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CPR is a lifesaving procedure that is performed when an infant's breathing or heartbeat has stopped, as in cases of drowning, suffocation, choking, or injuries. CPR is a combination of:

• Rescue breathing, which provides oxygen to the infant's lungs.
• Chest compressions, which keep the infant's blood circulating.

Permanent brain damage or death can occur within minutes if an infant's blood flow stops. Therefore, you must continue these procedures until the infant's heartbeat and breathing return, or trained medical help arrives.

CPR can be lifesaving, but it is best performed by those who have been trained in an accredited CPR course. The procedures described here are not a substitute for CPR training.

All parents and those who take care of children should learn infant and child CPR if they haven't already. This jewel of knowledge is something no parent should be without. (See www.americanheart.org for classes near you.)

Time is very important when dealing with an unconscious infant who is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later.

In infants, major reasons that heartbeat and breathing stop include:

• Choking
• Drowning
• Electrical shock
• Excessive bleeding
• Head trauma or serious injury
• Lung disease
• Poisoning
• Suffocation

• No breathing
• No pulse
• Unconsciousness

The following steps are based on instructions from the American Heart Association.

1. Check for responsiveness. Shake or tap the infant gently. See if the infant moves or makes a noise. Shout, "Are you OK?"
2. If there is no response, shout for help. Send someone to call 911. Do not leave the infant yourself to call 911 until you have performed CPR for about 2 minutes.
3. Carefully place the infant on their back. If there is a chance the infant has a spinal injury, two people should move the infant to prevent the head and neck from twisting.
4. Open the airway. Lift up the chin with one hand. At the same time, tilt the head by pushing down on the forehead with the other hand.
5. Look, listen, and feel for breathing. Place your ear close to the infant's mouth and nose. Watch for chest movement. Feel for breath on your cheek.
6. If the infant is not breathing:
   • Cover the infant's mouth and nose tightly with your mouth.
   • Alternatively, cover just the nose. Hold the mouth shut.
   • Keep the chin lifted and head tilted.
   • Give 2 rescue breaths. Each breath should take about a second and make the chest rise.
7. Perform chest compressions:
   • Place 2 fingers on the breastbone -- just below the nipples. Make sure not to press at the very end of the breastbone.
   • Keep your other hand on the infant's forehead, keeping the head tilted back.
   • Press down on the infant's chest so that it compresses about 1/3 to 1/2 the depth of the chest.
   • Give 30 chest compressions. Each time, let the chest rise completely. These compressions should be FAST and hard with no pausing. Count the 30 compressions quickly: "1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30, off."
8. Give the infant 2 more breaths. The chest should rise.
9. Continue CPR (30 chest compressions followed by 2 breaths, then repeat) for about 2 minutes.
10. After about 2 minutes of CPR, if the infant still does not have normal breathing, coughing, or any movement, leave the infant if you are alone and call 911.
11. Repeat rescue breathing and chest compressions until the infant recovers or help arrives.

If the infant starts breathing again, place him or her in the recovery position. Periodically re-check for breathing until help arrives.

• Lift the infant's chin while tilting the head back to move the tongue away from the windpipe. If a spinal injury is suspected, pull the jaw forward without moving the head or neck. Don't let the mouth close.
• If the infant has signs of normal breathing, coughing, or movement, DO NOT begin chest compressions. Doing so may cause the heart to stop beating.
• Unless you are a health professional, DO NOT check for a pulse. Only a health care professional is properly trained to check for a pulse.

• If you have help, tell one person to call 911 while another person begins CPR.
• If you are alone, shout loudly for help and begin CPR. After doing CPR for about 2 minutes, if no help has arrived, call 911. You may carry the infant with you to the nearest phone (unless you suspect spinal injury).

Unlike adults, who often require CPR because of a heart attack, most children need CPR because of a preventable accident.

Never underestimate what an infant can do. Play it safe and assume the child is more mobile and more dexterous than you thought possible. Never leave an infant unattended on a bed, table, or other surface from which the infant could roll. Always use safety straps on high chairs and strollers. Never leave an infant in a mesh playpen with one side down. Follow the guidelines for using infant car seats.

Start teaching your infant the meaning of "Don't touch." The earliest safety lesson is "No!"

Choose age-appropriate toys. Do not give infants toys that are heavy or fragile. Inspect toys for small or loose parts, sharp edges, points, loose batteries, and other hazards.

Create a safe environment and supervise children carefully, particularly around water and near furniture. Keep toxic chemicals and cleaning solutions safely stored in childproof cabinets. Dangers such as electrical outlets, stove tops, and medicine cabinets are attractive to infants and small children.

To reduce the risk of choking accidents, make sure infants and small children cannot reach buttons, watch batteries, popcorn, coins, grapes, or nuts. It is also important to sit with an infant while he or she eats. Do not allow an infant to crawl around while eating or drinking from a bottle.

Never tie pacifiers, jewelry, chains, bracelets, or anything else around an infant's neck or wrists.

Rescue breathing and chest compressions - infant; Resuscitation - cardiopulmonary - infant; Cardiopulmonary resuscitation - infant

Emergency Cardiovascular Care Committee, Subcommittees, and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112(24 Suppl):IV1-203.

Hauda WE II. Pediatric cardiopulmonary resuscitation. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:chap 14.

Updated by: Jacob L. Heller, MD, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, Clinic. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.