I did a PALS ( Paediatric Advanced Life Support ) course this weekend. In addition to getting an internationally certified 'License to use defibrillator on kids and stick them with big pointy needles' card, I also learned a couple of things :
1. That it isn't just old dogs who have trouble learning new things. ( Woof ! )
2. All jokes aside, the majority of the 'parent' population of this country of billions are neither equipped nor aware of even the very basic knowledge to save their children should anything bad happen. Keeping that in mind, I thought, I'd share a few tips that may help you avert any possible tragedy.

Why you need to know this :
  • Accidents happen. You may be the best parent in the world, but your eyes cannot be glued to your child 24/7. There is always a swimming pool, a loose circuit, a simple peanut or just a bad chest cold lurking around the corner.
  • Unlike in adults who have a cardiac arrest due to heart problems, in children the issue is most commonly due to breathing/respiratory distress leading to failure. The other option maybe shock due to various causes ( severe loss of fluids due to vomiting and diarrhea /anaphylaxis /infective )
  • The survival rate for children in 'out-of-hospital' arrests worldwide is 10% (a meagre  4% if the child is below 1 year of age i.e. an infant ) The number for our country has to be lesser than that, given our lag period between a witnessed arrest and arrival at the hospital.
  • With basic CPR, upto 70% of these children survive without any neurological damage which may occur due to loss of prolonged blood flow to the brain. 
  • Statistics have proven consistently that the most important factor determining the survival of a child found unresponsive is when bystander high quality CPR is performed at the earliest. While each of those italicised words are important, I personally want to point out the term 'bystander' here. You don't need to be a doctor... if you can provide CPR till help arrives, you can save your child. 
  • Many children die because their parents don't know what to do and sadly, we live in a country where pizza arrives thrice as fast as an ambulance. So if you can start measures at home while waiting for help to arrive, it could be critical.
When I wrote the first draft of this, I added a whole lot of the science behind each step. The end result seemed like a medical exam answer. I've since deleted the explanations and instead borrowed diagrams for easier understanding. 

So what are the very basic steps that you do if you see a child lying unresponsive ?
  • Look for a response - call loudly, tap the child physically ( in infants, tap the sole of their feet. ) See if the child is breathing. If you are not getting a response, CALL FOR HELP.
  • Check for a pulse ( neck vessels in children - do not waste more than 10 seconds for steps 1 & 2 together. ) If you cannot feel one, assume the need for CPR and start compressions.
  • Remember C-A-B
    • Circulation ( of blood via heart )/ Compressions 
    • Airway 
    • Breathing.

Circulation/ Compressions : 


In infants, use 2 finger compression over breastbone ( not on the left side of chest where you assume the heart should be ) if you are alone. If two people are there, encircle the infant using both your hands and use both thumbs to compress over the lower 1/3rd of breast bone. For children, use the base of your palm over the lower third of the breastbone. 
The recommended rate is 100 compressions per minute - with a depth of atleast 1/3rd the chest ( ~4cm in infants). The ratio is 30 compressions to 2 rescue breaths if you are alone. Once help arrives, you can switch to a 15:2 ratio.

Airway : 

Before the issue of giving mouth to mouth arises, you need to make sure the airway is patent and air can enter the lungs. This can be done by basic maneuvering of the childs head. The concept is called 'head tilt, chin lift' - with one hand, gently press on the child's forehead while your other hand lifts the chin up ( the child appears to be tilting the head up and 'sniffing' ) This basic positioning opens up the airway and allows the breath you give a better chance of reaching the lungs. 
If you suspect trauma to the bones of the neck, do not use this maneuver but instead stabilize the neck and give a mild jaw thrust as shown below.


Choking on a foreign body is a whole different issue which I'll cover separately if anyone really wants a blogpost on that topic. Definitely, if you can visualise a foreign body in the airway, remove it. 

Breathing : 

Give two rescue breaths making sure you can see the chest rise. Cover the nose and mouth with your mouth for effective ventilation.

Resume compressions with same 30:2 ratio (15:2 if two people are around ) till help arrives or child starts breathing spontaneously. Switch between rescuers if you get tired ( and you will get tired - take it for granted. )

One factor which everyone is hesitant about - giving mouth to mouth. I get it. Diseases. Infections. The world is a worse place today for it. You maybe a good samaritan and try to save a child and end up getting AIDS/Hepatitis for your efforts. If you don't want to do it, that's your choice. But atleast provide chest compressions. Compressions alone ( and keeping the airway open ) are better than doing nothing at all.

There are so many more factors required to saving a child - identifying the cause, the need for defibrillation or cardioversion, the right medication, reevaluations, getting help, congested traffic, the distance from an emergency room. But none of that is going to matter unless you give the child a fighting chance to survive till you reach a hospital or an ambulance arrives at your location. 


Good one!. Deffinatly going to bookmark this.
I have been wondering? Why do ambulances in India not carry paramedics in them? If that strata of medical professionals/paraprofessionals does't exist why not create one? It takes over an hour for an ambulance to cut through traffic and get to the hospital. Surely trained paraprofessionals should be able to sustain life and/or administer life support would be crucial here more than anywhere else..
I will bookmark this for sure...! Thats called blogging for a cause doc! I hope this will be helpful for all young and older parents !
broca's area said…
nice info bro :)
there are so many excuses - poor infrastructure of hospital, additional equipments for ambulance as compared to basic ambulance, need to employ skilled emts... and believe me, those skilled paramedics exist. But even in the few specialities that have trained emts, it doesnt matter because they are so far apart and Indian traffic is Indian traffic..
its only recently that more importance is finally being given for emergency medicine here in India, but its still a way to go before you have them available at your doorsteps ( which is the ideal way things should be )

As I said, this blogpost is just the very first step alone in saving a child - if you could get an emergency team to the child (or vice versa) within 10 mins, it would make a huge difference in saving that child because they would know the specific treatment based on history and signs.
This is definitely focused on young parents, Anita...nobody practises CPR or bothers to learn it. If any one parent can remember these steps from the pictures atleast when needed, they can avoid a lifetime of regret.
Thanks man... once in awhile, I do need to put up a medical post I guess...
Illeen said…
Very Informative Roshan. I'll be passing this on to some of my friends who just became parents.
Thanks.. was shocked at the statistics... so many lives which can be saved get lost simply.
Rohan said…
Very informative. . It is a shame that many in the medical field are also ignorant about these basic life saving steps. . This should be made part of the curriculum I feel. .
Lazy Pineapple said…
A very good post which needs to be circulated. I am going to share this with my friends. Thanks for this informative post.

Please also do a post on choking on foreign objects. I just know of the Heimlich Maneuver.
True Rohan.. I wish they would incorporate the BLS ( basic life support ) part atleast as compulsary to all in medical field... and then CPR training could be done for other occupational institutes on a certain day convenient to their staff... its just a matter of sharing knowledge and practising with a mannequin..can save lives. Yet everyone just takes it for granted.
Sure thing Vinita.. will do a post on foreign bodies aspiration too in near future.
Harman said…
very informative,,, thanks for sharing..
sharmila said…
Pizza faster than Ambulance-indeed !A precise, informative post on a very important aspect of child care.
Thanks Sharmila...I really wish there would be more endeavors to teach the public CPR... felt the need for the few who read this blog to 'atleast mistakenly' read this so that it may be helpful some day.
amit said…
I will share this on Facebook. There is a sudden avalanche of kids in my friendlist this year.
Binu Thomas said…
Your post is very informative doctor. Nice to have someone who's explaining medical steps using a simple langauage. (And I am happy that you removed the medical explanation :D)
Varsha Naik said…
Ahh PALS! Just finished my exams, coming back to this was great!
Varsha Naik said…
Oops I meant BLS....anyway
likewise.. seeing a lot of small kids running through my Facebook timeline :)
yes, the first time I wrote this, it was close to 1800 words.. with the whole physiology of what you are doing with each move.. then figured, what the heck ! If people just remember what they are supposed to do at that moment, isnt that enough ?
ironically, as always, Im going in opposite direction.. finished PALS first :) BLS/ACLS coming up !!
very informative..but it scares me out too! is it enough to learn to resuscitate using pictures as a reference? what if we inadvertently do something wrong? with 2 little kids at home, i want to know if an actual training of the CPR can be got somewhere? also do include tips for other minor accidents that keep happening at home and what to do in an emergency...thanks!
you're absolutely rt, of course. seeing pictures isnt the ideal way to learn... this post is nothing more than putting a visual image.
there will definitely be courses available for general public for CPR ( a random check on internet got me this in chennai - http://www.tact-india.com/heart-saver.html and http://www.tact-india.com/heart-saver-cpr.html ). but definitely , in your state too, there would be similar institutes/hospital based teaching programs... it wouldnt take more than a few hours of a single day and trust me - it literally is life-saving. so often, the child bought to the emergency ward/casualty could have been saved if any bystander had atleast bothered to do a little more in those moments while getting the child to the hospital.

as for other posts - as Vinita suggested, will go for a foreign body choking post soon...
resh said…
Radha..loved the article..thanks a lot....am sure it provided insight for many.
Thanks Reshma, I really feel it's sad that noone bothers to focus on teaching the general public such basics as these... everyone knows Kareena's a size zero ( brain or body, dont ask ! :) ), but noone seems to think sharing basic life saving measures are necessary.

As 'TLP' above rightly asked, there should be basic stuff like this taught to the general public... especially in our Indian set up where there r more crooks than emergency docs, if you can keep the heart pumping long enough by knowing the basics of compression and airway, can still save a kid's life.
resh said…
i second that...n ur article was a huge step in that direction...i think classes must be introduced at school n college levels,where the audience is massive.
still remember the shock when we first learnt during MBBS that "spleen" is an actual organ in our body!!..the general public will be surprised too,to know they are not as helpless as they think,in life n death situations,if trained rite.

exactly... docs cant b everywhere.. and even still, a good % of docs have never practised CPR.. I know I never did in UG. And yet, its so simple and easy to do once u see it... totally agree that it should be a basic part of college/office... one day ya. Thats all it takes.. go in batches of 10-20, listen, learn and practise on a mannequin.. atleast something will stick in the head, right ?
Anyway, thats why I made this post as 'small' as possible, just giving basic steps to follow.. atleast some will recall the steps or C-A-B alphabets, if nothing else.
resh said…
You're rite...somethings WILL definitely stay with u after a session.

n btw,the size of the post,illustrations,description r all PERFECT!
kudos roshan!
jaish_vats said…
That was so informative,Roshan. Thanks. Somehow the whole concept of CPR seems to be prevalent in the West and is still an alien topic in our country where as you rightly mentioned, a pizza arrives faster than an ambulance.
true.. it seems like an English movie thing.. and perhaps thats the biggest misconception of them all.. because its way more relevant here than in the west.. their emergency services are like a well-oiled machine: each piece falls into place perfectly the moment the emergency call comes through.
Anonymous said…
Hi Roshan,

I don't know how I stumbled across your blog..but I should say it's a great place to spend a quiet Sunday afternoon! Great post! I took a CPR course when I had my son who is now 4.I was born in India and currently live in Canada and all staff who work with children should be CPR certified here.Wish India implements such standards. There lies the difference in what we call "quality of life".
You're right.. therein indeed lies the difference. I wish there were proper CPR training awareness atleast given to the public instead of spending time running around praising politicians. This is my contribution, I guess for a public I never get to see... as I said above, even if people remember C-A-B , they can do something life saving.