1. Abstract Cardiopulmonary Resuscitation with Rescue Breathing Is Superior to Hands-Only Cardiopulmonary Resuscitation for Children and Infants: Results of a Systematic Review Joseph W. Rossano Joseph W. Rossano Children’s Hospital of Philadelphia / University of Pennsylvania Richard N. Bradley Richard N. Bradley The University of Texas Health Science Center at Houston For the American Red Cross Scientific Advisory Council 190

2. Financial Disclosures The authors have no relevant financial conflicts to disclose.

3. Introduction Evidence supports teaching hands-only CPR for the initial treatment of cardiac arrest in adults. Unlike adults, however, children and infants with cardiac arrest are more likely to have non- cardiac causes. Hypothesis: The objective of this project was to conduct a structured literature review to answer the question, “In children and infants with cardiac arrest treated in an out-of-hospital setting, does compression-only CPR, alone or with supplemental oxygen, compared to CPR with rescue breathing lead to improved outcomes?”

4. Methods We performed a MEDLINE search ("compression only"[Title/Abstract]) AND cardiopulmonary resuscitation[MeSH Terms] with limits children (ages 0 -18). We also performed a search in the Cochrane database for systematic reviews, the Central Register of Controlled Trials, and EMBASE using similar search terms. We also searched applicable bibliographies and used the ‘Cited By’ function in Google Scholar. The study included papers if they evaluated the difference between compression only CPR and CPR with rescue breathing in infants or children. Papers that reported results from studies that used procedures that were beyond the basic life support level were excluded. Each paper was evaluated using specific criteria to determine the level of evidence.

5. Results Sixty-nine records were identified and screened. Fifty-four of these did not meet inclusion/exclusion criteria, leaving fifteen full-text articles that we assessed for eligibility. Eleven of these did not meet inclusion/exclusion criteria, leaving four that we included in the qualitative synthesis. Of these, one good quality study with level of evidence (LOE) 2a and 3 other studies (LOE 4) all opposed the hypothesis. There is a relative paucity of published data on this subject. The majority of the papers published describe evidence from animal models.

6. Key Studies Berg, R. A., R. W. Hilwig, et al. (1999). "Simulated mouth-to- mouth ventilation and chest compressions (bystander cardiopulmonary resuscitation) improves outcome in a swine model of prehospital pediatric asphyxial cardiac arrest." Crit Care Med 27(9): 1893-1899. Berg, R. A., R. W. Hilwig, et al. (2000). ""Bystander" chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless "cardiac arrest"." Circulation 101(14): 1743-1748. OutcomeOdds Ratio95% c.i. 24 hr survival82.3 – 32 24 hr neurologically intact 11.42.8 - 47

7. Key Studies Kitamura, T., T. Iwami, et al. (2010). “Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study.” Lancet 375(9723): 1347-1354. Type1 month outcomeOdds ratio95% c.i. Non- cardiac survival1.891.21-3.82 Non- cardiac neurologically intact5.542.52-16.99 Cardiac survival1.070.53-2.15 Cardiac neurologically intact0.960.52-1.75

8. Conclusions In conclusion, rescuers should provide chest compressions with rescue breathing to children and infants in cardiac arrest; rescuers unwilling or unable to provide compressions with rescue breathing may provide chest compressions alone for these patients. Recommendation Standards: None Guidelines: Rescuers should provide chest compressions with ventilations to children and infants in cardiac arrest. Options: Rescuers unwilling or unable to provide compressions with ventilations may provide chest compressions only to infants and children.