• Failure to breathe, cyanosis
• Inability to move air into lungs with rescue breaths
1. Ensure that the scene is safe. Check for unresponsiveness. Gently tap child’s shoulder. Ask, “Are you okay?”
2. Simultaneously assess the child's breathing and pulse.
   • Check for breathing. Is the breathing normal, no breathing, or abnormal (only agonal gasps)?
   • Assess the carotid pulse and look for other signs of circulation (no more than 10 sec). If signs of circulation are present but the child is still not breathing, give rescue breaths at the rate of 20–30 breaths/min (1 breath every 2–3 sec).
3. If there is no response with no breathing, and no pulse, abnormal breathing (only agonal gasps), send a second rescuer, if available, for help and an AED, if available.
4. If you are alone, begin the steps for CPR.
5. Position the child supine on a hard, flat surface.
6. If a pulse and signs of circulation are not present, begin chest compressions.
   • One hand: Place the heel of one hand on the center of the chest over the lower half of the sternum.
   • Two hands: Place the heel of one hand on the center of the chest over the lower half of the sternum; place the heel of your other hand over the first.
   Firmly compress the chest at least one third the depth of the chest (at least 2.0 in.). Push hard and fast. Give 30 compressions. Compress at a rate of at least 100–120/min. Ensure complete chest recoil after each compression. Avoid leaning on the chest between compressions.
7. If the child is not breathing, begin rescue breaths. Open the airway by the head tilt–chin lift method or, if spinal injury is suspected, use the jaw thrust method, if possible.
8. Using a face mask or barrier device, give 2 breaths (1 sec each) with sufficient volume to cause the chest to rise. Do not overventilate.
9. If the chest does not rise, reposition the head, chin, and jaw, and give two more breaths. Each time the airway is opened, look for an object in the child’s mouth. Only use a finger sweep to remove material you see obstructing the airway. Never perform a finger sweep if you do not see a foreign body in the airway.
10. Continue to give 30 compressions followed by opening the airway, looking for an object, and performing a finger sweep if object is visible, and then attempt to give 2 breaths. After the fifth cycle of 30:2 (2 min), if you are still alone and no signs of circulation are present, summon help, call a code, activate EMS response via mobile device (if appropriate), phone 911, and get an AED, if available.
11. If circulation is still not present, continue CPR until the AED is available. If an AED is unavailable, continue to give 30 compressions followed by 2 breaths. After each fifth cycle of 30:2 (2 min), recheck the pulse and look for other signs of circulation (no more than 10 sec).
12. Once AED arrives check for shockable rhythm.
    • Shockable: Give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
    • Continue until advanced life support (ALS) providers take over or child begins to move.
13. If circulation resumes but breathing does not resume or is inadequate, continue rescue breathing at 20–30 breaths/min (1 breath every 2–3 sec).
14. If adequate breathing and circulation resume, place the child in the recovery position and monitor until help arrives.

Clinical Tip: Never perform a blind finger sweep.