Should CPR be started in an infant with bradycardia (<60 bpm) accompanied by poor perfusion and ineffective breathing?

Should CPR Be Initiated on a Bradycardic Infant?

Yes, you must immediately start CPR on an infant with a heart rate less than 60 beats per minute when signs of poor perfusion are present. 1, 2

The Critical Threshold

The 2020 American Heart Association Pediatric Basic Life Support guidelines establish a clear, non-negotiable decision point: 1

• If heart rate is <60 bpm WITH signs of poor perfusion → Start CPR immediately 1, 2
• If heart rate is <60 bpm WITHOUT signs of poor perfusion → Continue rescue breathing only (1 breath every 2-3 seconds), check pulse every 2 minutes 1

This threshold exists because in infants and children, a heart rate below 60 bpm with poor perfusion represents imminent cardiac arrest where the cardiac output is insufficient to maintain tissue perfusion, particularly to the brain and heart. 2, 3

Signs of Poor Perfusion to Assess

Before initiating CPR, rapidly assess for: 2

• Altered mental status or unresponsiveness
• Weak or absent peripheral pulses
• Prolonged capillary refill (>3 seconds)
• Mottled or pale skin
• Cool extremities

Proper CPR Technique for Infants

Once you determine CPR is needed: 1, 4, 2

• Compression depth: At least one-third of the anterior-posterior diameter of the chest 4, 2
• Compression rate: 100-120 compressions per minute 4, 2
• Compression-to-ventilation ratio:
  • 30:2 if you are alone 1, 4, 2
  • 15:2 when two rescuers are present 1, 4, 2
• Allow complete chest recoil after each compression 4, 2
• Minimize interruptions in chest compressions 4

The Evidence Behind This Recommendation

The guideline's approach is based on the understanding that bradycardia with poor perfusion in pediatric patients represents a fundamentally different physiologic state than in adults. 2 While adults typically arrest from primary cardiac causes (ventricular fibrillation), pediatric arrests are predominantly respiratory in origin, progressing through hypoxia → bradycardia → asystole. 5, 6

Important nuance: Recent research questions whether asynchronous chest compressions during bradycardia might be harmful in neonates specifically, suggesting ventilation alone may be sufficient. 7 However, the current AHA guidelines remain unchanged and apply to all infants beyond the immediate newborn period. 1, 2

A 2024 study found that among pediatric patients receiving CPR, those with bradycardia and poor perfusion (versus pulseless electrical activity) had higher pre-CPR pulse pressures and better outcomes, but this does not change the indication to start CPR—it simply confirms that earlier intervention in the bradycardia phase may prevent progression to full arrest. 8

Critical Pitfalls to Avoid

• Never delay CPR to obtain additional history, labs, or imaging when an infant meets criteria (HR <60 bpm with poor perfusion) 4, 2
• Do not use atropine in pediatric cardiac arrest—it delays appropriate epinephrine administration and is not evidence-based 4
• Do not wait for the heart rate to reach zero before starting compressions if poor perfusion is present 2, 3
• Do not confuse transient bradycardia during feeding or sleep (normal vagal response) with pathologic bradycardia requiring intervention 3

After Starting CPR

Once CPR is initiated: 1, 4

• Activate emergency response system immediately if not already done 1
• Obtain vascular access (IV/IO) as soon as possible 4
• Administer epinephrine 0.01 mg/kg IV/IO as soon as access is obtained, repeat every 3-5 minutes 4
• Continue CPR until heart rate improves to >60 bpm with adequate perfusion, advanced life support providers take over, or the child shows signs of recovery 2