Every year in the United States, more than 20,000 infants and children experience sudden cardiac arrest. Although in-hospital cardiac arrest survival rates and neurological outcomes have improved, out-of-hospital cardiac arrest outcomes remain poor, according to the 2020 American Heart Association^® (AHA^®) guidelines for CPR and ECC.

As with adults, administering CPR on a child greatly improves their chances of survival. To emphasize the importance of CPR for children, the 2024 American Heart Month theme is focused on pediatric CPR. However, performing CPR on a child is different than adults and requires separate training and certification. So, understanding the key differences is crucial.

To commemorate this year’s Heart Month, RQI Partners will be hosting an exclusive webinar on February 29. The event will offer strategies for creating a culture of pediatric resuscitation excellence within hospital communities and feature conversations with renowned professionals in the field, including Lynda J. Knight, MSN, RN, director for Revive Initiative for Resuscitation Excellence at Stanford Children’s Health.

In advance of the webinar, we sat down with Knight to discuss the pediatric chain of survival and best practices for responding to sudden cardiac arrest in children. Here are her insights.

Q: What are some key differences between children and adults when it comes to CPR?

I would say the key differences between adult and pediatric CPR, in current state, is that children have healthy hearts for the most part, so the common cause of an arrest is a respiratory arrest. They are usually suffering a respiratory arrest caused by hypoxia, which can cause the heart rate to dip below 60 with poor perfusion. This is defined as sinus bradycardia.

Unlike adults — who we know have great outcomes with hands-only CPR — children are rate dependent, which means we need to start compressions before they go pulseless. This differentiates children from adult CPR because you would not start CPR in an adult until they are pulseless.

Q: How should CPR be performed on a child vs. on an adult?

Because of the need for ventilation, there are different compression/ventilation ratios. For adolescents and adult compression/ventilation, the ratio is 30:2. For children, the ratio is 15:2 for two providers (but stays the same for one provider), while increasing ventilations provided.

If there is an advanced airway there is also a different ratio for children under 12 months old: 30 ventilations every minute (every 2 seconds) and 100-120 compressions per minute. For older children and adolescents, 20 ventilations are needed every minute (every 3 seconds) and 100-120 compressions per minute. It’s very different for adults, we provide a respiration every 6 seconds (10 per minute).

Q: Why is it important for healthcare workers to have training in pediatric CPR?

I believe it is so important to be trained in both pediatric and adult CPR skills. It is really the only thing that has enough evidence to show that without a doubt, it is the one thing that will improve outcomes after a cardiac arrest.

To be proficient in pediatric CPR we need to practice consistently. Again, pediatric cardiac arrests are rare, so due to the low volume but extremely high-risk nature, we need to make sure we are providing high-quality CPR for the best outcomes.

Q: What are the components of high-quality CPR?

It means you have the correct depth — about 1/3 diameter of the chest, which is approximately 1.5 inches for children under a year and 1-2.4 inches for older children.

The correct rate is 100-120 compressions per minute. Minimizing interruptions of CPR to less than 10 seconds, meaning if the arrest lasts 10 minutes, we should be on the chest 90% of the time to prevent a decrease in cerebral and coronary perfusion.

Finally, we need to allow for full chest recoil with each compression to allow for coronary perfusion and no leaning. When compressors get tired they tend to lean, so that is why we try to rotate compressors every two minutes.

Q: What are the main things to know about the need for pediatric CPR?

We now know that CPR skills must be practiced more frequently than the previous recommendation of every two years. The Resuscitation Quality Improvement program allows healthcare providers to practice every three months instead. This helps maintain their CPR skills, enabling them to feel more competent while promoting the very best neurological outcomes in pediatric patients who suffer a cardiopulmonary arrest.

Here are my main takeaways for keeping CPR skills fresh:

• Frequently practice the components of high-quality CPR.
• Provide CPR immediately when an individual’s heart rate falls below 60 beats per minute with poor perfusion.
• Call 911 right away for a child who is unresponsive and begin CPR immediately.
• Educate family and friends around high-quality CPR, as EMS may take several minutes to arrive. For every minute that goes by without CPR, the chance of survival decreases by 10%. Many cardiac arrests occur outside the medical setting and unfortunately this can affect outcomes.

Routine Pediatric CPR Training Can Help Improve Outcomes

The mission of the AHA is to ensure that as many people are trained to provide CPR as possible, thereby increasing the number of survivors with a favorable neurological outcome. Healthcare providers can benefit from a low-dose, high-frequency training model to keep their pediatric CPR skills current.