Pediatric Chest Compression Depth (PLS): Scoping Review

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: Robert M. Sutton

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees:

Robert M Sutton published 2 studies which were used for this scoping review {Sutton RM 2014 1179-84}; {Sutton RM 2015 150-7} and is excluded from bias assessment and narrative summaries of this review.

Task Force Scoping Review Citation

Ong GY, Reiss A, Sutton RM, de Caen A, Atkins DL, Maconochie I, Aicken R, Bingham R, Couto TB, , Guerguerian AM, Nadkarni V, Ng KC, Nuthall G, Ong G, Reis A ,Schexynader S, Tijssen J , Van de Voorde P. on behalf of the International Liaison Committee Pediatric Life Support Taskforce. Pediatric chest compression depth: Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2020 09 Jan. Available from:

Preamble and Link to Published Scoping Review<>

The continuous evidence evaluation process started with a scoping review of basic life support conducted by the ILCOR BLS Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Task Force and the Pediatric Task Force groups respectively.

Scoping Review





Among infants and children who had received chest compression after out-of-hospital or in-hospital cardiac arrest (excluding newborn children)


does the use of any specific chest compression depth


compared with the depth specified in the current treatment algorithm

- at least 1/3 AP chest depth

- approximately 4cm in infants, 5cm in children


Clinical outcomes, including

- short-term survival and neurological outcomes (e.g. return of spontaneous circulation (ROSC), hospital discharge, 28-days, 30-days, and 1-month),

- long-term survival and neurological outcomes (e.g. 3-months, 6-months, and 1-year).

Study Design

Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.


All years and all languages are included as long as there is an English abstract

Search Strategies

Database: Articles for review were obtained by searching PubMed, EMBASE, Cochrane, and Allied Health Literature (CINAHL), for all entries from database inception onwards (last searched on October 31st, 2019).

The search terms/keywords: “Chest compression”, “Chest compression depth”, “Quality of chest compressions”, “Chest compression metrics”, “Pediatrics”, “Cardiac arrest”, and “Cardiopulmonary resuscitation”; including their MESH terms, and Embase exploded terms.

The search strings used are detailed in Appendix A.

Inclusion and Exclusion criteria

  1. Newborn at delivery, adult and animal studies were excluded
  2. Populations who were not in cardiac arrest were excluded (pre- and post- arrest).
  3. Case reports with <5 patients were excluded.
  4. Pre-arrest epidemiological variables and other intra-cardiac arrest interventions other than chest compression depth were not evaluated (including compression rates and recoil).

Data tables

Table 1. Pediatric studies on chest compression depth correlations with clinical outcomes



Design, Country



Main findings


{Sutton 2014 1179}





Cohort with >60% of CCs administered with an average depth

of ≥51 mm compared to the cohort that did not


aOR = 4.21, 95%CI:1.34–13.2, p = 0.014

-unadjusted analysis

74% vs 31% i.e. OR 0.16 (0.06, 0.47), p<0.05

24h survival:

- aOR = 10.3, 95%CI: 2.75-38.8, p < 0.001

- unadjusted 70% vs 16% i.e. OR 0.08 (0.06, 0.25), p<0.05

- Survival to hospital discharge

- unadjusted analysis OR 0.26 (0.06, 1.09), p>0.05

- Long term neurological outcome -

no difference in survival with good neurological outcome (PCPC 1–2 or no change from baseline)- OR 0.25 (0.05, 1.25), p>0.05

Adjusted for year of arrest and first documented rhythm

Unable to adjust for survival to hospital discharged or neurological outcome as long-term survival rates were low

Note that the percentages were derived from total events and not index events for 24H survival and ROSC

Index events were used for survival to discharge and CPC

{Sutton 2015 150}



N= 153


Cohort with mean CC depth ≥38mm vs CC depth <38mm


- adjusted analysis: aOR 1.99, 95% CI (0.9, 4.42), p =0.09

- unadjusted analysis showed increased rates of ROSC

(49.4% vs. 29.7%; p = 0.01)

Chest compression depth was a secondary analysis

Task Force Insights

1. Why this topic was reviewed.

ILCOR COSTR 2015 recommendations for paediatric chest compression depths were based on evidence provided by 2 observational studies. {Sutton 2014 1179}; {Sutton 2015 150}

Current literature suggests that there appears to be difficulty in achieving the current recommendations for chest compression depth targets, especially for the younger cardiac arrest patients. {Niles 2018 421}

However, with increased availability of CPR feedback devices for infants and children that can provide real-time chest compression depth measurements, recommended chest compression depth (4cm in infants and 5 cm in children) can be targeted, coached, and better achieved. {Cheng 2018 33}

There were some adult studies that observed potential harm in over-compression; which were not previously looked at in the pediatric population. A large adult out-of-hospital cardiac arrest (OHCA) study {Steill 2014 1962} found a trend towards lower survival with chest compression depths >4.56cm (maximum survival was in the depth interval of 40.3 to 55.3 mm with peak, 4.56cm, after adjusting for confounders); suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target for adults may be too high.

{Hellevuo 2013 760} demonstrated in their forensic study, increased rates of CPR-related injuries with deeper compressions if >6cm in adults.

In a pediatric experimental (piglet) model that approximated the size and chest dimensions of young toddlers, {Morgan 2017 41} demonstrated that the group which received standardized compression depth of 4.4±0.1cm had poorer survival rates when compared to the hemodynamics-targeted directed group. The hemodynamics-targeted directed group had notably received significantly shallower chest compressions (mean chest compression depth of 3.0±0.2cm).

The above literature informed a need for review of recent updates on pediatric chest compression depth studies. This scoping review seeks to update current evidence in the pediatric population since 2015.

2. Narrative summary of evidence identified

There were only 2 pediatric studies identified in the search.

Clinical outcomes:

Return of spontaneous circulation (ROSC)

Sutton {Sutton 2014 1179} reported increased rates of ROSC if ≥60% of compressions had a mean depth ≥5.1cm after adjusting for potential confounders in an inhospital pediatric cohort (N=78); adjusted OR 10.3, 95%CI: 2.75-38.8, p < 0.001.

Sutton {Sutton 2015 150} observed in a cohort of paediatric out-of hospital cardiac arrest patients (N=153) that after adjusting for confounders, there were no increased rates of ROSC if patients received a mean compression depth ≥38mm; adjusted OR 1.99 (95% CI 0.9, 4.42), p =0.09. In their unadjusted analysis, a mean chest compression depth ≥38 mm showed increased rates of ROSC (49.4% vs. 29.7%; p = 0.01).

24H survival

Sutton {Sutton 2014 1179} reported favourable 24H inhospital survival if ≥60% of compressions were ≥5.1cm after adjusting for potential confounders with an adjusted OR 0.16 (95% CI 0.06, 0.47), p<0.05

Survival to hospital discharge

Sutton {Sutton 2014 1179} did not find any difference in survival to hospital discharge after inhospital cardiac arrest if patients received chest compressions with ≥60% of epoch had a mean depth ≥5.1cm; OR 0.26 (95% CI 0.06, 1.09), p>0.05 (unadjusted analysis). They were unable to adjust for confounders due to the low number of survivors.

Long-term neurological outcomes

Sutton {Sutton 2014 1179} did not find any difference in survivors attaining CPC 1-2 if they received chest compression with ≥60% of epoch had mean depth ≥5.1cm after inhospital cardiac arrest; OR (95% CI 0.25, 1.25), p>0. OR (95% CI 0.25, 1.25), p>0.05. They were unable to adjust for confounders due to the low number of survivors.

3. Narrative Reporting of the task force discussions

  • This scoping review has not identified sufficient new evidence to prompt a new systematic review or reconsideration of current resuscitation guidelines/treatment recommendations.
  • Previous chest depth studies used feedback devices with a single displacement sensor/accelerometer.
  • Compression depth measured by older feedback machines can be affected by the type of surface on which the compressions were performed (over-estimation if surface is allows for movement e.g. on a bed or trolley mattress even if a CPR board was used).

Chest depth studies using feedback devices with dual displacement sensors/accelerometers may be more accurate.

An ongoing large, prospective international, multi-center study on CPR quality with dual sensor CPR feedback devices was identified.

PediResQ study (prospective, observational)

This multi-center study on CPR quality with dual sensor CPR feedback devices may be able to better address this question. Publication of the study is expected to be within the next 1-2 years.

Knowledge Gaps

We recognize the paucity of pediatric studies and identified many gaps in the limited published literature.

Larger studies on critically important outcomes especially on long-term neurobehavioral outcomes will be needed to inform chest compression depth recommendations.

With increasing availability of CPR feedback devices even in both in- and out-of-hospital settings, it may be necessary to investigate clinical correlations of paediatric chest compression depth targets when cardiopulmonary resuscitation is rendered with CPR feedback devices and without.

Other areas of studies on chest compression depth in the pediatric population that may require further research include:

  1. Chest compression depth correlations with (diastolic) blood pressures in cardiac arrest patients with invasive blood monitoring in-situ and their clinical outcomes.
  2. Clinical outcomes of using absolute versus relative chest compression depth target recommendations.
  3. Clinical outcomes for the different age groups undergoing chest compressions: Infants (<1 year old), toddlers, school-going children and adolescents
  4. Ethnic differences in the pediatric population (potential anthropometric differences)


References listed alphabetically by first author last name in this citation format (Circulation)

Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y; International Network for Simulation-based Pediatric Innovation Research and Education (INSPIRE) CPR. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: A randomized simulation-based clinical trial. Resuscitation. 2018;132:33-40.

Considine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, Olasveengen TM, Vaillancourt C, Nishiyama C, Hatanaka T, Mancini ME, Chung SP, Escalante-Kanashiro R, Morley P. Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review. Resuscitation. 2019 Sep 16. pii:


Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, HoppuS. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760-5.

Morgan RW., Kilbaugh, TJ, Shoap, W, Bratinov G., Lin Y., Hsieh TC, on behalf of the Pediatric Cardiac Arrest Survival Outcomes (PiCASO) Laboratory Investigators. (2017). A Hemodynamic-Directed Approach to Pediatric Cardiopulmonary Resuscitation (HD-CPR) Improves Survival. Resuscitation, 111, 41–47

Niles DE, Duval-Arnould J, Skellett S, Knight L, Su F, Raymond TT; pediatric Resuscitation Quality (pediRES-Q) Collaborative Investigators. Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative. Pediatr Crit Care Med. 2018;19:421-432.

Stiell IG, Brown SP, Nichol G, Cheskes S, Vaillancourt C, Callaway CW; Resuscitation Outcomes Consortium Investigators. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation. 2014;130:1962-70.

Sutton RM, French B, Niles DE, Donoghue A, Topjian AA, Nishisaki A, Leffelman J. 2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014;85:1179-84.

Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J; ROC Investigators. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality-A report from the ROC epistry-cardiac arrest. Resuscitation. 2015;93:150-7.



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