3.2 Child CPR and AED Decisions
Key Takeaways
- Compress the lower half of the sternum about one third of chest depth (~2 inches/5 cm) using one or two hands, whichever achieves depth.
- Rate is 100–120/min with full recoil; single rescuer 30:2, two rescuers 15:2.
- For a child 1–8 years, use a pediatric dose-attenuator AED if available; otherwise use a standard AED rather than withholding a shock.
- Allow complete chest recoil and minimize interruptions; aim for a high chest compression fraction.
- Do not delay defibrillation of a shockable rhythm to hunt for pediatric pads.
Compression Mechanics for a Child
For a child (1 year to puberty), place the heel of one hand — or two hands stacked, as for an adult — on the lower half of the sternum, avoiding the xiphoid process. The choice of one versus two hands is pragmatic: use whatever lets you reach the target depth of about one third of the chest's anterior-posterior diameter, roughly 2 inches (5 cm). A small child may be compressed adequately with one hand; a larger child often needs two. Compress at 100–120 per minute, allow complete chest recoil between compressions (leaning on the chest impairs venous return and coronary perfusion), and minimize interruptions.
Depth is the parameter most often performed poorly. Rescuers under-compress out of fear of injuring a child, but inadequate depth produces inadequate perfusion. The guideline tolerance is built around "at least" one third of the chest diameter; you should push to that depth even though it feels aggressive on a small body.
Ratios and rescuer count
- Single rescuer: 30 compressions to 2 breaths (30:2).
- Two rescuers (healthcare providers): 15 compressions to 2 breaths (15:2).
The 15:2 ratio exists because asphyxia drives most pediatric arrests, so more frequent ventilation is beneficial when a second trained rescuer can deliver it. The number of rescuers in a question stem is never filler — it determines the ratio.
AED Decisions for a Child
Defibrillation still matters in children — a small subset of pediatric arrests are shockable (VF or pulseless ventricular tachycardia, e.g., commotio cordis from a chest blow during sport, or arrest from certain congenital or toxicologic causes). The AHA priority order for a child 1 to 8 years (or under ~25 kg) is:
- Pediatric dose-attenuator system (pediatric pads/key) — preferred, because it lowers the delivered energy.
- Standard AED — acceptable if no attenuator is available; do not withhold a shock.
For children over 8 years (or over ~25 kg), use a standard AED with adult pads. If adult pads are the only option on a small child and they risk touching, use anteroposterior placement (one pad on the chest, one on the back) so the pads do not overlap.
AED priority table
| Patient | First choice | If unavailable |
|---|---|---|
| Child 1–8 yr (<25 kg) | Pediatric attenuator AED | Standard AED (don't delay) |
| Child >8 yr (>25 kg) | Standard AED, adult pads | — |
| Infant <1 yr | Manual defibrillator | Attenuator AED, then standard AED |
Sequence and Common Traps
For a witnessed sudden collapse with an AED immediately at hand, attach it as soon as possible; otherwise give about 2 minutes of CPR while the AED is retrieved and readied, then analyze. Resume compressions immediately after any shock — do not pause to recheck a pulse before the next 2-minute cycle.
Classic stem: a 7-year-old collapses during a soccer match and the only AED has adult pads. The right answer is to use it now for a shockable rhythm, not to send someone searching the building for pediatric pads. Other traps: applying the infant two-thumb technique to a child, and compressing too shallowly out of fear of injury. Match technique and equipment to age, but never let an equipment search override a lifesaving shock or compressions.
High-Quality CPR Metrics for a Child
The quality of compressions matters as much as the technique. The five components of high-quality CPR apply to children just as to adults: adequate rate (100–120/min), adequate depth (~one third of chest depth, about 2 inches), full recoil between compressions, minimal interruptions (keep pauses under 10 seconds and aim for a chest compression fraction of at least 60%), and avoidance of excessive ventilation.
When two rescuers are present, switch the compressor about every 2 minutes (or sooner if fatigued) to prevent the depth decay that creeps in as a rescuer tires — fatigue-related shallowing often begins within the first minute even though the rescuer does not perceive it.
Coordinate the switch with the rhythm/pulse check so the interruption does no extra harm: at the end of a 2-minute cycle, the AED analyzes (if attached), and the compressor change happens in the same brief pause. Announce roles clearly — "I'll take compressions, you take the airway and AED" — because closed-loop communication reduces dangerous gaps.
Putting It Together: A Worked Child Scenario
A 6-year-old is found unresponsive and not breathing after near-drowning. Two trained rescuers respond. Rescuer 1 confirms unresponsiveness, checks the carotid pulse for up to 10 seconds, finds none, and begins compressions on the lower half of the sternum to a depth of about 2 inches at 110/min with full recoil. Rescuer 2 activates EMS, retrieves the AED, and prepares to ventilate. Because two rescuers are present, they use 15:2.
The AED arrives with a pediatric attenuator key, which they use; it advises a shock, they clear and shock, then immediately resume compressions without a pulse check, completing a full 2-minute cycle before reanalyzing. This single scenario integrates depth, rate, recoil, the two-rescuer ratio, AED priority, and the no-pause-after-shock rule — the exact bundle a child CPR question tests.
Two healthcare-provider rescuers are performing CPR on a 5-year-old child in cardiac arrest. What compression-to-ventilation ratio should they use?
Which compression depth is correct for a child during CPR?