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Infant CPR - When the Unthinkable Happens

Nothing is more frightening than knowing that the life of a tiny infant is in your hands. No matter your level of education and expertise, no one is completely confident and unafraid when it comes to infant CPR. And we should be afraid- infants are not small adults and can’t be treated as such. Although there are few differences between adult and child CPR, there are several differences when performing CPR on an infant. In this article, we’ll look at some of these differences.

Checking for responsiveness

Obviously, it is never a good idea to shake a baby! In adults and children, rescuers should shake the victim’s shoulders while asking if the victim is okay (shake and shout), but this is not acceptable in infants. Instead, the soles of the infant’s feet or the infant’s chest should be tapped briskly to assess responsiveness while verbally trying to rouse the infant.

Witness versus unwitnessed arrest

If you witness the sudden collapse of an infant, you should call EMS (activate the emergency response system) immediately, then return to the victim and check for a pulse. On the other hand, if you come upon an infant who is unresponsive and is not breathing (or is breathing ineffectively) and the infant does not have a pulse, you should provide CPR for two minutes before activating the emergency response system. What is the rationale for waiting to call for help? Infants (and children) are far more likely to experience arrest as a result of asphyxia rather than a cardiac problem, therefore providing CPR for two minutes is recommended before calling for help. 

Checking for a pulse

Infants have a very short neck, which makes it very difficult to detect a carotid pulse. Femoral pulses are equally difficult to find due to the infant’s small size. In an infant victim, the brachial pulse is used to check for the presence (or absence) of a pulse.

To find the brachial pulse, use one or two fingers on the inner part of the infant’s upper arm. Locate the slight gap between muscles and palpate gently- applying too much pressure may occlude the pulse. Check for a pulse for no longer than 10 seconds- if you cannot locate a pulse within 10 seconds, you should begin compressions.

If the infant has a pulse and it is equal to or less than 60 beats per minute and the infant has signs of poor perfusion such as pallor, cyanosis and/or delayed capillary refill, you should start compressions. Why? Think about the infant’s normal heart rate. Under normal circumstances, the infant’s heart rate can range between 100 and 160 beats per minute, depending on age in months and activity level. Heart rate in infants may even be higher when they are upset or ill. Thus, a heart rate of 60 beats per minute is hardly sufficient to adequately perfuse the brain, heart and other vital organs. This is why compressions are started in infants with a pulse of 60 beats per minute or less.

Compressions

Performing compressions on an infant is far different than performing compressions on an adult or child. Although infants are smaller, high quality compressions are just as important.

To perform compressions on an infant, draw an imaginary line between the nipples of the infant (inframammary line). Use the index finger and the middle finger to depress the lower half of the sternum just below the imaginary line to a depth of approximately 1/3 the anterior-posterior diameter of the chest. This corresponds to a depth of approximately 1 ½ inches. Avoid pressing the xiphoid process or ribs, as this could result in fractures. You should provide compressions at a rate of at least 100 compressions/minute, allowing the chest to recoil fully in between compressions.

If there are two rescuers, the two thumbs encircling hands technique is used. The rescuer providing compressions encircles the infant’s chest with both hands, with the fingers spread out along the back on either side to provide support. The rescuer places both thumbs side by side on the lower half of the sternum, avoiding the xiphoid, and compresses at the same rate and depth as described above. The thumbs may overlap on a very small infant. Why the change? You can imagine that there is little room to move if there are two adult rescuers working on an infant victim. With this hand placement, the rescuer providing ventilations has more room to work, as does the rescuer providing compressions, without getting in each other’s way.

Providing ventilations

The obvious difference when providing ventilations to an infant is that a much smaller volume of air is needed to inflate an infant’s lungs. Rescuers should be careful not to be too overzealous when ‘bagging’ an infant- this can lead to injury to the lungs, including pneumothorax. What is the ideal volume of air? You should aim to provide just enough volume to produce visible rise and fall of the chest, as if the infant was taking a normal breath. If you are giving mouth-to-mouth resuscitation, you will need to cover both the nose and mouth when providing ventilations- a puff of air from your cheeks should suffice. In terms of masks, round masks may provide a better seal than oblong masks if you are using a bag-valve-mask device. Be sure to choose a mask that fits correctly [Note: it is often easier to get a seal with a mask that is a little too large as opposed to one that is too small]. Provide ventilations at a rate of 3 to 5 breaths per minute (12 to 20 breaths/minute). If you are providing CPR, you will give 2 breaths for every 30 compressions; with 2 rescuers, the ratio changes to 2 breaths for every 15 compressions.

Using an AED

The American Heart Association recommends that rescuers use a manual defibrillator on infant victims of cardiac arrest. If a manual defibrillator is not available, an AED with appropriate-sized paddles and the ability to deliver the appropriate (lower) dose of energy is recommended. Adult paddles delivering an ‘adult dose’ of energy can be used if there are no appropriate options available. Research has shown that infant hearts can withstand higher energy doses without sustaining permanent damage.

As can be seen, there are many differences when performing CPR on an infant victim. However, regardless of the victim’s age it is important to remember to push hard and push fast, allowing the chest to fully recoil between compressions. High quality CPR can mean the difference between life and death. If the thought of performing CPR on an infant victim fills you with dread, you can minimize your anxiety by learning how to perform CPR properly on the smallest victims.