Cardiopulmonary resuscitation (CPR) for infants and children requires specific knowledge distinct from adult procedures. The primary goal of pediatric CPR is to restore oxygen delivery to the body’s vital organs, particularly the brain, before significant damage occurs. Because the causes of collapse in children often differ from those in adults, the balance between chest compressions and rescue breaths shifts to prioritize ventilation. Understanding the precise ratios and proper techniques is important for anyone who might need to provide life support to a young victim.
Required Ventilation Ratios and Rates
Current resuscitation guidelines define an Infant as a child under the age of one year and a Child as one year of age until the onset of puberty. The compression-to-ventilation ratio for infants and children depends on the number of rescuers present.
When a single rescuer is performing CPR, the compression-to-ventilation ratio is 30 compressions followed by 2 breaths, which is the same ratio used for adult CPR. This 30:2 cycle simplifies training and makes it easier for lay rescuers to remember, ensuring that compressions are started quickly. The single rescuer should continue this cycle until help arrives or the child shows signs of life.
If two or more rescuers are present, the ratio changes to 15 compressions followed by 2 breaths for both infants and children. This higher ventilation rate acknowledges the greater need for oxygenation in pediatric cardiac arrests. The two-rescuer approach allows one person to focus on chest compressions while the other manages the airway and delivers breaths with minimal interruption.
In the specific scenario where an infant or child is not breathing normally but still has a pulse, only rescue breathing is required. The recommended rate for this rescue breathing is one breath every two to three seconds, which translates to a rate of 20 to 30 breaths per minute. This rate is significantly higher than the adult rescue breathing rate and is designed to quickly restore adequate oxygen levels. This higher ventilation rate of 20 to 30 breaths per minute is also recommended when an advanced airway, such as an endotracheal tube, is in place, allowing for continuous compressions without pausing for breaths.
Proper Technique for Rescue Breaths
Effective rescue breathing requires opening the airway and creating a proper seal to ensure the air enters the lungs. For both children and infants, the preferred method for opening the airway is the head-tilt/chin-lift maneuver, which moves the tongue away from the back of the throat. In infants, care must be taken to only tilt the head to a neutral or “sniffing” position to avoid closing off the soft airway.
For a child, the rescuer pinches the nose shut and forms a tight seal over the child’s mouth with their own. For an infant, the rescuer typically covers both the mouth and nose with their mouth to create a good seal due to the infant’s small facial structure. The breath should be delivered steadily over approximately one second.
The most important visual cue for an effective rescue breath is seeing the chest rise visibly. Rescuers should deliver only enough volume to achieve this chest rise, which prevents hyperventilation. Excessive ventilation can push air into the stomach, causing gastric inflation, which may lead to vomiting and can also compromise blood flow back to the heart. If the chest does not rise after the first breath, the rescuer must quickly reposition the head, ensure a better seal, and attempt the second breath.
Why Ventilation is the Priority in Pediatric CPR
The physiological reason pediatric CPR guidelines emphasize ventilation more heavily than adult guidelines lies in the typical cause of cardiac arrest. In adults, the cause is most often a primary cardiac event, such as a heart attack. This means the body’s tissues are often well-oxygenated at the moment of collapse, making initial chest compressions the priority to circulate that existing oxygenated blood.
Conversely, cardiac arrest in infants and children is overwhelmingly caused by respiratory failure, often resulting from conditions like drowning, choking, severe infection, or trauma. This sequence is known as asphyxial arrest, where a lack of oxygen causes the heart to slow down and eventually stop. The heart is usually healthy initially but fails due to profound oxygen deprivation.
Because the primary issue is a lack of oxygen, resuscitation efforts must focus on quickly providing oxygen to the blood. Delivering rescue breaths early is paramount to re-oxygenate the blood before the cardiac arrest becomes irreversible. The higher ventilation ratio of 15 compressions to 2 breaths in two-rescuer pediatric CPR reflects this physiological need for a greater proportion of breaths.