At what pediatric age is cardiopulmonary resuscitation (CPR) initiated for bradycardia?

From the Guidelines

In pediatric patients, CPR should be initiated when the heart rate is less than 60 beats per minute with signs of poor perfusion, regardless of age. This guideline is based on the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, as outlined in the study by Berg et al. 1. The decision to start CPR is based on the presence of inadequate perfusion along with bradycardia, which includes symptoms such as pallor, mottling, cyanosis, and poor responsiveness.

Key Considerations for CPR in Pediatric Patients

• The absolute heart rate at which chest compressions should be initiated is unknown, but a heart rate <60 per minute with signs of poor perfusion is recommended as an indication for chest compressions due to ease of teaching and retention of skills 1.
• Imminent and beginning CPR prior to full cardiac arrest results in improved survival, highlighting the importance of early recognition and intervention for bradycardia with poor perfusion 1.
• When performing CPR on pediatric patients, compressions should be delivered at a rate of 100-120 compressions per minute with a depth of approximately one-third the anterior-posterior diameter of the chest.
• The compression to ventilation ratio is 30:2 for single rescuers and 15:2 for healthcare providers with two rescuers.

Technique for Pediatric CPR

• For infants, use two fingers or two thumbs encircling technique; for children, use one or two hands depending on the child's size.
• Early recognition and intervention for bradycardia with poor perfusion are critical to prevent full cardiac arrest, as children primarily arrest due to respiratory issues that lead to cardiac arrest, rather than primary cardiac problems 1.

From the Research

Cardiopulmonary Resuscitation (CPR) for Bradycardia in Pediatrics

• The American Heart Association (AHA) Pediatric Advanced Life Support (PALS) guidelines recommend interventions such as oxygen, chest compressions, epinephrine, and atropine for pediatric patients with bradycardia 2.
• According to the AHA PALS guidelines, age-based bradycardia is defined, but the exact pediatric age at which CPR is initiated for bradycardia is not explicitly stated in the provided studies.
• A study published in 2024 found that pediatric CPR guidelines recommend starting CPR for heart rates less than 60 beats per minute (bpm) with poor perfusion 3.
• The International Liaison Committee on Resuscitation (ILCOR) recommends the initiation of chest compressions during neonatal resuscitation after 30 s of effective ventilation if the infant remains bradycardic (defined as a heart rate less than 60 bpm) 4.
• There is no clear consensus on the exact age at which to transition from neonatal to pediatric resuscitation guidelines, and it is up to healthcare teams and institutions to decide based on local circumstances and resource limitations 5.

Key Findings

• A heart rate less than 60 bpm is considered bradycardic in neonates and pediatric patients 4, 3.
• CPR is recommended for pediatric patients with bradycardia and poor perfusion, but the exact age at which to initiate CPR is not clearly defined 2, 3.
• The decision to initiate CPR in pediatric patients with bradycardia should be based on individual patient circumstances and clinical judgment 5, 3.

Age-Based Considerations

• Neonatal resuscitation guidelines apply to newborns, while pediatric resuscitation guidelines apply to older infants and children 5.
• The transition from neonatal to pediatric resuscitation guidelines is not well-defined, and more research is needed to determine the optimal approach 5.
• A study published in 2024 found that pre-CPR pulse pressure and heart rate are used clinically to differentiate bradycardia from pulseless electrical activity, but the optimal thresholds for initiating CPR are not clearly defined 3.