CHOP Researchers Find Bystander CPR with Rescue Breathing Leads to Better Outcomes in Pediatric Cardiac Arrest

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When children and adolescents go into cardiac arrest outside of a hospital setting, CPR with rescue breathing – rather than CPR using only chest compressions – leads to better outcomes, according to a new study by researchers at Children’s Hospital of Philadelphia (CHOP). The findings, published today in the Journal of the American College of Cardiology, support the use of bystander CPR with rescue breathing in children experiencing cardiac arrest.

Maryam Y. Naim, MD, MSCE Maryam Y. Naim, MD, MSCE “At the moment, most lay people are trained in compression-only CPR because that is the standard of care in adults,” said Maryam Y. Naim, MD, MSCE, a pediatric cardiac intensive care physician in the Division of Cardiac Critical Care Medicine at Children's Hospital of Philadelphia and first author of the study. “However, children are not simply small adults, and our study shows there is a tremendous need for education in all communities about the benefits of CPR with rescue breathing in the pediatric population. For infants in particular, our study shows that CPR with rescue breathing is the only type of CPR that is associated with good neurological outcomes; infants who received compression-only CPR had similar outcomes to infants who did not receive bystander CPR.”

Fewer than 10% of children who experience cardiac arrest outside of a hospital setting survive. The rates of survival improve when a bystander performs CPR, but prior to this study, the frequency and type of bystander CPR in out-of-hospital pediatric cardiac arrest in different age groups was unknown. In adults, compression-only CPR has been shown to be as effective as CPR with rescue breathing, so since 2010, the American Heart Association (AHA) and European Resuscitation Council (ERC) have recommended compression-only CPR for bystanders who witness an adult in cardiac arrest. However, the researchers suspected this form of CPR might be less effective in children, as pediatric cardiac arrest most often stems from breathing problems.

To better understand the frequency, type, and outcomes of bystander CPR for children, the researchers analyzed 10,429 out-of-hospital cardiac arrests between 2013 and 2019 in patients between 0 and 18 years of age. The data for the study was derived from the Cardiac Arrest Registry to Enhance Survival (CARES) database, a registry maintained by the Centers for Disease Control and Prevention in collaboration with the Department of Emergency Medicine at the Emory University School of Medicine, which includes an overall catchment area of nearly 145 million people in 28 states across the United States.

The researchers found that less than half (46.5%) of those who experienced pediatric cardiac arrest outside of the hospital received bystander CPR. Of those who did receive CPR, the majority (55.6%) received compression-only CPR. Those children who received CPR with rescue breathing were nearly 1.5 times as likely to have better neurological outcomes than those who received compression-only CPR. In children and adolescents, both types of CPR had better neurological outcomes than no CPR at all, but to the researchers’ surprise, infants receiving compression-only CPR had essentially the same outcomes as infants who received no CPR.  

Additionally, the researchers examined the changes in rates and types of CPR over the six-year study period and found that although the rates of bystander CPR did not change, the proportion of compression-only CPR increased, with no change in neurologically favorable survival.

“While public health efforts to teach compression-only CPR have benefited adults who have cardiac arrests, children have likely been disadvantaged by these efforts. The results of this study have important implications on bystander CPR education and training, which should continue to emphasize rescue breathing CPR for children – and especially infants –in cardiac arrest and teach lay rescuers how to perform this type of CPR,” Naim said.

Naim et al. “Compression-only versus Rescue-breathing Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrests,” Journal of the American College of Cardiology, online August 30, 2021, DOI: 10.1016/j.jacc.2021.06.042.

Contact: Natalie Solimeo, The Children’s Hospital of Philadelphia, 267-426-6246 or

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