CPR is a lifesaving procedure that is performed when a child'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 a child's lungs
• Chest compressions, which keep the child's blood circulating

Permanent brain damage or death can occur within minutes if a child's blood flow stops. Therefore, you must continue these procedures until the child'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 child 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.

Machines called automated external defibrillators (AEDs) can be found in many public places, and are available for home use. These machines have pads or paddles to place on the chest during a life-threatening emergency. They use computers to automatically check the heart rhythm and give a sudden shock if, and only if, that shock is needed to get the heart back into the right rhythm.

When using an AED, follow the instructions exactly.

In children, 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 child gently. See if the child moves or makes a noise. Shout, "Are you OK?"
2. If there is no response, shout for help. Send someone to call 911 and retrieve an AED (if available). Do not leave the child alone to call 911 and retrieve an AED until you have performed CPR for about 2 minutes.
3. Carefully place the child on his or her back. If there is a chance the child has a spinal injury, two people should move the child 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 child's mouth and nose. Watch for chest movement. Feel for breath on your cheek.
6. If the child is not breathing:
   • Cover the child's mouth tightly with your mouth.
   • Pinch the nose closed.
   • 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 the heel of one hand on the breastbone -- just below the nipples. Make sure your heel is not at the very end of the breastbone.
   • Keep your other hand on the child's forehead, keeping the head tilted back.
   • Press down on the child'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 child 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 child still does not have normal breathing, coughing, or any movement, leave the child if you are alone and call 911. If an AED for children is available, use it now.
11. Repeat rescue breathing and chest compressions until the child recovers or help arrives.

If the child starts breathing again, place him or her in the recovery position. Periodically recheck for breathing until help arrives.

• Lift the child'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 child 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 child with you to the nearest phone (unless you suspect spinal injury).

Unlike adults, who may have a heart attack, most children need CPR because of a preventable accident. With this in mind, remember these simple measures:

• Teach your children the basic principles of family safety.
• Teach your child to swim.
• Teach your child to watch for cars and ride bikes safely.
• Make sure you follow the guidelines for using children's car seats.
• Teach your child firearm safety.
• Teach your child the meaning of "don't touch."

Never underestimate what a child can do. Play it safe, and assume the child is more mobile and more dexterous than you thought possible. Think ahead to what the child may get into next, and be ready. Climbing and squirming are to be expected. Always use safety straps on high chairs and strollers.

Choose age-appropriate toys. Do not give small children toys that are heavy or fragile. Inspect toys for small or loose parts, sharp edges, points, loose batteries, and other hazards. Keep toxic chemicals and cleaning solutions safely stored in childproof cabinets.

Create a safe environment and supervise children carefully, particularly around water and near furniture. Dangers such as electrical outlets, stove tops, and medicine cabinets are attractive to small children.

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-IV203.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:83.