What are the differences in cardiopulmonary resuscitation (CPR) techniques for pediatric patients under 5 years old and over 5 years old?

Pediatric CPR Technique: Key Differences by Age

For children under 5 years old, use a 15:2 compression-to-ventilation ratio with 2 rescuers (or 30:2 if alone), compress at least one-third the chest depth (approximately 1.5-2 inches/4-5 cm), and use 2 fingers for infants or 1-2 hands for children; for children over 5 years old (approaching puberty), transition to adult techniques with deeper compressions (at least 2 inches/5 cm) and maintain the same compression-to-ventilation ratios. 1

Compression Technique by Age

Infants (Under 1 Year)

• Hand position: Single rescuers should use 2 fingers placed just below the intermammary line on the sternum 1
• Two-rescuer technique: Use the 2-thumb encircling hands technique, which is the preferred method when 2 healthcare providers are present 1
• Compression depth: At least one-third of the anterior-posterior chest diameter, approximately 1.5 inches (4 cm) 1

Children (1 Year to Puberty/Under 5 Years)

• Hand position: Either 1-hand or 2-hand technique may be reasonable, depending on the child's size and rescuer strength 1
• Compression depth: At least one-third of the anterior-posterior chest diameter, approximately 2 inches (5 cm) 1
• Compression rate: 100-120 compressions per minute 1

Children Over 5 Years (Approaching/At Puberty)

• Transition point: Once children reach puberty (defined as breast development in girls or axillary hair in boys), use adult compression techniques 1
• Compression depth: At least 5 cm but no more than 6 cm 1
• Hand position: Standard 2-hand adult technique 1

Compression-to-Ventilation Ratios

Critical distinction: The ratio changes based on number of rescuers, not just age 1

• Single rescuer (all pediatric ages): 30 compressions to 2 breaths 1
• Two rescuers (all pediatric ages): 15 compressions to 2 breaths 1

This differs from adults where the ratio remains 30:2 regardless of rescuer number. The 15:2 ratio for two-rescuer pediatric CPR reflects the greater importance of ventilation in pediatric arrests, which are predominantly asphyxial in origin 1

Ventilation Requirements

Pediatric cardiac arrest is typically asphyxial, making ventilations critically important 1

• With advanced airway: Provide 1 breath every 2-3 seconds (20-30 breaths/min), without pausing compressions 1
• Without advanced airway: Follow the compression-to-ventilation ratios above, pausing compressions for breaths 1
• Oxygen concentration: Use 100% oxygen during CPR when available 1

Important Caveat on Compression-Only CPR

While compression-only CPR is acceptable for adults, CPR with rescue breaths should be provided for all infants and children in cardiac arrest 1. However, if bystanders are unwilling or unable to deliver rescue breaths, chest compressions alone are superior to no CPR 1. For children 1-18 years with presumed cardiac (non-asphyxial) arrest, compression-only CPR may be as effective as conventional CPR, but this is the exception 1

High-Quality CPR Components

All ages require attention to these five critical elements 1:

1. Adequate compression rate: 100-120/minute 1
2. Adequate compression depth: As specified above by age 1
3. Full chest recoil: Allow complete chest re-expansion between compressions 1
4. Minimize interruptions: Limit pauses to less than 10 seconds 1
5. Avoid excessive ventilation: Do not hyperventilate 1

Sequence: CAB vs ABC

Use the CAB sequence (Compressions-Airway-Breathing) for all pediatric ages 1. While pediatric arrests are predominantly asphyxial and ventilations are crucial, starting with compressions delays the first breath by only 18 seconds for a single rescuer and less for two rescuers 1. This universal sequence simplifies training and increases the likelihood of bystander CPR 1

Common Pitfalls to Avoid

• Inadequate compression depth: Studies show compressions often fail to reach adequate depth; aim for visible chest compression 1
• Leaning on the chest: This is common during pediatric CPR and impairs venous return 1
• Excessive ventilation rates: Rates exceeding 30 breaths/min may compromise hemodynamics 1
• Prolonged pulse checks: Limit rhythm/pulse checks to no more than 10 seconds every 2 minutes 1
• Wrong compression-to-ventilation ratio: Remember 15:2 for two rescuers in pediatrics, not 30:2 1