New pediatric basic life support guidelines seek to improve outcomes, optimize care, says UB co-author

BUFFALO, N.Y. – While sudden cardiac arrest in a child or adolescent is rare — about 20,000 cases occur each year in the U.S. — the survival rate when it happens outside of a hospital is estimated to be under 20%. Significantly improving those grim odds is the goal of the 2025 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care for pediatric patients.

“These basic life support guidelines are first aid class types of guidelines intended for the public as well as health care personnel whenever advanced equipment isn’t available,” says Benny L. Joyner, MD, A. Conger Goodyear Professor and Chair of the Department of Pediatrics in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo and co-author of the 2025 guidelines with Tia T. Raymond, MD, medical director, quality and patient safety, for the Heart Center of Medical City Healthcare in Dallas.

Jointly released last month in Rotterdam by the American Heart Association and American Academy of Pediatrics, these international guidelines provide information on how best to deliver basic life support during cardiopulmonary resuscitation (CPR) and emergency cardiovascular care of pediatric patients, other than newborns.

Joyner and Raymond were featured in the AHA/AAP podcast on the guidelines.

The guidelines are based on new evidence published over the past three years and reviewed by a writing group that included professionals from intensive care, emergency medicine, respiratory therapy, nursing, pediatrics and others.

Included are specific directions for the best ways to resuscitate children and adolescents undergoing sudden cardiac arrest or respiratory events. “We are learning more and more about the optimal ways to deliver this care,” says Joyner, who is president and CEO of UBMD Pediatrics, pediatrician-in-chief at John R. Oishei Children’s Hospital and chief of service for pediatrics at Kaleida Health.

“How many times do you need to do chest compressions? How do you manipulate the chin to open the airway? When using an automated external defibrillator, where is the best place to put the pads on a child?”

‘Not just little adults’

Joyner explains the challenges of addressing sudden cardiac arrest events in pediatric patients. “These guidelines are tailored to the anatomy of kids,” he says. “They’re not just little adults. Their airway anatomy is different and their heart rates and oxygen needs differ by age. From a physiological perspective, they have smaller functional reserves and higher metabolic rates, and their oxygen consumption is higher, so they’re more vulnerable.”

He notes that sudden cardiac arrest is a very different phenomenon in children than it is in adults. In adults, sudden cardiac arrest events are sudden and cardiac in origin, but in children, he says, cardiac arrest is usually the result of respiratory failure or shock that leads to hypoxia, which is insufficient oxygen in the blood that, in turn, leads to bradycardia, an abnormally slow heartbeat and, if untreated, cardiac arrest.

“In kids, the origins of sudden cardiac arrest are more likely to start with breathing difficulties or cessation of breathing — events we refer to as respiratory distress or arrest. If we recognize these events and intervene earlier, we could prevent these episodes leading to cardiac arrest and improve outcomes,” he says.

Another complicating factor is that there are so many variables involved in basic life support with children and adolescents. Joyner notes that resuscitating a 6-pound baby is vastly different from resuscitating a 400-pound adult. And there is so much variability in the pediatric population as well.

“You don’t use the heel of both hands to resuscitate an infant,” says Joyner, “but when do you make that transition to using both hands? These guidelines will tell you.”

From fingers to thumbs

One of the significant changes in the 2025 guidelines is that evidence shows that it’s more effective to use two thumbs encircling the chest to resuscitate a baby or the heel of one hand. The previous guidelines had recommended it could be done with two fingers.

“Historically, we’ve done it with two fingers,” says Joyner, “but it has been demonstrated that technique often didn’t achieve the depth that was needed. It’s also hard to do it with two fingers because when pressing on the breastbone, the force from a fingertip is not much. The heel of one hand provides much more force.”

Since most pediatric cardiac arrest events are respiratory in origin, the guidelines stress prioritizing rescue breaths in addition to chest compressions if the person doing the resuscitation is willing and able to do so.

Other topics covered by the guidelines include new recommendations for treating severe foreign-body airway obstruction for infants and children, and how to use an automated external defibrillator with a pediatric attenuator, which delivers a reduced electric shock to children under 55 pounds.