ANZCOR Guideline 12.2 Update: Major 2026 Changes to Paediatric Advanced Life Support
ANZCOR Guideline 12.2 is the core advanced life support guideline for infants and children in healthcare environments. The 2026 update is broad, with changes spanning recognition of cardiac arrest, airway management, ventilation, compression technique, fluid therapy, defibrillation, physiological monitoring and family-centred care.
Because the changes affect multiple stages of the resuscitation, organisations should review algorithms, equipment, education and policy together rather than treating each statement as an isolated amendment.
Recognising arrest and starting CPR
Healthcare providers should begin CPR when an infant or child is unresponsive and breathing is absent or agonal. The previous wording asked providers to begin CPR unless they could definitely feel a pulse within 10 seconds. The updated approach reduces reliance on an uncertain pulse check.
When a bag-mask ventilation device is not immediately available, chest compressions should begin while the equipment is being obtained. If the device is immediately available, two initial ventilations should be provided before compressions.
Bag-mask ventilation and advanced airways
For out-of-hospital paediatric cardiac arrest, ANZCOR suggests bag-mask ventilation rather than immediate endotracheal or supraglottic airway insertion. Transition to an advanced airway can be considered when the team has the expertise, resources and equipment to place it with minimal interruption to chest compressions, or when bag-mask ventilation is not providing adequate oxygenation or ventilation.
The update also supports cuffed tracheal tubes for emergency intubation of infants older than 28 days and heavier than 3 kg, and for children. Excessive cuff pressure should be avoided.
Ventilation after a secure airway
After a secure airway is in place, ventilation should be close to the child’s age-appropriate respiratory rate while avoiding both hypoventilation and hyperventilation. The guideline suggests an approximate rate of 30 breaths per minute for infants and 25 breaths per minute for children older than one year.
This is an important training change because many clinicians have learned lower generic rates during CPR. Services should update airway cards, ventilator prompts and simulation scripts.
Compressions, fluids and defibrillation
- Infant compressions should use the two-thumb encircling technique where possible because it gives more consistent depth and reduces fatigue. The heel of one hand may be considered if adequate depth cannot be achieved.
- If hypovolaemia is suspected as the cause of arrest, an initial IV or IO crystalloid bolus of 10 mL/kg may be used. The previous range was 10 to 20 mL/kg.
- For manual defibrillation in infants and children, pads should be placed in an anterior-posterior position.
- A single-shock strategy followed by immediate CPR is suggested for ventricular fibrillation or pulseless ventricular tachycardia in both out-of-hospital and in-hospital arrest.
Monitoring CPR quality and circulation
End-tidal carbon dioxide may be considered as part of paediatric cardiac arrest monitoring to provide feedback on CPR quality and help identify ROSC early.
Where invasive blood pressure monitoring is already in place, ANZCOR suggests targeting an intra-arrest diastolic blood pressure of at least 25 mmHg in infants younger than one year and at least 30 mmHg in children aged one to 18 years. These targets are relevant mainly to highly monitored in-hospital arrests and should be integrated with the wider clinical picture.
Family presence during resuscitation
Family members should be offered the option to be present during resuscitation. The update also calls for policies or protocols that support decision-making, and for staff education about managing family distress, communication and the emotional impact on healthcare workers.
Family presence therefore needs more than an informal invitation. It requires a planned process, an appropriate support person and a team that understands how to maintain clinical focus while communicating compassionately.
What organisations should do now
- Revise PALS algorithms and arrest trolleys to reflect the airway, fluid and defibrillation changes.
- Check that cuffed tube sizes, cuff-pressure monitoring and capnography are available where advanced airways are used.
- Update age-based ventilation prompts and simulation assessment criteria.
- Review defibrillator pad stocks and the diagrams used for paediatric manual defibrillation.
- Incorporate ETCO2 and invasive pressure targets into appropriate high-acuity scenarios.
- Develop or update a family-presence policy and staff support process.
The practical takeaway
The 2026 Guideline 12.2 update aims to make paediatric resuscitation faster, more physiologically informed and more consistent. It reduces delay at the start of CPR, favours effective bag-mask ventilation before advanced airway placement in many out-of-hospital cases, updates ventilation and fluid guidance, strengthens monitoring, and embeds family-centred care within the resuscitation system.
Continue your training
A broad guideline update is best implemented through hands-on education. PALS training allows clinicians to practise the revised sequence, airway decisions, age-based ventilation, defibrillation and team communication in realistic scenarios.
PALS1 – Paediatric Advanced Life Support
Primary clinical source: ANZCOR Guideline 12.2 – Paediatric Advanced Life Support (PALS)
Publication disclaimer: Educational summary only. It does not replace the full ANZCOR guideline, local policy, formal training or clinical judgement. Verify the current official guideline before publication or clinical use.
