AED on infants: risks of using adult pads

Question

Until a couple of years ago, in case of cardiac arrest, first-aid guidelines (in France at least) were instructing not to use an AED on infants (< 1 yo), even with pediatric pads or with an energy dose reducer.

Nowadays, it is more and more recommended to use an AED on infants¹. Preferably using pediatric pads, and even with adult pads should no pediatric pads or reducer be available:

• What the French guidelines say:

Children and infants
Defibrillation should be performed using appropriate devices (pediatric pads, energy dose reducer...). Should no suitable AED be available, an "adult" AED may be used. The pads are in this case applied to the center of the chest for one, and to the center of the back for the other.

^{The above is a translation I made. The original text is:}

^{Chez l’enfant ou le nourrisson
La défibrillation doit être réalisée avec des appareils adaptés (électrodes enfants, réducteur d’énergie...). En l’absence d’un DAE adapté, un DAE «Adulte» peut être utilisé. Les électrodes adultes sont alors positionnées en avant au milieu du thorax pour l’une et au milieu du dos pour l’autre.}

^{Source: "PRÉVENTION ET SECOURS CIVIQUES de niveau 1", French Ministry of Interior}

• What the Fairview Health Services, Minneapolis, US, say:

Use the small pads meant for infants. If these are not available, use the adult pads. When applying the adult pads, make sure the pads don’t touch each other. If it looks like the pads will touch, apply one pad to the center of the baby’s chest. Apply the other pad to the center of the baby’s upper back.

^{Source: "CPR And Automated External Defibrillator (12 Months Or Younger)", Fairview Health Services, Minneapolis}

What is the precise drawback of using adult pads? Is the AED likely to harm the infant², or is it likely to miss shockable rhythms (and therefore fail to deliver required shocks)³, or even both?

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^{1- The Ministry of Interior of France, the Fairview Health Services (Minneapolis, US), The Life Saving Society (Toronto, CA) do. The Mayo Clinic doesn't.}

^{2- As the recommended dose is 2-4 J/Kg (Defibrillation in children, Pubmed, 2010 Jul-Sep)}

^{3- Found no reference, just wondering whether the nature of the pads would lead to a calibration problem impairing the rhythm detection process.}

Answer 1

Adult pads have a larger area. And they provide more energy. The higher energy is needed because most adults have more body mass than children.

Lower energy is more suitable for children. Source

I teach CPR according to the European standards (ERC). You can use an AED with adult pads on a child, but you should put one pad on the front and the other on the back (both sides of the heart). So they can't touch.

http://www.aedbrands.com/blog/2012/07/30/do-you-really-need-pediatric-pads/

Answer 2

Depending on the size mismatch, the delivery of energy may be effected. In the case that the two pads touch there is clearly the risk of electrical shorting.

It’s a matter of physics (energy delivered the a surface, vector, etc) and what needs to happen for successful defibrillation.

Although it is not recommended to use adult pads on children, it is possible apply them differently than shown on the pads: apply one on the front of the chest, the other on the back, so they do not touch.

Off label use of adult pads in children would not have a randomized study. It would be anecdotal reports without properly controlling any variable.

Sources:

Center for Advanced Cardiac & Vascular Interventions

https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Using-an-AED.aspx

https://nhcps.com/lesson/bls-automated-external-defibrillator-aed-infants-children/