Expert Consensus: AEDs OK for Use On Young Children in Ventricular Fibrillation (VF)

ILCOR Recommendations

ILCOR recently examined (October 2002) the literature regarding the use of AEDs in children. The consensus was:

AEDs may be used for children 1 to 8 years of age with no signs of circulation. Ideally the device should deliver a pediatric dose. The arrhythmia detection algorithm used in the device should demonstrate high specificity for pediatric shockable rhythms, ie, the device will not recommend a shock for nonshockable rhythms (Class IIb).

• Currently the evidence is insufficient to support a recommendation for or against the use of AEDs in children <1 year of age.

• For a lone rescuer responding to a child without signs of circulation, provision of 1 minute of CPR is still recommended before any other action such as activating EMS or attaching the AED.

• Defibrillation is recommended for documented VF/pulseless VT (Class I).

Limitations

One important limitation that arose during task force deliberations on this topic was the lack of data on clinical use of newly developed pediatric pad/cable systems that reduce the energy delivered by AEDs designed for use in the adult. This was especially problematic when discussing the risks and benefits of use of AEDs in very young infants. Relevant points of discussion included the following:

1. The experimental data in the Atkinson study³⁸ examining sensitivity and specificity included infants, but the sample size diminished with decreasing age, and thus there is less confidence in the data from that study analyzing sensitivity/specificity in the youngest patients.

2. Very small infants might receive doses demonstrated to cause myocardial damage in animal studies.

3. The incidence of shockable rhythms as a clinical cause of unresponsiveness in young infants is lower than in older children.

The last 2 points suggest that the number needed to harm and the number needed to treat would move in unfavorable directions with decreasing age, and thus there is consensus in the task force that the recommendations for very young infants be more conservative. The task force recognized that there were insufficient clinical data to determine the best appropriate lower age (the age at which the number needed to harm exceeds number needed to treat). Therefore, a pragmatic decision was made to limit the recommendation to children 1 to 8 years of age because many resuscitation councils use 1 year as the transition from infant to child CPR. Linking the recommendation to 1 year of age will facilitate training and retention.

Until clinical data from pediatric AED use becomes available, the task force recommends that institutions that routinely care for children at risk for arrhythmias and cardiac arrest (eg, in-hospital settings) should continue to use defibrillators capable of energy adjustment for weight-based doses.

Because there is insufficient evidence to determine the best placement of AED pads (ie, anterior/posterior versus sternal/apical), the task force has not recommended a preferred position for pad placement.

Conclusion

The AED is becoming widely available and may be the first device available for defibrillation in the prehospital setting. Current evidence suggests that AEDs are capable of appropriate sensitivity and specificity for pediatric arrhythmias and are both safe and effective for defibrillation of children 1 to 8 years of age. Ideally pediatric pads/cables should be used, whenever available, to deliver a child dose. Each specific AED model must be tested against a library of pediatric arrhythmias to document its efficacy in detection of shockable and nonshockable rhythms. The task force strongly encourages industry to continue to develop pediatric rhythm diagnostic programs and investigate appropriate pediatric AED energy doses. The task force applauds efforts in this area and will conduct a comprehensive review of new data as they become available.

Footnotes

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 11, 2003. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0256. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail klbradle@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.

This statement has been copublished in the July 2003 issue of Pediatrics and in the June 2003 issue of Resuscitation.

*Current density (amperes/cm²) in the myocardium is the total amount of current flow that passes through an area defined by a plane perpendicular to the path of the current and the myocardium that intersects with that plane.