Pediatric cardiopulmonary resuscitation (CPR) is performed when an infant or child is unresponsive and not breathing normally. Immediate action is important because the outcome depends on how quickly blood flow and oxygenation can be restored. Unlike adult CPR, where cardiac events are often the primary cause, pediatric emergencies are commonly triggered by respiratory failure. This difference means the specific techniques and ratios used for children vary from those used for older patients.
The Universal Target Rate
The most current guidelines establish a specific range for the speed of chest compressions applied to children. The standardized target rate is between 100 and 120 compressions per minute, which applies universally to victims of all ages. This speed is designed to maximize the circulation of oxygenated blood without causing undue fatigue to the rescuer. Rescuers should strive for a consistent rhythm.
Achieving this rate means delivering close to two compressions every second. Many rescuers use a metronome or familiar songs with the appropriate tempo to maintain this steady pace. A rate slower than 100 compressions per minute is less effective at maintaining sufficient blood flow to the brain and other organs. Exceeding 120 compressions per minute can lead to compressions that are too shallow, reducing the effectiveness of the procedure.
Proper Depth and Hand Placement
While the rate is the same across all age groups, the physical technique and required depth must be adjusted based on the patient’s size. Proper hand placement and depth ensure the procedure is effective without causing unnecessary injury to the child’s delicate rib cage or internal structures. The goal for compression depth is to depress the chest by approximately one-third of its anterior-posterior diameter.
For infants, defined as children under one year old, the recommended technique involves using two fingers placed on the sternum just below the imaginary nipple line. This aims to achieve a depth of about 1.5 inches (roughly 4 centimeters). This relatively shallow depth reflects the small size of the infant’s chest cavity. An alternative for two rescuers is the two-thumb-encircling hands technique, which provides better depth and stability.
For children over the age of one year and up to puberty, the technique shifts to using the heel of one hand or two hands, depending on body size. The rescuer should select the method that allows them to reach the target depth of approximately 2 inches (about 5 centimeters). This depth is maintained by pushing straight down on the center of the chest, avoiding the soft tissue of the abdomen.
Between each compression, allow the chest wall to fully return to its original position without the rescuer leaning on the chest. Full recoil is necessary for the heart to adequately refill with blood before the next compression. Maintaining both adequate depth and full recoil contributes significantly to the quality of the resuscitation effort.
Integrating Compressions into the CPR Cycle
Chest compressions are only one component of pediatric CPR, which must also include rescue breaths to supply necessary oxygen. Unlike adult CPR, children generally require both compressions and ventilations because their cardiac arrest often stems from a lack of oxygen. Since respiratory issues are the frequent underlying problem, delivering oxygen is important. The ratio of compressions to breaths depends on the number of rescuers present.
When a lay rescuer is alone, the sequence involves a ratio of 30 compressions followed by 2 rescue breaths (30:2). This 30:2 cycle is the same ratio used for single-rescuer CPR across all age groups. It is typically performed for about two minutes before the rescuer pauses to activate emergency services or retrieve an automated external defibrillator (AED).
When two or more rescuers are present, particularly trained providers, the ratio changes to 15 compressions for every 2 rescue breaths (15:2). This adjustment provides a higher number of ventilations per minute, which is recommended because the underlying cause is frequently respiratory failure. Having two people allows one person to focus on compressions while the second manages the airway and rescue breathing.
Regardless of the ratio used, deliver the breaths quickly, ensuring the chest visibly rises, to minimize the interruption in chest compressions. Maintaining a high chest compression fraction—the proportion of time spent actively performing compressions—is important for sustaining adequate blood flow. Rescuers should aim to switch compression roles every two minutes to prevent fatigue and maintain quality.