Child/Infant Cardio Pulmonary Resuscitation (CPR)

A child is defined as being aged under puberty and an infant under 1-year old. What you need to remember, children are not small adults they have many physiological differences that will need to be discussed in a separate article.

It is not unknown, but highly unlikely, that a child will have a cardiac arrest; when requiring CPR it is more common for a child to have had an accident or illness that caused them to stop breathing (respiratory arrest) and then for their heart to stop beating (Cardiac Arrest). So it is with this in mind that the Resuscitation Council (UK) guidelines for Child CPR differ to Adult CPR.

Child CPR (Newborn to Puberty)

  • Method – Danger/Response/Airway/Breathing
  • Result – Unresponsive/Non-Breathing infant
  • 5-Rescue Breaths
  • 30-chest compressions
  • 2-Rescue Breaths
  • Repeat – CPR at ratio 30:2 for 1-minute (Approx. 3 reps of 30:2)
  • 999 – If no one has called emergency services it must be done now
  • Continue – CPR at ratio of 30:2

Previous articles have referred to the primary survey Danger Response Airway Breathing (DRAB) to define whether a casualty is in the state of dying and requiring Cardio Pulmonary Resuscitation (CPR). Once again this approach needs to be adhered to, but obviously the language you speak to a child needs to be refined slightly for them to be able to understand.

Danger – Children don’t have life experiences and the foresight to see they are getting themselves into perilous situations and sometimes the scene can be amusing but it can make it difficult for would-be-rescuers to assist. Circumstances involving children are highly sensitive and emotional; the highly charged scene can drive first aiders into putting themselves in danger and becoming a casualty. If you cannot access a scene because of safety issues please call the emergency services – they have the equipment and training to deal with these situations – a call to the emergency services is a positive first aid action.

It is extremely likely that you will have more than one casualty to deal with. Children are not usually alone; they will have parents, grandparents, brothers, sisters or other guardians in close proximity. They may not just put themselves into danger but may suffer from ‘shock’ which is perilous situation in its own right.

Response – Once you know the scene and bystanders are safe you need to quickly decipher the conscious ability of the child by using the Alert Voice Pain Unresponsive (AVPU) scale. With an infant it’s difficult to strike up a conversation to decide whether they are Alert or responding to Voice; nevertheless, talk to the baby in a very calm manor but use your senses – they are never usually wrong! – Babies usually have good colour and are constantly on the move- a silent, limp, pale child is very rarely healthy; use these early visual clues.

To confirm the infant is Unresponsive we need to check their Pain response; this is done by the ‘Tap-and-tickle’ method. Tap the child’s arms, shoulders and hips as if tickling and look for a normal reaction; if you’re still unsure, run your finger-nails along the soles of the feet – the normal reaction is to move away from the response. If the child fails these basic tests you can diagnose your patient has being Unresponsive.

Airway – The delicate airway of an infant needs to be protected. If you look at an adult head it is a pea-on-a-drum; while a baby’s head is larger and has a bulbous back. When a baby is unresponsive and on its back with its shoulders on the floor the bulbous rear part can push the head into the bowing position with the chin almost of the chest and compromising the airway. With this in mind it is best practise to raise the shoulders slightly by either, putting the palm of your hand beneath the Childs shoulders and cupping your thumb and forefinger around the neck for support or, placing a folded magazine/newspaper or towel beneath the shoulders of the child and position the head in the flat neutral position.

With young children do not perform a full Head-Tilt-Chin-Lift as you would to an Adult; you can equally kink and compromise the airway by over extension; start with the ‘sniffing’ position; increase the tilt the nearer the child is to puberty and adulthood.

Once you have positioned the child correctly you need to take a look in the mouth and remove any foreign objects you may find using your thumb and forefinger as pincers.

Tip: The infant’s pallet is very delicate and has the consistency of a fine membrane. Never blind sweep the mouth for objects with your finger has you can do untold damage and penetrate the pallet.

When you know the airway is clear, leave the head in the correct position and place yourself so you can look down the Childs chest, listen at the airway for breathing and feel any breath on your cheek (Look, Listen and Feel). An infant breathes at a more rapid rate than an adult (20-40 breaths/min) and is more diaphragm orientated – they breathe from their tummy muscles. So when you look, listen and feel watch their breathing mechanism and look for 4-8 normal breaths in 10 seconds. If you have any doubts about normal breathing and the child remains unresponsive you must commence CPR immediately.

Tip: At this stage – If there are bystanders available allow them to call the emergency services but if you are alone remain with the casualty and perform CPR for 1-minute.

Start CPR by giving 5-rescue breaths; with small infants the best technique can be ‘mouth over nose and mouth’ – this is where the rescuer places their mouth over the nose and mouth of the infant to give rescue breaths.  Use the usual technique of pinching the soft part of the nose and breathing through the mouth of older children.

Tip: Don’t over inflate the child’s lungs; over inflation may damage the lungs and air may spill into the casualty’s stomach causing them to vomit.

Follow the 5-rescue breaths with 30-chest compressions. Force needs to be applied to the central chest between the nipples; with infants the pressure of two-fingers may be sufficient, the pressure of one-hand to small children and adult two-handed method for children close to puberty. Nevertheless, the compression must be at least a third of the depth of the chest of all casualties under the age of puberty and at a pace of 100 to 120 compressions per minute.

Following chest compressions give a further two-rescue breaths.

Repeat the process of 30-chest compressions to 2-rescue breaths (30:2) for 4-repetitions; this is approximately 1-minute of CPR; if an ambulance has not yet been called it is now time to do so – it may be necessary for the rescuer to leave the casualty to make the call. For children over 1-year old a defibrillator needs to be requested. Once it is confirmed an ambulance is enroute CPR must be returned to immediately at a ratio of 30:2 and be continuous until assistance arrives and takes over the care of the casualty.

This adapted CPR is known as ‘Child/Infant CPR’ and is best care practise for all casualties under puberty who are unresponsive and not breathing normally. This practise can also be used when casualties are brought from non-oxygenated atmospheres such as drowning or toxic atmospheres. If the lay person has not been taught in these techniques then Adult CPR should be performed.

Tony Clough