Revised guidelines for cardiopulmonary resuscitation (CPR) of infants and children recommend new techniques to revive breathing, clear obstructed airways, and improve survival rates.

The pediatric guidelines on CPR and emergency cardiovascular care were recently released by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) and published in Circulation and Pediatrics.

Updated every 5 years, the new recommendations aim to improve neurologic outcomes following cardiac arrest. They also emphasize the importance of high-quality chest compressions, early defibrillation, and the integration of advanced resuscitation techniques.

“We want the highest levels of survival possible,” said Benny Joyner Jr, MD, MPH, chair in the Department of Pediatrics at the Jacobs School of Medicine and Biomedical Sciences, University of Buffalo in Buffalo, New York, and co-chair of the guidelines group.

The guidelines for CPR were first published in 1966 to provide standards and recommendations for training and response. They are updated based on the latest findings from studies and an evaluation of evidence by the International Liaison Committee on Resuscitation. The current iteration, an update from the 2020 guidelines, marks the first time AAP collaborated on the document.

“Having different experts from the AAP and the AHA that can talk about different elements of the resuscitation, prevention, intra-arrest, and then post-arrest, having all of those individuals weigh in, is really important,” Joyner said.

Cardiac arrest in infants and children typically results from progressive respiratory failure or shock, according to the guidelines. Every year, more than 7000 out-of-hospital cardiac arrests occur in children in the US, with survival rates ranging from 6% to 38%, depending on the age. Approximately 20,000 in-hospital cardiac arrests occur in infants and children with survival to hospital discharge ranging from 38% for pulseless cardiac arrest to 66% for nonpulseless cardiac arrest.

CPR Techniques, Foreign Body Airway Obstruction

One of the most significant changes in the guidelines is the recommended technique for CPR in infants, Joyner said. The guidelines for basic life support eliminate the advice to use a two-finger chest compressions technique. Instead, a two-thumb encircling hands technique is recommended, in which a rescuer’s hands are wrapped around the infant’s chest with two thumbs on top of the sternum pressing down. If this position is not possible, compressing the infant’s chest with the heel of one hand is recommended.

Studies have shown the two-finger chest compressions generate significantly less force than using the two-thumb encircling technique. The change may be difficult for people to adopt since two-finger technique has been recommended since the early 1990s, Joyner said.

Another change is the inclusion of back blows to clear foreign body airway obstruction in children. Historically, the use of abdominal thrusts has been recommended to expel an object, Joyner said. But many people hit the back intuitively. The guidelines recommend cycles of five back blows followed by five abdominal thrusts.

The guidelines also include a new list of actions for lay rescuers without access to advanced medical equipment. They advise starting CPR using the heel of one hand for infants or two hands for children. After 30 chest compressions, clinicians are directed to provide two breaths into the airway, one every 2-3 seconds.

Although the guidelines do not specifically recommend parents receive CPR training, “it’s usually what is incorporated in the language of pediatrician recommendations for new parents,” Joyner said.

Approximately 5%-10% of newborn infants need help to begin breathing at birth, and approximately 1% require advanced resuscitative measures to restore cardiorespiratory function, according to the guidelines on neonatal resuscitation.

The neonatal mortality rate in the US has decreased from nearly 20 per 1000 live births in the 1960s to approximately 3.5 per 1000 live births in 2022.

Neonatal Resuscitation

The guidelines add a newborn chain of care, which starts during pregnancy to mitigate risks to the fetus. This initial care includes psychosocial support and education to prevent cardiac arrest at home or in the hospital.

The next step includes risk assessment to help identify newborns who are more likely to require resuscitation. Clinicians are advised to provide assisted ventilation if an infant does not breathe within the first 60 seconds after birth. If an infant has a heart rate of less than 100 per minute, clinicians should administer advanced resuscitation, such as chest compressions and epinephrine; conduct subsequent monitoring of respiration, oxygenation, heart rate, and blood glucose; and should follow-up during recovery.

The guidelines are “incrementally advancing the science to make things even better,” said Henry Lee, MD, medical director of the NICU at the Jacobs Medical Center at the University of California San Diego Health and co-chair of the neonatal writing group.

One example of this incremental advance is the new recommendation to defer umbilical cord clamping in most instances for at least 60 seconds after birth, Lee said. Doing so may reduce the need for cardiorespiratory support. Receiving this extra transfusion from the placenta is beneficial in both term and preterm infants, studies have shown.

Epinephrine Use, Blood Pressure (BP) Monitoring

The chapter on administering advanced life support encourages earlier use of epinephrine during CPR to optimize coronary perfusion pressure. For infants and children in cardiac arrest with initial nonshockable rhythm, administration is recommended as soon as possible.

For those in cardiac arrest with initial shockable rhythm, epinephrine is recommended after two attempts at defibrillation or sooner if rapid defibrillation is not possible.

The guidelines also recommend healthcare professionals use diastolic BP to assess the child’s response to resuscitation efforts and continuously monitor arterial pressure to identify and treat post-cardiac arrest hypotension. Systolic and mean arterial BP should be maintained at the 10th percentile or higher for age to increase the odds of survival and discharge from the hospital.

One study showed that mean arterial BP below the 10th percentile for age in the first 24 hours after cardiac arrest was associated with unfavorable neurologic outcomes.

Joyner said the guidelines were informed by clinicians who weighed in on the practical realities of administering CPR to kids and babies.

Groups like AHA and AAP have a responsibility to develop “not just a scientific approach, but also one that’s practical that could be learned by healthcare professionals all over,” Lee said. “I do believe there’s been a lot of thought that’s gone into the guidelines for that purpose, really to save more lives.”

Lee reported receiving funding from AHA, AAP, Genentech, and Chiesi. Joyner reported having no relevant financial disclosures.

Brenda Sandburg is a freelance journalist based in New York City. She has written about the biopharmaceutical industry and legal issues for The Pink Sheet and The American Lawyer.