cm) in children.| |2a|C-EO|7. For health care professionals, it is reasonable to perform a rhythm check, lasting no more than 10 s, approximately every 2 min.| |2a|C-EO|8. It is reasonable to provide ventilations with 100% oxygen during CPR.| |2a|C-EO|9. When performing CPR without an advanced airway, it is reasonable for single rescuers to provide a compression-to-ventilation ratio of 30:2 and for 2 rescu- ers to provide a compression-to-ventilation ratio of 15:2.|

Synopsis

High-quality CPR generates blood flow to vital organs and increases the likelihood of ROSC. The 5 main com-ponents of high-quality CPR are(1) adequate chest compression depth,(2) optimal chest compression rate,(3) minimizing interruptions in CPR(ie, maximizing chest compression fraction or the proportion of time that chest compressions are provided for cardiac arrest),(4) allow-ing complete chest recoil between compressions, and(5) avoiding excessive ventilation. Compressions of in-adequate depth and rate,12 incomplete chest recoil,3 and high ventilation rates4,5 are common during pediatric re-suscitation.

Recommendation-Specific Supportive Text

1. Despite increasing frequency of compression-only CPR in adults and children and mixed results when comparing conventional CPR (chest compressions and breaths) and compression-only CPR, large observational studies of children with OHCA show the best outcomes with conventional CPR.1-12 A small observational study of school-aged children found similar outcomes between conventional and compression-only CPR.12

2.While 2 observational studies and a secondary anal-ysis of a prospective multi-institutional randomized trial found that chest compression fraction(the percent of time during the CPR event where chest compressions were ongoing) of>70% to 90%could be achieved in a majority of resuscitations,the association between a set chest compression fraction threshold to achieve best pediatric out-comes is unclear.13-15 There are inadequate data to recommend a goal chest compression fraction

threshold for high-quality CPR in infants and chil-dren. However, two studies from a multinational multi-institutional observational cohort registry showed that increased frequency and duration of pauses in CPR were significantly associated with lower probability of ROSC.16,17 Additionally, longer duration of pauses at the end of CPR prior to can-nulation for extracorporeal life support were asso-ciated with poor neurological outcomes and lower survival.17

3.Allowing complete chest re-expansion improves the flow of blood returning to the heart, and there-fore by increasing preload, increases blood flow to the body during CPR. There are no pediatric studies evaluating the effect of incomplete re-expansion during CPR, although leaning during pediatric CPR is common.18-20 In one observa-tional study of invasively monitored and anes-thetized children, leaning was associated with elevated cardiac filling pressures, leading to decreased coronary perfusion pressures during sinus rhythm.21

4. Large observational studies of children with OHCA show that compression-only CPR is superior to no-bystander CPR.3,4,12,22

5. A small observational study found that a compres-sion rate of at least 100/min was associated with improved systolic and diastolic blood pressures during CPR for pediatric IHCA.23 One multicenter,observational study of pediatric IHCA demon-strated increased systolic blood pressures with chest compression rates between 100 and 120/min when compared with rates exceeding 120/min.24 Rates<100/min were associated with improved survival compared to rates of 100 to 120/min; however, the median rate in this slower category was approximately 95/min(ie, very close to 100/min).24

6.Three anthropometric studies have shown that the pediatric chest can be compressed to one-third of the anteroposterior chest diameter without dam-aging intrathoracic organs.25-27 An observational study found an improvement in rates of ROSC and 24-hour survival, when at least 60% of 30-second epochs of CPR achieve an average chest com-pression depth>5 cm(about 2 inches) for pediat-ric IHCA in children. ${}^{28}$

7.Once an AED or monitor is available, a pause in chest compressions every 2 minutes allows for a brief rhythm check as well as allowing the change of personnel performing chest compressions to avoid fatigue.

8.There are no human studies addressing the effect of varying inhaled oxygen concentrations during CPR on outcomes in infants and children. Given that the etiology of pediatric cardiac arrest is

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respiratory in nature, the use of 100% oxygen is physiologically appropriate.

9. The optimum compression-to-ventilation ratio is uncertain. Large observational studies of children with OHCA demonstrated better outcomes with compression-ventilation CPR with ratios of either 15:2 or 30:2 compared with compression-only CPR.1/2

REFERENCES

1. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nagkami VM, Berg RA, Hiraade A; on behalf of the implementation working group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. Convention-al and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardiac arrests: a prospective, nation-road of hospital cardi

2. Goto Y,Maeda T,Goto Y.Impact of dispatcher-assisted bystander cardiopulmo-nary resuscitation on neurological outcomes in children with ouh-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. J Am Heart Assoc.2013;4e00049. doi:10.1161/JAHA.113.000499

3. Naim MY.Rie,RW,McNlyBF,Song L,Grifles HM, Berg RA,Valiano K,Markenson D,Bradley RN, Rossano JW, Association of bystander cardiopul-mary resuscitation with overall and neurologically favorable survival after pediatric out-of-hospital cardiac arrest in the United States: a report from the Cardiac Arrest Registry to Enhance Survival Surveillance Registry. JAMA Pediatr:2017;171:133-141. doi:10.1001/jamapiedolus:2016.36434

4.Fukuda T, Ohashi-Hufuda N,Kobayashi H,Gunshin M,Sera T,Kondo Y,Yahagi N. Conventional versus compression-only versus no-bystero cardiopul-ronary resuscitation for pediatric out-of-hospital cardiac arrest. Circulation 2016;134:2060-2070. doi:10.1161/CIRCULATIONAHA.116.023831

5. Ashoor HM, Lillie E, Zarin W, Pham B, Khan PA, Nincic V, Yazdi F, Ghassemi M, Ivory J. Cardoso R, et on at behalf of the ILCOR Basic Life Support Task Force. Effectiveness of different compression-to-ventilation meth-ods for cardiopulmonary resuscitation: a systematic review. Resuscitation.2017;118:112-125. doi:10.1016/j.resuscitation.2017.05.032

6.Graser JT,Whent J, Herlitz J, Perkins GD, Lefering T, Helmeli J, Koster RW, Mastowski S, Rossell-Ort F, Maurer H et al. Sunvival after out-of-hospital cardiac arrest in Europe-4's use of the ReEuC TWO study. Re-uscitation.2020;148:218-226. doi:10.1016/j.resuscitation.2019.12.042

7. Naim MY, Grifts HM, Berg RA, Bradley RN, Burke RV, Kanudery J, McNally, McNally BF, Nadkami VM, Song L, Vellano K, et al. Compression-only ver-sus-rescue |breeding cardiopulmonary resuscitation after pediatric out-of-hospital cardiac arrest, J Am Coll Cardiol 2021:7874-1062-02; doi:10.1016/j.jacc.2021.06.042

8. Yoshimoto H.Fukui K,Nishimoto Y,Kuboyama K,Ohishi Y,Sekine K,Hiraide A. Annual improvement trends in resuscitation outcome of patients debitril-lated by layersphons after out-of-hospital cardiac arrests and compression-only resuscitation of layerspos. Resuscitation. 2023:183,10967.20210.1016/j.resuscitation.2022.120.10

9. Goto Y,Funada A, Maeda T,Goto Y. Temporal trends in neurologically in-tact survival after paediatric bystander-wetressed-out of hospital cardiac arrest: a nationwide population-based observational study. Resuscus Plus.2021:61004.1004. doi:10.1016/j.resplu.2021.100104

10. Goto Y, Funada A, Maeda T, Goto Y. Dispatcher and servitrates: convenational tional cardiopulmonary resuscitation and outcomes for paediatric out-of-hospital cardiac arrests. Resuscitation. Resuscitation. 2022:172.106-114. doi:10.1016/j.resuscitation.2021.10.003

11.Murasaka K, Yamashita A, Owada H, Wato Y, Inaba H. Association be-tween the types of bystander cardiopulmonary resuscitation and the sur-vival with good neurologic outcome of preschool pediatric out-of-hospital cardiac arrest cases in Japan: a propensity score matching analysis using an extended nationwide database. Frond Piatd. 2023:10:1075983. doi:10.3389/fped.2022.1075983

12. Kiyohara K, Kitamura Y, Ayusawa M, Nitta M, Iwami T, Nakata K, Sobue T, Kitamura J. Dissemination of chest compression-only cardiopulmo-nary resuscitation by bystanders for out-of-hospital cardiac arrest in stu-dents: a nationwide investigation in Japan. J Clin Med 2022;119828. doi:10.33901cm/11040928

13.O'Connell KJ, Keane RR, Cochrane NH, Sandler AB, Donoghue AJ, Kerrey BT, Myers SR, Vaarflutan, TAN. PC Pauses in compressions

ing pediatric CPR: opputto quantities for improving CPR quality. Resuscitation.2019;145:158-165. doi: 10.1016/j.resuscitation.2019.08.015

14. Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R,Bockors M, Burns C, Carillora J, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatrics Critical Care Research Network(CPCCRN). Association of CPR simula-tion program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest. Resuscitation.2023;191:109939. doi:10.1016/j.resuscitation.2023.109939

15. Sorcherl H, Hunt EA, Shaffner DH,O'Brien CE,Jeffers JM, Jones SI,Newton H,Duval-Arnould J. Association of end-tidal carbon dioxide levels during car-diopulmonary resuscitation with survival in a large paediatric cohort. Resusci-tation.2022;170:316-3238. doi:10.1016/j.resuscitation.2021.10.029

16. Lauridsen KG, Morgan RW, Berg RA, Niles DE, Kleinman ME, Zhang X, Grifthiss H, Del Castillo J, Skellett S, Lasa JJ, et al; on behalf of the pedi-RES-IO Investigators. Association between chest compression pause duration and survival after pediatric in-hospital cardiac arrest. Circulation.2024;149:1493-1500.doi: 10.1161/CIRCULATIONAHA.123.066882

17. Lauridens KG, Lasa JJ, Raymond TT, Yu P, Niles D, Sutton RM, Morgan RW, Fran Hazinski M, Griffiths H, Hanna R,et al; on behalf of the pediRES-Q Investigators. Association of chest compression pause duration prior to E-CPR cannulation with cardiac arrest survival outcomes. Resuscitation.2022:1775-82.92. doi:10.1016/j.resuscitation.2022.05.004

18. Katzenschlager S, Kelpanides IK, Ristau P, Huck M, Seewald S, Brenner S, Hoffmann F, Whent J, Kramer-Johansen J, Tjelmeland IBM, et al.Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation. Crit Care. 2023;27:349. doi:10.1186/13508-023-04630-3

19. Sutton RM, Niles D, Nyaether J, Abella BS, Arbogust KB, Nishisaki A,Malleis R, Homode,Aishnoir,Relfaher MA,et al.Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adoles-ents. Pediatrics.2009;124:494-499. doi:10.1542/peds.2008-1930

20.Glatz A, Nishisaki A, Niles DE, Hanna BD, Eilevstjonn J, Diaz LK, Gillespie MJ,Rone JJ,Sutton RM, Berg RA,et al. Sernal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynam-ics anesthetized child levels during cardiac catheterization. Resuscitation.2013;84:1674-1679. doi: 10.1016/j.resuscitation.2013.07.010

21. Niles D, Nysaether J, Sutton R, Nishisaki A, Abella BS, Arbogast K, Maltese MR,Berg RA, Helfafer M, Nadkarni V. Leaning is common during in-hospital pediatric CPR and decreased with automated corrective feedback. Resusci-tation 2009;80:553-557 doi:10.1016/j.resuscitation.2009.02.012

22.Albargi H, Maffel S, Blerhane S, Booth S, Hawkes C, Perkins GD,Norton M, Foster T, Solefield B, Bystander cardiopulmonary resus-citation for paediatric out-of-hospital cardiac arrest in England: An ob-servational regulatory cohort study. Resuscitation.2022;170:17-25. doi:10.1016/j.resuscitation.2021.10.042

23. Sutton RM, Benrich B, Nishaki A, Niles DE, Maltese MR, Boyle L, Stavland M,Eilevstjonn J, Arbogast KB, Berg RA, et al. American Heart Associa-tion cardiopulmonary resuscitation quality targets are associated with im-proved arterial blood pressure during pediatric cardiac arrest. Resuscitation.2013;84:168-172. doi:10.1016/j.resuscitation.2012.08.335

24. Sutton RM, Reeder RW Landis W, Meert KL, Yates AR, Berger JT, Newth CJ,Carcillo JA, McQuillen PS, Harrison RE,et al; Eunice Kennedy Shriver National al Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network(CPCCRN) Investigators. Chest compres-sion rates and pediatric end-hospital cardiac arrest survival outcomes. Resus-citation.2018;130:159-166. doi:10.1016/j.resuscitation.2018.07.015

25.Kao PC,Chiang WC,Yang CW,Chen SJ,Liu YP,Lee CC,Hishd MJ,Ko PC,Chen SC,Ma MH.What is the correct depth of chest compression for infants and children? a radiological study. Pediatrics.2009;124:49-55. doi:10.1016/502.1495.206.2586

26. Sutton R, Niles D, Nyaether J, Arbogast KB, Nishisaki A, Maltese MR,Bishnoir R, Helfser MA, Nadkarmi V, Donoghue A. Pediatric CPR qual-ity monitoring: analysis of thoracic anthropometric data. Resuscitation.2009;80:1137-1141.doi:10.1016/j.resuscitation.2009.06.031

27. Braga MS, Dominguez TE, Pollock AN, Niles D, Meyer A, Myklebust H,Nysaether J, Nadkarni V, Estimation of optimal CPR chest compression depth in children by using computer tomography. Pediatrics.2009;124:e69-e74. doi:10.1542/peds.2009-0153

28. Sutton R, French B, Niles DE, Donoghue A, Topjian AA, Nishisaki A,Leffelman J, Wolfe H, Berg RA, Nadkarni VM, et al. 2010 American Heart Association recommender compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014;85:1179-1184.doi:10.1016/j/resuscitation.2014.05.007

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

 Figure 11. 1-hand technique for chest compressions in infants.

SEQUENCE OF RESUSCITATION

CPR Technique

|Recommendations for CPR Technique|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|B-NR|1. For infants, rescuers should compress the sternum using either the 1-hand technique(heel of one hand on sternum) or the 2 thumb-en-circling hands technique. If the rescue cannot physically encircle the chest, it is recommended to compress the chest with the heel-of-1-hand technique.|| |2b|C-LD|2. For children, it may be reasonable to use either a 1- or 2-hand technique to perform chest com-pressions.||

Synopsis

In pediatric patients, due to the wide variation in the size of each patient, effective chest compression perfor-mance can be highly variable and depends on multiple

 Figure 12.2 thumb-encircling hands technique for chest compressions in infants.

 Figure 13.2-hand technique for chest compressions in children.

factors, including the size and position of the rescuer as well as the hand position during CPR. Numerous studies have sought to determine optimal compression technique for each patient population.1-4 Prior recom-mendations were based solely on manikin studies for the optimal compression technique in the various pediatric age groups. However, new evidence from patient regis-tries has led to new outcome-based recommendations.5 See Figure 11 for the 1-hand technique and Figure 12 for the 2 thumb-encircling hands technique for infants,and see Figure 13 for the 2-hand technique for children.

Recommendation-Specific Supportive Text

1.In infants, systematic reviews and meta-analyses from simulation studies suggest that the 2 thumb-encircling hands technique is a superior technique when compared with 2-finger compressions, par-ticularly for depth.6-10 In a multicenter prospective observational registry study, the 1-hand technique resulted in greater compression depth than the 2 thumb-encircling hands technique in infants with no difference in chest compression rate between hand positions.5 The 2-finger technique was uti-lized rarely in this study but, when used, no chest compression segments were compliant with AHA guidelines. An earlier single-center study did not show differences in chest compression depth between 1-hand and 2 thumb-encircling hands technique but noted 1-hand chest compressions were associated with an inappropriately fast rate."11

2.In children 1 to 8 years of age, the 2-hand com-pression technique resulted in greater compression depth than the 1-hand technique.5 A secondary study from the same prospective observational reg-istry showed that the 1-hand technique had better compliance with guideline chest compression rates than the 2-hand technique.5 There are no clinical

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

data to determine if the 1-hand or 2-hand tech-nique is associated with better outcomes for chil-dren receiving CPR. In manikin studies, the 2-hand technique has been associated with improved com-pression depth ${}^{12}$ and compression force ${}^{13}$ and less rescuer fatigue. ${}^{14,15}$ More vertical compression angle(i,force, force applied closer to 90° perpendicular to the chest) to improve depth and recoil, ${}^{16}$ with an“elbow-lock” technique while delivering chest compressions to maintain consistent vertical force and minimize fatigue, ${}^{17}$ and the use of a stepstool during CPR5 have been studied as modifications to improve com-pression depth and reduce rescuer fatigue.

REFERENCES

1.Finholt DA,Ketrickg,RWagnerHR,Swedlow DB.The heartisunder the lower third of the stem.implications for external cardiac massage. Am J Dis Child 1986;140:646-649. doi:10.1001/archpedi.1986.02140210044202

2.Orłowski JP. Optimum position for external cardiac compression in in-fants and young children. Ann Emerg Med. 1986;15:657-1673. doi:10.1016/s0196-0644(86)80423-1

3.Phillips GW, Zideman DA. Relation of infant heart to sternment: its signifi-cance in cardiopulmonary resuscitation. Lancet. 1986;1:1024-1025. doi: 10.1016/s0140-6736(86)91284-5

4. Clements F; McGowan.J.Finger position for chest compressions in cardiac arrestiner infants. Resuscitation.2000;44:43-46. doi:10.1016/s0300-957(99)00165-3

5.O'Connell KJ, Sandler A, Dutta A, Ahmed R, Neubrand T, Myers S, Kerrey B, Donoghue A. The effect of hand position on chest compression quality during CPR in young children: findings from the Videography in Pediatric Resuscitation(VIPER) collaborative. Resuscitation. 2023;185:109741. doi:10.1016/19iscususcitation.2023;109741

6.Douvanas A, Koulouglioti C, Kalafati M. A comparison between the 2 methods of chest compression in infant and neonatal resuscitation. A review according to 2010 CPR guidelines. J Matem Fetal Neonatal Med 2018;31:805-816. doi:10.1080/14767058.2017.1295953

7. Lee J, Lee J, Oh J Park, CH K, Hang H, Lim TH, Yoo KH. Comparison of two-thumb encircling and two-finger technique during infant cardiopul-monary resuscitation with single rescuer in simulation studies: a system-atic review and meta-analysis. Medicine (Baltim) 2019;98:e17853. doi:10.1097/MD.0000000000017853.

8. Chang CY, Hou YT, Chien Y, Chen Y-L, Lin P-C, Chen C-S, Wu M-Y.Two-thumb or two-finger technique in infant cardiopulmonary resuscitation by a single rescuer? a meta-analysis with GOSH Analysis. Int J Environ Res Public Health.2020;17:5124. doi:10.1390/jeffarh 117145214

9. Chang CY, Lin PC, Chien YJ, Chen CS, Wu MY. Analysis of chest-compression depth and full recoil in front chest-compression techniques performed by a single rescue; systematic review and meta-analysis. Int J En-Viron Res Public Health.2020;17:4018.339/doi:10.3390/jerph17114018

10. Millin MG, Bogumil D, Fishe JN, Burke RV. Comparing the two-finger versus two-thumb technique for single person infant CPR: a system-atic review and meta-analysis. Resuscitation. 2020;148:161-172. doi:10.1016/j.resuscitation.2019;12.039

11. Jang HY, Wolfe H, Hsieth TC, Abbadessa MK, Myers S, Nadkari V, Donoghue A. Infant chest compression quality: a video-based comparison of two-thumb versus one-hand technique in the emergency department.Resuscitation. 2018;122:36-40. doi: 10.1016/j.resuscitation.2017.11.044

12. Kim MJ, Lee HS, Kim S, Park YS. Optimal chest compression technique for paediatric cardiac arrest victims. Scard J Traus Resuscus Emerg Med 2015;23:36. doi:10.1186/s13049-015-0118-9

13.Stevenson AG, McGowan J, Evans AL, Graham C.AC. CPR for chil-dren: one hand or two? Resuscitation. 2005;64:205-208. doi: 10.1016/j.resuscitation.2004.07.012

14. Peska E, Kelly AM, Kerr D. Green D. One-handed versus two-handed chest compressions in paediatric cardiomy-locardusion resuscitation. Resuscitation 2006;71:65-69. doi:10.1016/j.resuscitation.2006.02.007

15.Tsu JY,Kao CL,Chang CJ,Tu YF,Scu CHi,Chomechanics of two-thumb versus two-finger chest compression for pulmonary resuscitation on tion in an manikin model. Eur J Emerg Med.2020;27:132-136. doi:10.1097/MEJ/1999/0000000000000631

16. Oh JH, Noh H, Lee JG, Kim DK. Effects of vertical compression dur-ing pediatric cardiopulmonary resuscitation using the one-handed chest compression technique. Am J Emerg Med. 2022;59:24-29. doi:10.1016/j.ajem.2022.06.044

17.Kang JH,Jang YD,Hang K,Jung E-K,Yu J-K,Ji J-G,Lee S-W,Yoon YS, Kim Y-W,"Elbow-Lock" chest compression method in the set-ting of single rescuer pediatric cardiopulmonary resuscitation: a cross-simulation study. Pediatr Emerg Care. 2022;38:e583-e587. doi: 10.1097/PEC.00000000000002418

SEQUENCE OF RESUSCITATION

Support Surface

|Recommendations for Support Surfaces for CPR||| |---|---|---| |COR|LOE|Recommendations| |2a|C-LD|1. It is reasonable to perform chest compressions on a firm surface in infants and children.| |2a|C-LD|2. During IHCA, it is reasonable to use a backboard to improve chest compression depth in infants and children.|

Synopsis

Chest compression depth can be optimized by placing the child in a supine position on a hard, flat surface. ${ }^{1}$ It is challenging to perform adequate chest compressions on soft surfaces, such as mattress, because both the chest and the surface itself can be compressed. In mani-kin studies, up to 57% of the compression force may be absorbed by the mattress, leading to inadequate com-pression depth and increased rescuer fatigue. ${ }^{2-4}$ Back-board placement, use of the CPR mode on specially equipped hospital bed disks to return them to a flat position at a low height, and defiating air matters quickly or mov-ing patients to the floor or have been proposed to counter the impact of soft surfaces. ${ }^{5}$

Recommendation-Specific Supportive Text

1.Chest compression depth is overall inadequate,with few studies reaching the recommended targeted depth.6 Use of a firm surface in meta-analyses of manikin studies and a single pediat-ric case series show that compression depth is increased on a firm surface. ${}^{7-9}$

2.Meta-analysis of 7 studies ${}^{4,10-15}$ showed a 2 mm(95% CI,0.5-4 mm) increase in chest compres-sion depth when CPR was performed on a mani-kin on a hospital mattress with a backboard in place. ${ }^{9}$

REFERENCES

1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: pediatric basic life support. The American Heart Association in collaboration with the International Liaison Commit-tee on Resuscitation. Circulation. 2000;102(suppl_1):1-253-1-290. doi:10.1161/circ.102,suppl_1.1-253

2.Lin Y,Wan B,Belanger C,Hecker K,Gilfoyle E,Davidson J,Cheng A.Re-ducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study. Advances in Simulation. Adv Simul(London,England).2017;22:20. doi:10.1186/s41077-017-0057-y

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

3. Noordergraaf GJ, Paulussen WF, Venema A, van Berkom PFJ, Woerlee PH, Schheffer GJ, Noordergraaf A. The impact of compliant surfaces on in-hospital chest compressions: effects of common matterses and a backboard.Resuscitation.2009;80:546-552. doi:10.1016/j.resuscitation.2009.03.023

4. Oh J, Chee Song, Y. Lim T, Kang H, Cho Y. a novel method to de-crease mattress compression during CPR using a mattress compress-sion cover and a vacuum pump. Resuscitation. 2013;84:987-991. doi:10.1016/j.resuscitation.2012.12.027

5. Nolan JP, Maconochie I, Soar J, Asleyengen TM, Greif R, Wyckoff MH,Singletary EM, Aickin R, Berg KM, Martcini ME, et al. Executive summary:2020 International Consensus on Cardiopulmonary Resuscitation and Emer-gency Cardiovascular Care Science With Treatment Recommendations. Re-suscitation; 2020;156:A1-222. doi:10.1016/j.resuscitation.2020.09.009

6. Niles DE, Duval-Arnold J, Skellett S, Knight L, Su F, Raymond TT, Sweberg T, Sen Al, Atkins DL, Friy S, Ther St, on: behalf of the pediatric Resuscit-tation quality(Pedius-RES) Collaborative Investigators. Characterization of pediatric in-hospital cardiopulmonary resuscitation quality metrics across an international resuscitation collaborative. Pediatr Cat Care Med.2018;19:421-432. doi: 10.1097/PCC.00000000000000000

7. Nishiki A, Maltese MR, Niles DE, Sutton RM, Urbano J, Berg RA,Naldkari VM. Backboards are important when chest compressions are provided on a soft mattress. Resuscitation. 2012;83:1013-1020. doi:10.1016/j.resuscitation.2012.01.016

8. Holt J, Ward A, Mohamed Tyh, Chukowry P, Grolmusova N, Couper K,Morley P, Perkins GD. The optimal surface for delivery of CPR: a system-atic review and meta-analysis. Resuscitation: 2020;155:159-164. doi: 10.1016/j.resciustation.2020.07020

9. Dewan M, Schachna E, Eastwood K, Perkins G, Bray J; on behalf of the International Liaison Committee on Resuscitation Basic. Life Sup-port Task Force. The optimal surface for delivery of CPR: an updated systematic review and meta-analysis. Resuscus Plus. 2024;19:100718. doi: 10.1016/j.respu.2024.100718

10. Andersen L0, Isbye DL, Rasmussen LS. Increasing compression depth during manik CPR using a simple backboard. Acta Anaeseal Scandl Cnodation (2007;51:747-750. doi: 10.1111/j.1399-6576.20070.1304.x

11. Fischer EJ, Mayrand K, Ten Eyck RP. Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study. Am J Emerg Med.2016;34:2747-277. doi:10.1016/j.ajem.2015.10.035

12.Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B,Thicket DR. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med.2006;32:1632-1635. doi:10.1007/800134-006-0273-8

13. Sanri E, Karacabeys. S. The impact of backboard placement on chest com-pression quality: a mannequin study. Prehosp Disaster Med.2019;34:182-187.18 of.1017/1049023X19000153

14. Sato H, Komasawa N, Uekki R, Yamamoto N, Fujii A, Nishi S-I, Kaminoh Y. Backboard insertion in the operating table increases chest com-pression depth: a manikin study. J Aneshz. 2011;25:770-772. doi: 10.1007/s00540-011-1196-2

15.Cuvierel Z, Houthoudtch R, Seraes B, Haentjens C, Blot S, Mptos N. Ef-fect of a backboard on chest compression quality during in-hospital adult cardiopulmonary resuscitation: a randomised, single-blind, controlled trial using a manikin model. Intensive Cit Care Nurs. 2025:669:103164. doi:10.1016/j.jccan.2021.103164

MANAGEMENT OF SHOCKABLE RHYTHMS

Coordination of Shock and CPR

|Recommendations for Coordination of Shock and CPR||| |---|---|---| |COR|LOE|Recommendations| |1|C-EO|1. In infants and children, CPR should be per- formed until the AED/manual defibrillator is ready to deliver a shock.| |1|C-EO|2. Prompt defibration with a single shock followed by immediate CPR, starting with compressions, is rec-ormended for infants and children with VF/pVT.| |1|C-EO|3. Peri-shock pauses should be minimized dur-ing CPR in infants and children.|

Synopsis

Shockable rhythms are rare in infants and children.The risk of shockable rhythms, VF and pVT, steadily increases throughout childhood and adolescence, but remains less frequent than in adults. Shockable rhythms may be the ini-tial rhythm of the cardiac arrest(primary VF/pVT) or may develop during the resuscitation(secondary VF/pVT). De-fibrillation is the definitive treatment for VF/pVT. The short-er the duration of VF/pVT, the more likely that the shock will result in a perfusing rhythm. Minimizing frequency and duration of pauses in CPR for shock delivery improves chances of favorable short- and long-term outcomes.

Recommendation-Specific Supportive Text

1. There are currently no pediatric data available regard-ing the optimal timing or duration of CPR prior to defibrillation. Adult studies show no benefit of a pro-longed period of CPR before initial defibrillation.1-4

2. Adult studies comparing a stacked shock(1-shock protocol versus a 3-shock protocol) for treatment of VF suggest a significant survival benefit with the single-shock protocol.5,6 The effectiveness of sin-gle compared to sequential(stacked) shocks has not been evaluated in infants and children with a shockable rhythm,7 and therefore it is reasonable to give a single defibrillation dose of monophasic or biphasic energy followed by immediate resump-tion of chest compressions.6,8

3. Prolonged pauses in chest compressions before and after shock delivery decrease blood flow and oxygen delivery to vital organs, such as the brain and heart, and are associated with decreased survival.9,10

REFERENCES

1. Baker PW,Conway J,Cotton C,Ashby DT,Smyth J,Woodman RJ,Grantham H on behalf of the Clinical Investigators. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? a randomised control trial. Resus-citation.2008;79:424-431. doi: 10.1016/j.resuscitation.2008.07.017

2.Jacobs IG,Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas.2005;17:39-45. doi:10.1111/j.1742-6723.2005.00694.x

3.Stiell IG,Nichol G, Leroux BG, Rea TD,Orato JP, Powell J,Christenson J,Callaway CW, Kudenchuk PJ, Aufderheide TP, et al; on behalf of the ROC Innovators. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med. 2011;365:787-797. doi:10.1056/NEg/NAo1010076

4. Bobrow BJ,Clark LL,Ewry GA,Chikani V,Sanders AB,Berg RA,Richman PB, Kern KB. Minilly interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008;299:1158-1165. doi:10.1001/jama.299.10.1158

5.Rea TD,Heibock M, Perry S,Garcia M,Cloyd D,Becker L,Eisenberg M.In-creasing use of cardiopulmonary resuscitation during out-of-hospital ventric-ular fibrillation arrest: survival implications of guideline changes. Circulation.2006;114:2760-2765, doi:10.1161/CIRCULATIONAHA.106.654715

6. Cheskes D, Sorian F, Feldman M, McLeod S, Scales DC, Pinto R, Turner L, Morrison LJ, Drennan IR, Verbeek PR. Double sequential exter-nal defibrillation for refractory ventricular fibrillation: the DOSE VF pi-lot randomized controlled trial. Resuscitation. 2020;150:178-184. doi:10.1016/j.resuscitation.2020.02.010

7. Scholefield BR, Acworth J, Ng K-C,Tiwari LK, Raymond T, Christoff A,Katzenschlager S, Escalante-Kanashiro R, Bansal A, Topjian A, et al. Pedi-atic life subject 2025 International Liaison Committee on Resuscitation

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

Consensus on Science With Treatment Recommendations. Circulation.2025;152(suppl 1):S116-S164. doi:10.1011/CIR.CIR0000000000001362

8.Kim S, Jung WJ, Roh YI, Kim TY, Hwang SO, Cha K-C. Comparison of re-suscitation outcomes between 2- or 3-stacked defibrillation strategies with minimally interrupted chest compression and the single defibrillation strat-egy: a swine cardiac arrest model. J Am Heart Assoc. 2021;10:e021250. doi: 10.1161/JAHA-121.021250

9. Kang JY, Kim Y-J, Shin YJ, Huh JW, Huh, Hong S-B, Kim WY. Associa-tion between time to defibrillation and neurologic outcome in patients with in-hospital cardiac arrest. Am J Med Sci. 2019;358:143-148. doi:10.1016/j.amjms.2019.05.003

10. Lauritsden KG, Morgan RW, Berg RA, Niles DE, Kleinman ME, Zhang X, Frischis H, Del Castillo J, Skellett S, Lasa JJ, et al; on behalf of the pediRES-Q Investigators. Association between chest compression pause duration and survival after pediatric in-sospital cardiac arrest. Circulation 2024;149:1493-1500. doi: 10.1161/CIRCULATIONAHA.123.066882

MANAGEMENT OF SHOCKABLE RHYTHMS

Type of Defibrillator

|Recommendations for Type of Defibrillator||| |---|---|---| |COR|LOE|Recommendations| |1|C-LD|1. When using an AED on infants and children <8 y of age, use of a pediatric attenuator is recommended.| |2a|C-LD|2. For infants and children under the care of a trained health care professional, it is reasonable to use a manual defibrator when a shockable rhythm is identified.| |2b|C-EO|3. If neither a manual defibrator nor an AED equipped with a pediatric attenuator is available, an AED without a pediatric attenuator may be con- sidered for infants and children.|

Synopsis

Manual defibrillators and AEDs can both be used to treat VF/pVT in children. AEDs have high specificity in recog-nizing pediatric shockable rhythms.1-4 Manual defibrilla-tors, when used by health care professionals, can be used to titrate energy dose to a patient's weight. Their use also minimizes pauses for rhythm analysis. Use of monophasic defibrillators has fallen out of favor because biphasic defi-brillators require less energy with fewer side effects. Many AEDs are equipped to attenuate(reduce) the energy dose to make them more suitable for infants and children.

Recommendation-Specific Supportive Text

1.Although there are no direct comparisons between pediatric attenuator and nonattenuator AED-delivered shocks, multiple studies document shock success with survival when a pediatric attenuator was used.1-13 A retrospective cohort study in chil-dren<18 years of age with OHCA showed that return of an organized rhythm was more likely when lower energy dose was utilized.14

2.In adults, use of an AED in hospitals did not improve survival, ${}^{15}$ and the peri-shock CPR pauses needed for rhythm analysis were prolonged. ${}^{16}$ In children<18 years of age with IHCA, 1 well-designed ret-rospective multicenter cohort study, found that 30%

<EndOfPara>of defibrillations were delivered for nonshockable rhythms with manual defibrillators,17 while previ-ous studies suggest that AEDs misclassify pediat-ric shockable rhythms only 2% to 4% of the time.However, the adverse impact of shocking non-shockable rhythms in IHCA is unknown, and manual defibrillators allow for titration of energy dose to a patient's weight while minimizing peri-shock CPR pauses compared to AED-associated CPR pauses.

3. AEDs without pediatric attenuation deliver 120 to 360 J, exceeding the recommended dose for children weighing<25 kg. However, there are reports of safe and effective AED use in infants and young children when the dose exceeds 2 to 4 J/kg.7-9,11,18,19 Because defibrillation is the only effective therapy for shockable rhythms, an AED without a dose attenuator may be lifesaving.

REFERENCES

1. Atkins DL, Acworth J, Chung SP, Reis A, Van de Voorde P; on behalf of the International Liaison Committee on Resuscitation(ILCOR) Pediatric and Basic Life Support Task Forces. Lay rescuer use of automated external de-fibrillators in infants, children and adolescents: a systematic review. Resusc Plus.2022;11:100283.doc:10.1016/j.resplu.2022.100283

2.Cecchin F, Jorgenson DB, Berul Cl, Perry JC, Zimmerman AA, Duncan BW, Lupinetti FM, Snyder L, Lyster TD, Rosenthal GL, et al. Is arrhyth-mia detection by automatic external defibrillator accurate for children?:sensitivity and specificity of an automatic external defibrillator algorithm in 696 pediatric arrhythmias. Circulation. 2001;103:2483-2488. doi:10.1161/01.cir.103.202483

3. Atkinson E, Mikysa B, Conway JA, Parker M, Christian K, Deshpande J, Knikians TK, Smith J, Walker C, Stickney RE, et al. Specificity and sensitivity of automated external defibrillator rhythm analysis in infants and children.Ann Emerg Med.2003;42:185-196. doi: 10.1067/mem.2003.287

4.Akins DL,Scott WA, Blaufox AD, Law IH, Dick M, Geheb F, Sobh J, Brewer JE. Sensitivity and specificity of an automated external defibrillator algo-rithm designed for pediatric patients.Resuscitation.2008;76:168-174. doi:10.1016/j.resuscitation.2007.06.032

5. Atkins DL,Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA; and the Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children:the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009;119:1484-1491.doi: 10.1161/CIRCULATIONHAHA.108.802678

6.Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA;on behalf of the American Heart Association National Registry of CPR Investigators. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med.2006;354:2328-2339. doi: 10.1056/NEJMoa052917

7. Atkins DL, Jorgenson DB. Attenuated pediatric electrode pads for auto-mated external defibrillator for use in children. Resuscitation. 2005;66:31-37.doi: 10.1016/j.resuscitation.2004.12.025

8.Bar-Cohen Y, Walsh EP. Love BA, Cecchin F. First appropriate use of au-tomated external defibrillator in an infant. Resuscitation. 2005;67:135-137.doi: 10.1016/j.resuscitation.2005.05.003

9.Divekar A, Soni R. Successful parental use of an automated external defi-brillator for an infant with long-QT syndrome. Pediatrics. 2006;118:e526-e529. doi: 10.1542/peds.2006-0129

10. Hoyt WJ, Fish FA, Kannarkeril RJ. Automated external defibrillator use in a previously healthy 31-day-old infant with out-of-hospital cardiac arrest due to ventricular fibrillation. J Cardiovasc Electrophysiol. 2019;30:2599-2602.doi:10.1111/jce.14125

11. Gurnett CA, Atkins DL. Successful use of a biphasic waveform automated external defibrillator in a high-risk child. Am J Cardiol.2000;86:1051-1053.10.1016/s0002-9149(00)01151-6

12.Mitani Y, Ohta K, Yodoya N, Otsuki S, Ohashi H, Sawada H, Nagashima M, Sumitomo N, Komada Y. Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. Europlace.2013;15:1259-1266. doi: 10.1093/europe/eut053

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

13. Pundi KN, Bos JM, Cannon BC, Ackerman MJ. Automated external defibril-lator rescues among children with diagnosed and treated long QT syndrome.Heart Rhythm.2015;12:776-781.doi:10.1016/j.hrthrm.2015.01.002

14. Lavignasse D, Lemoine S, Menetre S, Didon JP, Jost D, Jouven X. Improved survival to hospital discharge in paediatric in-hospital cardiac arrest us-ing 2Joules/kilogram as first defibrillation dose for initial pulseless ven-tricular arrhythmia. Resuscitation.2021:158(r8q,0332173):2912-292.doi:10.1016/j.resuscitation.2020.09.042

15. Chan PS, Krumholz HM, Spertus JA, Jones PG, Cram P, Berg RA,Pebpery MA, Nadkarni V, Mancini ME, Nallamothu BK; on behalf of the American Heart Association National Registry of Cardiopulmonary Re-suscitation(NRCPR) Investigators. Automated external defibrillators and survival after in-hospital cardiac arrest, JAMA 2010;304:2129-2136. doi:10.1001/jama.2010.1576

16. Cheskes S, Schmicker RH, Christenson J, Salcido DD, Rea, T Powell J,EdsonDP, Sell R, May S, ManeneGuzzi, et al; on behalf of the Resuscitation Outcomes Consortium(ROC) Investigators. Per-ish shock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011;124:58-66. doi:10.1161/CIRCULATIONAHA.110.010736

17. Gray JM, Raymond TT, Atkins DL, Ttegymer K, Niles DE, Nadkami VM,Pandit SV, Dewan M; on behalf of the pediRES-Q Investigators. In-appropriate shock delivery is common during pediatric in-hospital cardiac arrest. Pediatr Crit Care Med. 2023;24:e390-e396. doi:10.1097/PCC.00000000000003241

18. Konig B,Benger J,Goldsworthy L. Automatic external defibrillation in a year old.Arch Disc. Child.2005;90:310-311.d.1011.136/adc.2004.054981

19. Oeffi N, Krainer M, Kurath-Koller S, Koestenberger M, Schwaberger B,Ursberger B. Milder LP. Cardiac arrhythmias requiring electric counter-shock during the neonatal period-a systematic review. Children(Basel, Swit-lander).2023;10:838. doi:10.3390/children 10050838

MANAGEMENT OF SHOCKABLE RHYTHMS

Defibrillator Paddles and Pads: Size, Type, and Position

|Recommendations for Defibrillator Paddles and Pads: Size,Type,and Position||| |---|---|---| |COR|LOE|Recommendations| |1|C-EO|1. In infants and children, it is recommended to use the largest paddles or self-adhering pads that will fit on the chest while still maintaining good separa- tion between the paddles or pads.| |2b|C-LD|2. When using self-adhering pads in infants and chil- dren,either anteroposterior or anterolateral place- ment may be reasonable.| |2b|C-LD|3. When delivering electric current for defibrillation in infants and children, paddles or self-adhering pads may be considered equally effective and efficient.|


Synopsis

Incorrect defibrillator paddle or pad placement can lead to ineffective delivery of electric current to the heart and adversely impact return of a perfusing rhythm. The size of the defibrillator paddles or self-adhering pads depends on the age of the patient. Pad-dles or self-adhering pads of the largest size that can still be separated by at least 1 to 2 cm allow for ap-propriate current flow. When using paddles, an electri-cal conducting interface is needed to reduce skin and thoracic impedance. Figures 14 and 15 demonstrate placement of the pads in the anteroposterior position,and Figure 16 demonstrates placement of the pads in the anterolateral position.

Recommendation-Specific Supportive Text

1. Minimizing transthoracic impedance is important to optimize delivery of electric current. Studies com-paring shocks delivered to children with pediatric to adult paddles showed that transthoracic imped-ance was significantly higher with pediatric pad-dles due to smaller size.1-3

2. One pediatric study demonstrated no difference in rates of ROSC with anteroposterior compared to anterolateral pad placement.4 Among adults,a prospective cohort study showed statistically higher adjusted odds of ROSC at any time with anteroposterior pad placement while another study showed no significant difference.5,6

3. One simulation study demonstrated that the predominant factor to prompt defibrillation was rescuer familiarity with the defibrillator and the paddles/pads connections. There was no signifi-cant difference in median time to shock with use of paddles compared with self-adhering pads.7

REFERENCES

1. Atkins DL, Kerber RE. Pediatric defibrillation: current flow is improved by using"adult" electrode paddles. Pediatrics.1994;94:90-93.

2. Samson RA, Atkins DL, Kerber RE. Optimal size of self-adhesive preapplied electrode pads in pediatric defibrillation. Am J Cardiol. 1995;75:544-545.35. doi: 10.1016/s0002-9149(99)80606-7

Figure 14. Placement of pediatric pads in the anteroposterior position.One pad is placed in the center of the child's bare chest(anterior) and the other pad is placed in the center of the back(posterior).

pad is placed in the center of the back(posterior).

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

 3. Atkins DL, Sirna S, Kieso R, Charbonnier F, Kerber RE. Pediatric diffrabil-lation: importance of paddle size in determining transthoracic impedance. Pediatrics.1988;82:914-918.

4. Tibballs J, Carter B, Kiraly NJ, Ragg P, Clifford M. External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia. Pediatr Crit Care Med. 2011;12:14-20. doi: 10.1097/PCC.Ob013e3181dbb4fc

5. Lupton JR, Newgard CD, Dennis D, Nuttall J, Sahni R, Jui J, Neth MR,Daya MR. Initial defibrillator pad position and outcomes for shockable out-of-hospital cardiac arrest. JAMA Netw Open.2024;7:e2431673. doi:10.1001/jamanetworkopen.2024.31673

6. Steinberg MF,Olsen JA,Persse D,Souders CM,Wik L.Efficacy of defibrillator pads placement during ventricular arrhythmias, a before and after analysis.Resuscitation.2022;174:16-19. doi:10.1016/j.resuscitation.2022.03.004

7. Bhalala US, Balakumar N, Zamora M, Appachi E. Hands-on defibril-lation skills of pediatric acute care providers during a simulated ven-tricular fibrillation cardiac arrest scenario. Front Pediatr. 2018;6:107. doi:10.3389/fped.2018.00107

CRITICAL KNOWLEDGE GAPS AND ONGOING RESEARCH

During the literature review process, we identified sever-al critical knowledge gaps related to pediatric basic and advanced life support. These topics are either current areas of ongoing research or lack significant pediatric

 Figure 16. Placement of pediatric pads in the anterolateral position.

The right anterior pad is placed vertically on the right chest, with the top of the pad just below the clavicle. The left lateral pad is placed horizontally on the left side of the chest, centered at the midaxillary line, with the top of the pad on the lower ribcage in line with the sternal border(inferior portion of the xyphoid process). Do not place the pad on breast tissue or the abdomen.

Figure 15. Placement of pediatric pads in the alternative anteroposterior position.

One pad is placed on the left side of the chest, between the left side of the child's breastbone and left nipple (anterior)and the other pad is placed on the left side of the child's back, next to the spine (posterior).

evidence to support evidence-based recommendations.In addition, we identified topics for which systematic or

Table 2. Critical Knowledge Gaps Due to Insufficient Pediatric Data

|Critical knowledge gaps| |---| |With what frequency should the rhythm be checked during CPR? What is the optimal ventilation rate during CPR in patients with or without an advanced airway? Is it age dependent?| |What is the optimal chest compression rate during CPR? Is it age dependent?| |What is the optimal CCF for optimal outcomes in pediatrics?| |What is the optimal position for performing chest compressions(eg, on a stepstool, kneeling on the bed, standing)?| |What is the ideal concentration of oxygen to deliver when performing CPR?| |What is the ideal compression-to-ventilation ratio?| |What is the optimal timing and dosing of defibrillation for VF/pVT?| |What clinical tools can be used to help in the decision to terminate pediatric IHCA and OHCA resuscitation?| |What is the optimal timing or duration of CPR prior to defibrillation?| |What duration of pause in chest compressions is"prolonged" pause? Or, what is the duration of time that is considered a minimal pause in chest compressions?| |What is the effectiveness of single shock compared to sequential (stacked) shocks in pediatrics?| |What is the adverse impact of shocking nonshockable rhythms with a manual defibrillator in IHCA?| |Is the time to shock with self-adhesive pads significantly different than with paddles?| |Is there an optimal pad position for defibrillation in pediatrics? Is so, it is AP or AL?| |What is the ideal threshold of CCF associated with improved patient out- comes in pediatric CPR?| |What is the most effective intervention for FBAO in pediatric patients, chest compressions versus abdominal thrusts?| |What is the safety and efficacy of commercial devices for FBAO?| |What is the role of mechanical chest compression devices in pediatric patients?| |What is the role of point-of-care ultrasound(vascular or cardiac) during rhythm and pulse analysis?| |What is the best method to verify effectiveness of breaths/ventilations dur- ing rescue breathing and CPR?|

AL indicates anterolateral; AP, anteroposterior; CCF, chest compression frac-tion;CPR, cardiopulmonary resuscitation;FBAO,foreign-body airway obstruction;IHCA, in-hospital cardiac arrest;OHCA, out-of-hospital cardiac arrest;pVT, pulse-less ventricular tachycardia; and VF, ventricular fibrillation.

$$\text{Joyner et al}$$

$\text{Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC}$

scoping reviews are in process by the International Liai-son Committee on Resuscitation BLS or Pediatric Life Support Task Forces and elected not to make premature recommendations until these reviews are available.

As is so often the case in pediatric medicine, many recommendations are extrapolated from adult data. This is particularly true for the BLS components of pediatric resuscitation. The causes of pediatric cardiac arrest are very different from cardiac arrest in adults, and pediatric studies are critically needed. Furthermore, infants, chil-dren, and adolescents are distinct patient populations.Dedicated pediatric resuscitation research is a priority given the>20000 infants, children, and adolescents who suffer cardiac arrest in the United States each year.

Critical knowledge gaps are summarized in Table 2.

Disclosures

Appendix 1. Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/noronia|Expert witness|Ownership interest|Consultant/advisory board|Other| |---|---|---|---|---|---|---|---|---| |Benny L. Joyner|State University of New York, University at Buffalo|None|None|None|None|Career-Physician*|None|None| |Tia T. Raymond|Medical City Children's Hospital|None|None|None|None|None|New England Research Institute COMPAS Trial Adjudication Commit- tee*|None| |Aarti Bavare|Baylor College of Medicine, Baylor University|None|None|None|None|None|None|None| |Allan de Caen|University of Alberta (Canada)|None|None|None|None|None|None|None| |Maya Dewan|Cincinnati Children's Hospital Medical Center|None|AHRQt|None|None|None|None|None| |Kimberly DiMaria|Children's Hospital Colo= rado|None|None|None|None|None|None|Zoll Medical*| |Joelle Donofrio- Odmann|University of California San Diego School of Medicine|None|None|None|None|None|None|None| |Gwen Fosse|C.S Mott Children's Hospi- tal,University of Michigan, Congenital Heart Center|None|None|None|None|None|None|None| |Sarah Haskell|University of lowa|NIH NHLBlt|None|None|None|None|None|None| |Melissa Mahgoub|American Heart Associa- tion|None|None|None|None|None|None|None| |Garth Meckler|University of British Colum- bia(Canada)|NIH*|None|None|None|None|None|None| |Michelle Olech Smith|American Academy of Pediatrics|None|None|None|None|None|None|None| |Jennifer Requist|Inova Fairfax Hospital/L.J. Murphy Children's Hospital|None|None|None|None|None|None|None| |Stephen M. Schexnayder|University of Arkansas/ Arkansas Children's Hos- pital|None|None|None|Love& Kirschenbaum LLLCt; Best and Sharp*|None|American Heart Associationt|None|

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Pediatric Basic Life Support: 2025 AHA/AAP Guidelines for CPR and ECC

Appendix 1. Continued

|Writing group member|Employment|Research grant|Other research support|Speakers|Expert witness|Ownership interest|Consultant/advisory board|Other| |---|---|---|---|---|---|---|---|---| |David Werho|University of California San Diego|AHAt|None|None|None|None|Danone*; Orbees Medical*|Glaukos Corporation*; Aerie Phar- maceuticals, Inc*; Nu- wellis, Inc*|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be“significant” if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be“modest” if it is less than“significant” under the preceding definition.

Disclosures are reviewed and mitigated through a conflict-of-interest process that consists of reviewing pertinent information which is then used to decide what action is required to maintain content integrity. Disclosures may include salary, wages or other remuneration of any kind(including but not limited to consulting or advising fees,speaking fees, research funding, ownership interests, honoraria, participation in pension or benefit plans or programs or other perquisites, and reimbursement for travel,logging, and meals) given for services rendered or other activities for which remuneration is received or expected, whether that compensation or other remuneration is paid directly to the individual or to the individual's employer or another third party.

*Modest.

tSignificant.

Appendix 2. Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Jason Acworth|University of Queensland, Children's Health Clinical Unit(Australia)|None|None|None|None|None|None|None| |Jana Djakow|Masaryk University(Czech Republic)|None|None|None|None|None|None|None| |Jesse Hackell|Committee on Practice and Ambulatory Medicine|None|None|None|None|None|None|None| |Tomitra Latimer|Lurie Children's Hospital|None|None|None|None|None|None|None| |Joshua Nagler|Division of Emergency Medicine, Boston Children's Hospital|None|None|None|None|None|None|None| |Mohsen Saidinejad|Harbor Medical Center UCLA|None|None|None|None|None|None|None| |Linda Siegel|Cohen Children's Medical Center|None|None|None|None|None|None|None| |Sarah Tabbutt|University of California San Francisco|None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be“significant” if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be“modest” if it is less than“significant” under the preceding definition.