The use of automated external defibrillators (AEDs) has been advocated in recent years as one part of the chain of survival to improve outcomes for adult cardiac arrest victims. When AEDs first entered the market, they had not been tested for pediatric usage and rhythm interpretation. In addition, the presumption was that children do not experience ventricular fibrillation, so they would not benefit from the use of AEDs. Recent literature has shown that children do experience ventricular fibrillation, which has a better outcome than do other cardiac arrest rhythms. At the same time, the arrhythmia software on AEDs has become more extensive and validated for children, and attenuation devices have become available to downregulate the energy delivered by AEDs to allow their use on children. Pediatricians are now being asked whether AED programs should be implemented, and where they are being implemented, pediatricians are being asked to provide guidance on the use of them on children. As AED programs expand, pediatricians must advocate on behalf of children so that their needs are accounted for. For pediatricians to be able to provide guidance and ensure that children are included in AED programs, it is important for pediatricians to know how AEDs work, be up-to-date on the literature regarding pediatric fibrillation and energy delivery, and understand the role of AEDs as life-saving interventions for children.
Early defibrillation has been shown to be the most effective treatment for adult out-of-hospital cardiac arrest attributable to ventricular fibrillation (VF).1,2 The likelihood of survival decreases by approximately 7% to 10% with each minute of delay to defibrillation after cardiac arrest. Strategies to decrease the time to defibrillation that have been shown to be effective include the use of an automated external defibrillator (AED) by prehospital care providers and nonmedical personnel.3–6
For children, use of defibrillation traditionally has been downplayed, with a focus on early airway and ventilatory assistance as a result of data that showed that asystole was the predominant rhythm and that VF rarely occurred.7 Although not the most common rhythm, VF does occur in children. In addition, the chance of survival after VF is greater than that from other nonperfusing rhythms, which makes treatment of VF a priority in pediatric resuscitation.8
Although the incidence of VF in the pediatric population is low, there is a need for developing strategies to provide early defibrillation to patients younger than 8 years. This strategy may include the need for an AED that is suitable for use in pediatric patients from birth to 8 years of age with either an attenuated adult-dosage AED tested for efficacy and safety in children or an AED specifically designed for defibrillation of young children and infants. In the absence of either of such devices, standard nonattenuated adult-dosage AEDs should be used on children on the basis of protocols for use developed with medical oversight. Because of the limited data on effective energy dose, emergency medical services (EMS) systems, medical directors, and pediatric researchers should make efforts to gather information regarding pediatric uses of AEDs and report it by using the pediatric Utstein style,9 which represents an internationally accepted standard method of collecting and reporting respiratory and cardiac arrest and resuscitation data. In addition, because the use of AEDs on children may be a new concept to many responders, EMS and physician leaders should work with professional organizations, community organizations, and researchers to educate their community members regarding the benefits of early pediatric defibrillation and the use of available varieties of AEDs.
The message for the public and for EMS systems is to recognize the existence of VF in infants and children and use methods to treat it as early as possible to improve the survival of children and infants after sudden cardiac arrest. In addition, this possible life-saving therapy should not be withheld purely on the basis of absolute weight and size issues. The key is to pursue a long-term goal of providing devices that will support rapid pediatric and adult defibrillation. This approach would include the ability to treat infants and children without compromising adult care while minimizing training issues and minimizing the use of limited financial and personnel resources.
Although the incidence of VF in children is far less than that in adults, the outcome for VF is better than that for other nonperfusing rhythms and is improved with early defibrillation. Therefore, strategies and equipment availability for treatment of pediatric arrest should be focused on shortening the intervals from collapse to recognition of VF and to defibrillation.
Although most data available on the correct energy for defibrillation of children are from animal studies, data suggest that the immature heart is less susceptible to energy-related damage and that there is a wide therapeutic range of defibrillation energy doses. In addition, although using a fixed adult-energy AED on some children has a theoretical potential for harm, not treating VF has the proven potential for even greater harm: death of the child. On the basis of this risk/benefit assessment, prehospital programs and public-access AED programs should not withhold defibrillation because of weight or age criteria alone.
Children and infants of all ages who suffer VF must be provided defibrillation as soon as possible after arrest. The following approach to achieve this goal should be used:
Immediately provide defibrillation to all infants and children from birth to 8 years of age with either an attenuated adult-dosage AED tested for efficacy and safety in children or an AED specifically designed for defibrillation of young children and infants, depending on which device is available first. In the absence of the devices listed above, standard nonattenuated adult-dosage AEDs should be used on infants and children from birth to 8 years of age. Protocols for use of adult-dosage AEDs should be developed with medical oversight.
For children 8 years of age and older, immediately provide defibrillation with an adult-dosage AED or manual defibrillation.
EMS systems must have protocols to allow for pediatric defibrillation in the timeliest fashion and by all levels of responders. These protocols include pediatric AED capability and, in the interim, protocols for the use of an adult AED on infants and children.
Although a cost/benefit assessment of public-access defibrillation specifically for children has not been established, when a community or facility chooses to establish a public-access defibrillation program, the AED chosen for that program must have pediatric capability.
Although a cost/benefit assessment of school-based AEDs has not been established yet, school systems must, in their assessment of need for an AED, consider the benefit of AED purchase to adult staff members and adult visitors and as another component of school-based emergency care.
When determining the need for a school-based AED program, the following factors should direct the decision10 :
The frequency of cardiac arrest events is such that there is a reasonable probability of AED use within 5 years of rescuer training and AED placement. This probability can be established if 1 cardiac arrest has been known to have occurred at the site within the last 5 years or can be estimated on the basis of population demographics.
There are children attending the school or adults working at the school who are thought to be at high risk of sudden cardiac arrest (eg, children with conditions such as congenital heart disease and a history of abnormal heart rhythms, children with long QT syndrome, children with cardiomyopathy, adults or children who have had a heart transplant, and adults with a history of heart disease).
An EMS call-to-shock interval of less than 5 minutes cannot be achieved reliably with conventional EMS services, and a collapse-to-shock interval of less than 5 minutes can be achieved reliably (in >90% of cases) by training and equipping lay people to function as first responders by recognizing cardiac arrest, telephoning 911 (or other appropriate emergency response number), starting cardiopulmonary resuscitation, and attaching and operating an AED.
When placed in schools, AEDs must be part of a comprehensive emergency care plan that includes:
pediatric medical oversight;
staff training in basic first aid and cardiopulmonary resuscitation; and
integration with local EMS.
Any legislation that mandates placement of an AED also must provide the funding for such devices, including costs of staff training and maintenance of the equipment.
AED legislation must allow for pediatric AED usage and liability protection for those who use these devices and for the physicians who provide the medical oversight for these programs.
Committee on Pediatric Emergency Medicine, 2005–2006
Steven E. Krug, MD, Chairperson
Thomas Bojko, MD, MS
Margaret A. Dolan, MD
Karen S. Frush, MD
Patricia J. O'Malley, MD
Robert E. Sapien, MD
Kathy N. Shaw, MD, MSCE
Joan Shook, MD, MBA
Paul E. Sirbaugh, DO
Loren G. Yamamoto, MD, MPH, MBA
Jane Ball, RN, DrPH
EMSC National Resource Center
Kathleen Brown, MD
National Association of EMS Physicians
Kim Bullock, MD
American Academy of Family Physicians
Dan Kavanaugh, MSW
Maternal and Child Health Bureau
Sharon E. Mace, MD
American College of Emergency Physicians
Susan Eads Role, JD, MSLS
EMSC National Resource Center
David W. Tuggle, MD
American College of Surgeons
Tina Turgel, BSN, RN-C
Maternal and Child Health Bureau
*David Markenson, MD
Section on Cardiology and Cardiac Surgery, 2006–2007
Robert H. Beekman III, MD, Chairperson
Peter B. Manning, MD
Seema Mital, MD
William R. Morrow, MD
Frank M. Galioto, Jr, MD
Thomas K. Jones, MD
Gerard R. Martin, MD
American College of Cardiology
Reginald L. Washington, MD
NCE Planning Group
Lynn Colegrove, MBA
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.