Why is paediatric life support different from adult life support?
In adults, cardiac arrest is often caused by a primary heart problem such as a heart attack leading to ventricular fibrillation. In children this is uncommon. Most children arrest at the end of a period of worsening breathing or circulation, for example from bronchiolitis, asthma, pneumonia, sepsis, dehydration or trauma. The heart stops because of hypoxia and poor perfusion.
This has two practical consequences. Many paediatric arrests can be prevented by spotting deterioration early. And when arrest happens, the rhythm is usually non-shockable, so ventilation and oxygenation matter more than in adults.
RCUK published updated guidelines in October 2025. The core paediatric sequence did not change. Notable updates include recommending the two-thumb encircling technique for infant chest compressions and guidance on escalating shock energy for refractory VF.
Adult and paediatric life support: the key differences at a glance
| Adult | Child or infant (trained healthcare staff) | |
|---|---|---|
| Usual cause of arrest | Often primary cardiac | Usually respiratory or circulatory failure |
| First action after confirming no normal breathing | Start compressions | Five initial rescue breaths |
| Compression to ventilation ratio | 30:2 | 15:2 |
| Compression depth | 5 to 6 cm | At least one third of chest depth (about 4 cm infant, 5 cm child), not more than 6 cm |
| Technique | Two hands | Infant: two-thumb encircling; child: one or two hands |
| Pulse check (if trained) | Carotid | Brachial in infants; carotid or femoral in children |
| Common rhythm | Shockable rhythms more common | Non-shockable (asystole or PEA) most common |
| Drug doses and shocks | Fixed doses | Weight-based |
RCUK defines an infant as under one year and a child as one year to puberty. For a young person who has clearly gone through puberty, use adult guidance. Do not delay treatment trying to decide which category applies.
How do you recognise a seriously ill child before they arrest?
Use the same ABCDE approach as for adults, but interpret findings against age-specific normal ranges using your paediatric early warning score (PEWS) chart. Start with a quick look from the end of the bed: appearance, breathing effort and colour.
- Airway: stridor, gurgling, drooling, unable to cry or speak.
- Breathing: fast breathing, recession, nasal flaring, grunting, head bobbing. A falling rate in a tiring child is a sign of exhaustion, not improvement.
- Circulation: fast heart rate, prolonged capillary refill, cool or mottled skin, reduced urine output. Low blood pressure is a late sign.
- Disability: reduced responsiveness, floppiness, seizures. Check blood glucose early.
- Exposure: non-blanching rash, injuries, temperature. Keep the child warm.
In a seriously ill child, a heart rate below 60 a minute with signs of poor perfusion, despite good oxygenation and ventilation, should be treated with chest compressions.
What are the steps of paediatric basic life support?
- Safety and response: Check it is safe. Stimulate the child gently and ask loudly if they are all right. Do not shake an infant or a child who may have a neck injury.
- Shout for help and open the airway: Use head tilt and chin lift. Keep an infant's head neutral; older children need more tilt (the sniffing position). Use jaw thrust if a neck injury is possible.
- Check breathing: Look, listen and feel for no more than 10 seconds. Occasional gasps are not normal breathing.
- Give five rescue breaths: Preferably with a bag-mask and oxygen if you are trained. Each breath should make the chest rise. If it does not, reposition and check for obstruction.
- Check for signs of life: Movement, coughing or normal breathing. Trained staff may feel for a pulse for no more than 10 seconds. If there are no signs of life, or you are unsure, start compressions.
- 15 compressions to 2 breaths: Continue 15:2 at 100 to 120 a minute, with full recoil. Make sure the team has been called and the defibrillator is coming.
RCUK 2025 public guidance also stresses calling 999 straight away when a baby or child is unresponsive outside hospital, so the call handler can guide you. If you are not trained in paediatric life support, using the adult sequence is far better than doing nothing.
Paediatric advanced life support: shocks and drug doses
Once the team and defibrillator arrive, the paediatric ALS algorithm uses two-minute cycles of CPR with brief rhythm checks, as in adults. Continue 15:2 until an advanced airway is in place, then give continuous compressions with an age-appropriate ventilation rate.
| Non-shockable (asystole, PEA) | Shockable (VF, pulseless VT) | |
|---|---|---|
| Shock | Not indicated | 4 J/kg; for refractory VF, RCUK advises stepwise escalation from the fifth shock up to 8 J/kg (maximum 360 J) |
| Adrenaline | 10 micrograms/kg IV or IO (maximum 1 mg) as soon as possible, then every 3 to 5 minutes | 10 micrograms/kg IV or IO (maximum 1 mg) after the third shock, then every 3 to 5 minutes |
| Amiodarone | Not indicated | 5 mg/kg (maximum 300 mg) after the third shock; a further 5 mg/kg (maximum 150 mg) after the fifth |
| Focus | Ventilation, oxygenation, reversible causes | Early defibrillation with minimal pauses, reversible causes |
These figures reflect the 2025 RCUK paediatric ALS algorithm. Always confirm against the current algorithm and your local drug chart. Use pad size and position appropriate to the child's size as recommended by RCUK and the manufacturer.
Intravenous access is often hard in a child in arrest. If it is not achieved quickly, use the intraosseous route, which can be used for drugs, fluids and blood. The 4 Hs and 4 Ts apply to children too; hypoxia and hypovolaemia are the most common, and glucose should be checked early. Effective bag-mask ventilation, often with a two-person technique, is the most important airway skill.
How do you calculate paediatric resuscitation doses safely?
Ten-fold dose errors are a real risk in paediatric emergencies, especially under stress and with unfamiliar concentrations. Never rely on mental arithmetic alone.
- Agree the weight: Use a known recent weight, or a length-based tape or your local emergency chart. The leader says the weight aloud and it is written on a board.
- Use a cognitive aid: Pre-calculated charts or an approved app, not memory.
- State dose and volume: Say both the dose and the volume, with the strength of the preparation you are actually holding.
- Independent check: A second person checks drug, strength, dose and volume before it is given.
- Record: The scribe records the drug, dose, volume and time.
Worked example: an infant with bronchiolitis
Isla is on a children's ward with bronchiolitis. Overnight her father tells the nurse, Kwame, that she has stopped feeding and seems different. Kwame notices her breathing has become slow and irregular and she is pale and floppy, with falling saturations despite oxygen. He recognises exhaustion, presses the emergency buzzer and starts bag-mask ventilation with her head in a neutral position after suctioning. Her heart rate falls to around 50 with poor perfusion, so a colleague starts compressions with the two-thumb encircling technique at 15:2. The registrar leads, confirms the weight as 5 kg on the board, and an intraosseous needle is placed. Adrenaline 50 micrograms (0.5 mL of 1 in 10,000) is given after an independent check. With effective ventilation and CPR her heart rate recovers, and she is transferred to paediatric intensive care.
Reflection: The baby arrested and we did CPR. She got better after adrenaline.
Reflection: The first warning came from Isla's father, and her slowing breathing was a sign of exhaustion that I almost read as improvement. Effective ventilation was the most important intervention. Stating the weight aloud and checking the adrenaline volume independently prevented a calculation error under pressure. I will escalate earlier when a tiring infant's breathing slows, and I have shared this at our ward safety huddle.
Families, safeguarding and after the event
RCUK guidance supports offering parents the choice to be present during resuscitation. If they stay, a named member of staff should be with them to explain what is happening and keep them safe during defibrillation. Some children with life-limiting conditions have an advance care plan or ReSPECT form, so check early when a child with complex needs deteriorates.
Treat the child first, but stay alert to possible abuse or neglect, particularly in infants: unexplained bruising in a non-mobile baby, injuries that do not fit the history, or delay in seeking help. Follow your local safeguarding procedures and record what you see. In England, child deaths are reviewed through the child death review process, and unexpected deaths follow a joint agency response under Working Together to Safeguard Children.
Paediatric resuscitation is distressing for staff. Hold a debrief covering both learning and wellbeing, and use your organisation's support services.
Keeping your paediatric skills up to date
Most staff rarely see a paediatric arrest, so skills fade quickly. Regular simulation, mandatory updates and, where relevant, an accredited RCUK paediatric course are the best protection.
Our Paediatric Life Support course is a knowledge update on the current RCUK paediatric algorithms, covering recognition, basic and advanced life support, safe dose calculation and family-centred care, with a worked scenario. Adult Advanced Life Support and Trauma Primary Survey and Initial Management complement it. None of them replace hands-on accredited training.
Frequently asked questions
Why do you give five rescue breaths in children?
Because most children arrest from hypoxia caused by breathing or circulatory problems, not from a primary heart rhythm problem. Five initial rescue breaths deliver oxygen before compressions start. Each breath should make the chest rise visibly. If it does not, reposition the airway and check for obstruction before continuing.
Is paediatric CPR 15:2 or 30:2?
RCUK guidance for healthcare professionals trained in paediatric life support is 15 compressions to 2 breaths for infants and children. Adults use 30:2. If someone has not been trained in paediatric life support, using the adult sequence is much better than doing nothing. Once an advanced airway is in place, compressions become continuous.
What changed in the 2025 paediatric resuscitation guidelines?
RCUK published updated guidelines in October 2025. The main paediatric sequence is unchanged. The two-thumb encircling technique is now recommended for infant chest compressions instead of the two-finger technique, and there is guidance on escalating shock energy for refractory VF. Public guidance also stresses calling 999 immediately for an unresponsive child.
What is the adrenaline dose in paediatric cardiac arrest?
RCUK guidance is 10 micrograms/kg IV or IO, with a maximum single dose of 1 mg. In non-shockable rhythms it is given as soon as access is obtained; in shockable rhythms after the third shock. It is then repeated every 3 to 5 minutes. Always confirm with the current algorithm and your local emergency drug chart.
How deep should chest compressions be in a child?
At least one third of the depth of the chest. That is about 4 cm in an infant and about 5 cm in a child, but never more than the adult depth of 6 cm. Push at 100 to 120 a minute and allow full recoil between compressions.
When do you start compressions in a child with a pulse?
If a seriously ill child has a heart rate below 60 a minute with signs of poor perfusion despite effective oxygenation and ventilation, start chest compressions. Slow heart rate in a hypoxic child is a sign of imminent arrest.
At what age do you use adult resuscitation guidelines?
RCUK uses adult guidelines for young people who have clearly gone through puberty. An infant is under one year, and a child is from one year to puberty. If you are unsure, do not delay: start resuscitation using whichever approach you are most confident with.
Related courses
Paediatric Life Support (UK Guidelines)
This course teaches the recognition of the seriously ill or injured child and the management of paediatric cardiorespiratory arrest, based on current…
Adult Advanced Life Support (UK Guidelines)
This course explains the recognition and management of adult in-hospital cardiac arrest, based on the current Resuscitation Council UK adult advanced…
Trauma: Primary Survey and Initial Management
This course teaches a structured approach to the first hour of care for a seriously injured adult, based on UK practice and NICE major trauma…
Sources and further reading
- Paediatric basic life support guidelines (2025). Resuscitation Council UK.
- Paediatric advanced life support guidelines and algorithm (2025). Resuscitation Council UK.
- Newborn life support guidelines (2025). Resuscitation Council UK.
- ReSPECT: Recommended Summary Plan for Emergency Care and Treatment. Resuscitation Council UK.
- Working Together to Safeguard Children. Department for Education.
- Child death review: statutory and operational guidance (England). Department of Health and Social Care.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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