Infant and child CPR and choking: pediatric resuscitation guide¶

When an infant under 1 year old or a child stops breathing or chokes on food, a coin, or a small toy, every second matters. Unlike adults, whose sudden cardiac arrest is usually triggered by a primary coronary artery blockage or electrical heart rhythm disturbance, pediatric cardiac arrest almost always starts as a respiratory emergency (such as foreign-body airway choking, drowning, severe asthma, croup, pneumonia, or suffocation) that starves the heart muscle of oxygen until the heart stops beating.

Because children in cardiac arrest have already depleted the oxygen in their blood before their heart stops, pediatric CPR requires both chest compressions and rescue breaths (unlike Hands-Only CPR in adults). This guide follows current International Liaison Committee on Resuscitation (ILCOR), American Heart Association (AHA), UK Resuscitation Council, and Red Cross guidelines to help you clear a blocked airway and resuscitate an infant or child.

Do this now: conscious choking infant (under 1 year old)¶

If a baby is awake but suddenly cannot cry, cannot cough, cannot breathe, turns blue around the lips, or makes only silent mouth movements or high-pitched squeaks:

1. Confirm severe airway obstruction. If the baby is crying loudly or coughing forcefully, do not slap their back, as a strong cough clears the airway best; stay with them and watch closely. Act immediately only if the cough becomes silent, breathing stops, or they cannot make sound.
2. Position the infant face-down along your forearm. Sit or kneel and rest your forearm on your thigh for stability. Hold the baby face-down along your forearm with their head angled lower than their chest, supporting their bony jaw and cheekbones between your thumb and fingers without pressing on the soft throat under the chin.
3. Deliver 5 firm back blows. Using the heel of your free hand, deliver 5 quick, firm back blows squarely between the infant's shoulder blades.
4. Sandwich and turn the infant face-up. Place your free hand and forearm along the baby's back, cradle the back of their head in your palm, and flip the baby safely face-up onto your opposite thigh, keeping their head lower than their torso.
5. Deliver 5 downward chest thrusts. Place 2 fingers (or 2 thumbs) on the center of the breastbone, just below the imaginary line between the nipples. Press straight down 4 centimeters (1.5 inches), about one-third the depth of the chest, 5 distinct times at a rate of 1 thrust per second.
6. Repeat 5 back blows and 5 chest thrusts continuously. Keep alternating 5 back blows and 5 chest thrusts until the object pops out and the baby cries, or until the baby becomes limp and unresponsive (at which point you immediately begin Unconscious Infant CPR below).

Do this now: unresponsive infant or child CPR¶

If an infant (under 1 year) or child (age 1 to puberty) is unresponsive, limp, and not breathing normally (or only making occasional gasps):

1. Shout for help and call your local emergency number on speakerphone. Have a bystander dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, or 000 in Australia (see all emergency numbers) and fetch an Automated External Defibrillator (AED). If you have a mobile phone on you, dial immediately and put it on speakerphone so you start CPR with zero delay. (If you are completely alone with no phone nearby and the collapse was not sudden/witnessed, perform 2 minutes / 5 cycles of CPR first before carrying the baby or running to a phone).
2. Lay the infant or child flat on their back on a firm, hard surface. Use the floor, the ground, or a sturdy table; never perform CPR on a soft mattress or sofa where the whole body sinks down with every push.
3. Give 30 chest compressions hard and fast (100 to 120 per minute).
   • For an infant (under 1 year): Use the 2-thumb encircling hands technique (wrap both hands around the baby's ribcage and press the lower half of the breastbone with both thumbs side-by-side) or the 2-finger technique (press with two fingertips straight down on the center of the chest just below the nipple line). Push down 4 centimeters (1.5 inches), or one-third the front-to-back depth of the chest.
   • For a child (age 1 to puberty): Place the heel of 1 hand (or 2 hands interlaced if the child is larger or your hands tire) on the lower half of the breastbone. Push straight down 5 centimeters (2 inches), or one-third the depth of the chest.
   • Let the chest recoil (spring all the way back up) completely after every single push.
4. Open the airway and check the mouth if they were choking. If the arrest started from choking, open the mouth wide and look inside; if you clearly see a loose object, sweep it out gently with your pinky finger. Then open the airway using a neutral "sniffing" position for an infant (do not tilt a baby's head far back) or a gentle head-tilt, chin-lift for a child.
5. Give 2 gentle rescue breaths (1 second each).
   • For an infant: Cover both the baby's mouth and nose tightly with your mouth and blow a gentle puff of air from your cheeks for 1 second just until you see the baby's chest visibly rise. Let the chest fall, then give a second 1-second puff.
   • For a child: Pinch the child's soft nostrils closed with your thumb and index finger, seal your lips over the child's mouth, and give 2 gentle 1-second breaths just until the chest rises.
6. Continue cycles of 30 compressions and 2 breaths without stopping. Keep going at a 30:2 ratio until the infant or child begins breathing and moving, an AED arrives and is ready to analyze, or paramedics take over your position.

Pediatric choking and CPR decision algorithm¶

flowchart TD
    Start["Infant (<1 yr) or Child (1 yr to Puberty) in Crisis"] --> ConsciousCheck{"Is the infant or child conscious and responsive?"}

    ConsciousCheck -->|Yes, Conscious Choking| SoundCheck{"Can they cough forcefully, cry, or speak?"}
    SoundCheck -->|Yes, strong cough| Encourage["Do NOT Slap Back or Interfere<br/>Stay close and encourage coughing<br/>Call emergency dispatch if obstruction persists"]
    SoundCheck -->|No, silent/unable to breathe| AgeChoke{"What is the child's age?"}

    AgeChoke -->|Infant Under 1 Year| InfantChoke["Alternate 5 Back Blows and 5 Chest Thrusts<br/>Support jaw; keep head lower than chest<br/>NEVER perform abdominal thrusts on an infant"]
    AgeChoke -->|Child Age 1 to Puberty| ChildChoke["Give Abdominal Thrusts (Heimlich) or<br/>5 Back Blows + 5 Abdominal Thrusts<br/>Repeat until object clears or child goes limp"]

    InfantChoke --> GoesLimp{"Did they become limp/unresponsive?"}
    ChildChoke --> GoesLimp
    GoesLimp -->|Yes| StartCPR

    ConsciousCheck -->|No, Unresponsive| BreathCheck{"Breathing normally? (Ignore occasional gasps)"}
    BreathCheck -->|Yes, breathing normally| RecoveryPos["Place in Side Recovery Position<br/>Call 911 / 112 / 999 and monitor breathing"]
    BreathCheck -->|No, not breathing or only gasping| StartCPR["Call 911/112/999 on Speakerphone<br/>Give 30 Compressions : 2 Rescue Breaths<br/>Rate: 100 to 120/min; look in mouth before breaths if choking<br/>Attach AED with pediatric pads as soon as available"]

Comparing infant, child, and adult resuscitation rules¶

Anatomical differences between a baby, a growing child, and an adult require critical adjustments to hand placement, compression depth, and airway angle.

Critical anatomical differences in infant and child airways¶

Understanding why infant and child anatomy differs from an adult's prevents two common rescuer mistakes that accidentally block breathing or injure internal organs:

1. Why you must NEVER perform abdominal thrusts (Heimlich) on an infant under 1 year¶

In an infant under 12 months old, the abdominal cavity is small, the abdominal wall muscles are thin, and the liver and spleen are proportionally huge, extending well below the protective cage of the lower ribs. Performing upward abdominal thrusts on a baby under 1 year old frequently ruptures the baby's liver or spleen, causing fatal internal bleeding. That is why infants under 1 year receive 5 back blows and 5 chest thrusts on the hard breastbone, never abdominal thrusts.

2. Why hyperextending an infant's neck kinks their windpipe shut¶

An infant has a very large back of the skull (occiput) relative to their body, a short neck, a proportionally large tongue, and a windpipe (trachea) made of soft, pliable cartilage rings resembling a flexible drinking straw rather than a rigid pipe.

• When an infant lies flat on their back on a floor, their large back skull naturally tips their chin forward onto their chest.
• However, if you tilt an infant's head all the way back like an adult, the soft cartilage rings of the baby's trachea buckle and fold shut, completely blocking your rescue breaths from entering the lungs and forcing air into the baby's stomach instead.
• Always position an infant's head in the neutral "sniffing" position (looking straight up at the ceiling as if sniffing a flower, with the ear canal aligned horizontally with the front of the shoulder). Placing a thin folded hand towel under the baby's shoulders helps hold this exact neutral alignment naturally.

3. Why the 2-thumb encircling hands technique is superior for infant CPR¶

Current resuscitation guidelines from the AHA, ILCOR, and UK Resuscitation Council highlight the 2-thumb encircling hands technique over the older 2-finger method whenever possible:

• Wrap your fingers around the sides and back of the infant's ribcage to support their back while placing both of your thumbs side-by-side on the center of the breastbone just below the nipple line.
• Pressing with both thumbs generates higher coronary perfusion pressure, achieves a more consistent 4-centimeter (1.5-inch) depth, and prevents your fingers from cramping or slipping off the narrow sternum during 2-minute CPR cycles.

Conscious choking in a child (age 1 year to puberty)¶

If a toddler or school-aged child is choking and cannot speak, cough loudly, or breathe:

1. Ask "Are you choking?" and check for the universal choking sign (hands clutched to the throat, panicked expression, silent cough, or high-pitched inspiratory stridor).
2. Deliver back blows and abdominal thrusts:
   • International / Red Cross / UK / EU / ANZCOR protocol: Lean the child forward at the waist, support their chest with one hand, and give up to 5 sharp back blows between the shoulder blades with the heel of your other hand. If the object does not pop out, follow immediately with up to 5 abdominal thrusts.
   • How to perform child abdominal thrusts (Heimlich maneuver): Kneel or stand directly behind the child so your torso is at their height. Wrap your arms under their arms around their waist. Make a fist with one hand and place the thumb side of your fist flat against the midline of the abdomen, just above the belly button (navel) and well below the pointed tip of the breastbone (xiphoid process). Grasp your fist with your other hand and pull inward and upward with quick, distinct thrusts until the object shoots out.

Swallowed button batteries and high-powered magnets¶

Not every swallowed object blocks the windpipe; coins and small batteries often lodge halfway down the esophagus (food pipe) while the child can still breathe and talk. Two household items represent catastrophic internal emergencies if swallowed:

Lithium coin / button battery ingestion (The 2-hour chemical burn rule)¶

If a child swallows (or pushes into their nose or ear) a flat, round lithium coin cell battery (such as a 20-millimeter CR2032 battery found in car key fobs, remote controls, digital scales, flameless tea lights, and musical greeting cards), it is a life-threatening emergency even if the child is breathing normally with zero symptoms.

When a button battery lodges in the moist esophagus, saliva completes an electrical circuit between the positive and negative poles of the battery. This generates an external electrical current that splits water molecules via hydrolysis to produce caustic sodium hydroxide (lye) right against the esophageal wall. Within just 2 hours, the battery can burn a hole straight through the esophagus into the windpipe (tracheoesophageal fistula) or into the aorta, causing fatal internal hemorrhage days or even weeks after the battery is removed.

Immediate button battery protocol (AHA / Poison Control / NASPGHAN guidelines):

1. Drive immediately to a pediatric hospital emergency room for an emergency X-ray and endoscopic removal. Do not wait for symptoms to appear.
2. Give pasteurized HONEY en route ONLY if the child is 12 months (1 year) of age or older and the battery was swallowed within the last 12 hours:
   • Give 10 milliliters (2 teaspoons) of pure household honey by mouth every 10 minutes (up to 6 doses) while driving to the hospital, or 10 milliliters of sucralfate suspension if available. Viscous honey coats the surface of the button battery inside the esophagus, forming a physical barrier that neutralizes alkaline hydroxide buildup and reduces tissue burn depth before the surgeon extracts the battery.
   • NEVER give honey to an infant under 12 months (1 year) old due to the risk of infant botulism.
   • NEVER delay driving to the hospital to go buy honey, and do not give honey if the child cannot swallow, is choking, or if more than 12 hours have passed since ingestion (when the esophagus may already be perforated).
3. Do NOT induce vomiting and do not give any other food or drink.

High-powered neodymium magnets¶

If a child swallows two or more small rare-earth magnets (or one magnet and a metal object), the magnets attract each other violently across separate loops of the small and large intestine, pinching the bowel wall between them and causing ischemic necrosis, bowel perforation, and fatal peritonitis. Seek immediate emergency department X-rays for any suspected magnet ingestion.

Frequently asked questions¶

Sources checked¶

• American Heart Association (AHA): 2020 and 2024 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 4: Pediatric Basic and Advanced Life Support.
• International Liaison Committee on Resuscitation (ILCOR): Consensus on Science with Treatment Recommendations (CoSTR) for Pediatric Life Support.
• Resuscitation Council UK: 2021 Paediatric Basic Life Support Guidelines and Paediatric Foreign Body Airway Obstruction Algorithm.
• American Red Cross and International Federation of Red Cross and Red Crescent Societies (IFRC): First Aid, CPR, and AED International Resuscitation Guidelines.
• National Capital Poison Center (United States) and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN): National Button Battery Ingestion Triage and Honey Treatment Guideline.

Related guides¶

• Adult and adolescent Hands-Only CPR
• Adult choking rescue (Heimlich maneuver)
• Drowning rescue and resuscitation
• Severe allergic reactions and pediatric epinephrine
• Emergency numbers directory