Updates in PALS Guidelines: What’s Changed 2025

The latest Pediatric Advanced Life Support (PALS) guidelines, released in 2025, bring important updates to how we care for children in cardiac emergencies. The new guidelines cover everything from updated resuscitation algorithms to refined treatment techniques and post-arrest care. Healthcare providers who work with children should pay attention to these changes, as they can improve survival and neurological outcomes. This guide will summarize the key updates in the 2025 PALS guidelines,  from broad revisions to specific steps, and explain what clinicians need to know.

Read More: PALS Course Options: Blended Training Vs. Classroom Training

Overview of the Updated PALS Guidelines

The PALS guideline 2025 introduces several key updates to how healthcare providers respond to pediatric emergencies, including a focus on early recognition, high-quality CPR, and clear steps regarding choking and infant and child resuscitation. The latest PALS guideline updates include the following:

 

Key Updates	Description
2025 Guideline Release	The American Heart Association (AHA) and American Academy of Pediatrics (AAP) jointly published the first major pediatric CPR guideline update since 2020.  This 2025 PALS document reflects a comprehensive review of new evidence.
Unified Chain of Survival	A single, unified Chain of Survival now covers both adult and pediatric cardiac arrest.  This highlights the importance of prevention and preparedness in addition to rapid response.  The chain emphasizes early recognition and immediate CPR for all ages.
Early Recognition Emphasis	The update stresses recognizing pediatric arrest quickly.  Training now focuses on spotting signs of respiratory failure or shock early, and calling for help (activating EMS) without delay.  High-quality CPR should start as soon as an arrest is suspected.
Infant Choking (FBAO)	For infants with severe choking (foreign body airway obstruction), the guideline calls for cycles of 5 back blows followed by 5 chest thrusts.  Abdominal thrusts are no longer recommended for infants. This replaces previous recommendations.
Child Choking (FBAO)	For children over one year old who are choking, use 5 back blows followed by 5 abdominal thrusts.  This is a change from older advice (which had recommended only abdominal thrusts).  The combined back blow/chest thrust approach is now clear for both infants and children.
Infant Compression Technique	The CPR technique for infants has been updated.  Rescuers may use either one-hand compressions or the two-thumb encircling technique to achieve adequate depth.  The old two-finger method is not advised because it often gives too shallow compressions.

Major Changes in Pediatric Resuscitation Algorithms

The latest PALS updates bring clearer guidance on how to handle pediatric resuscitation, with a stronger focus on real-world situations. The changes stress early recognition of breathing or shock problems, better teamwork, and practical training. 

 

Change	Details
Respiratory arrest/Shock Focus	The new PALS guidance highlights that most child arrests start with breathing problems or shock, not sudden heart failure.  Providers are told to focus on early airway support and circulation.  Early recognition of respiratory distress or shock is emphasized.
CPR & Defibrillation	High-quality chest compressions remain the first priority, and prompt defibrillation is crucial for shockable rhythms.  The core PALS algorithm sequence (compressions, airway, breaths, defibrillation, drugs) itself is essentially unchanged.  What is new are improved training visuals and scenarios to teach this flow more clearly.
Team Coordination	Training now explicitly includes system-level steps.  For example, pediatric drills should practice early recognition and clear handoff protocols.  The guidelines note that tight communication (e.g., early activation of help, clear role assignment, and smooth escalation steps) is part of “doing PALS right”.  Teams are encouraged to rehearse these protocols.
Defibrillator Energy	Defibrillation doses for children remain the same as before.  The recommended energy is 2 J/kg for the first shock, 4 J/kg for the second, and ≥4 J/kg (up to 10 J/kg) for subsequent shocks.  This consistency means providers should continue using weight-based joules with modern (biphasic) defibrillators.
Opioid Overdose	For the first time, naloxone is explicitly included in the pediatric arrest algorithm.  If opioid overdose is suspected as a cause of respiratory or cardiac arrest, rescuers should administer naloxone early during the code.  This addition reflects the guideline’s focus on opioid-related emergencies.

Read More: Pediatric Vital Signs Normal Ranges

CPR Technique Updates for Infants and Children

The 2025 PALS updates bring clearer, easier-to-follow steps for performing CPR on infants and children. The CPR technique updates in the AHA PALS guidelines are:

• Infant Compressions

Use either the one-hand technique or the two-thumb encircling technique for infant CPR. Do not use the two-finger method. Aim for a compression rate of 100–120 per minute and a depth of about one-third the chest.

• Child Compressions

Use two hands (or one hand on very small children) for chest compressions. Compress to about one-third of the chest depth at 100–120/min, allowing full chest recoil between compressions.

• Infant Choking

For infants with severe choking, alternate 5 back blows and 5 chest thrusts (no abdominal thrusts). Repeat this cycle until the object is cleared or the infant becomes unresponsive.

• Child Choking

For choking children (older than 1 year), alternate 5 back blows with 5 abdominal thrusts. This replaces the older advice of using only abdominal thrusts. Continue cycles until relief of obstruction.

• CPR Quality

Emphasize pushing hard and fast. Compressions should be at least one-third of the chest depth at 100–120/min, minimizing interruptions and ensuring full recoil. Use a 30:2 compression-to-breath ratio (15:2 if two rescuers are present) during infant and child CPR.

Medication and Defibrillation Updates

The new PALS guidelines keep medication doses mostly the same but add clearer instructions on when and how to give them. 

Medication/Action	Update/Detail
Epinephrine (IV/IO)	0.01 mg/kg (0.1 mL/kg of 1:10,000) every 3–5 minutes (max 1 mg).  Give the first dose as soon as possible in a non-shockable arrest rhythm.  If IV/IO access is delayed, an endotracheal dose of 0.1 mg/kg may be given
Amiodarone (IV/IO)	5 mg/kg bolus for refractory ventricular fibrillation or pulseless ventricular tachycardia (may repeat up to 3 total doses).  Use amiodarone in children not responding to shocks and epinephrine.
Lidocaine (IV/IO)	Initial loading dose 1 mg/kg as an alternative antiarrhythmic for refractory VF/pulseless VT.  Use if amiodarone is unavailable or as per local protocol.
Defibrillation Energy	First pediatric shock: 2 J/kg; second: 4 J/kg; subsequent: ≥4 J/kg (max 10 J/kg).  No change from previous guidelines. Use a pediatric/attenuator pad if available.
Opioid Antagonists	For suspected opioid-related arrests, give naloxone (IV or IM) as early as possible in the resuscitation.  This new inclusion ensures opioid poisoning is addressed quickly.

Post–Cardiac Arrest Care Improvements

Post–cardiac arrest care centers on keeping body temperature normal, supporting blood flow, and protecting the brain. Such close monitoring of oxygen, glucose, and electrolytes improves the recovery and long-term outcome in the young patient.

Temperature Management

Temperature management remains paramount. Post-arrest emphasis is on normothermia-avoid temperatures above 37.5 °C in comatose infants and children.

• Prevent fever to improve neurological outcomes. 
• This approach remains an evolution away from aggressive cooling to an approach with emphasis on the prevention of heat injury to the vulnerable pediatric brain.

Hemodynamic Support

Hemodynamic support is key. After ROSC, target age-appropriate blood pressures to ensure organ perfusion.

• Use IV fluids or vasoactive infusions (epinephrine, dopamine, etc.) to increase systolic BP and MAP into the normal range for children.
• Maintain SBP above hypotensive levels to protect the brain and heart.

Oxygenation and Ventilation

Give oxygen to keep saturations normal after ROSC. Try to avoid hyperoxia while doing so. 

• Ventilate to maintain normal CO₂ (avoid both hypo- and hypercapnia). 
• Wean FiO₂ to target SpO₂ around 94–98% to prevent oxygen toxicity once the person is stable. 
• Adjust ventilator settings as needed while monitoring blood gases.

Neurological Monitoring

For comatose pediatric patients post-arrest, use continuous EEG to catch seizures early and treat them promptly. 

• Provide appropriate sedation and pain control, and perform frequent neurologic checks. 
• Ongoing neurocritical consultation and early rehabilitation planning help optimize recovery in these children.

Metabolic Support

Monitor and correct glucose and electrolytes closely. Avoid hypoglycemia or extreme hyperglycemia by keeping blood sugar in the normal range (roughly 70–180 mg/dL). 

• Check electrolytes(calcium, potassium, etc) and treat any abnormalities.
• Stable metabolism protects recovering organs.

Family and Follow-Up

Communicate early and clearly with the child’s family.

• Provide information about the condition of the child and the prognosis in a sensitive manner.
• Plan for long-term follow-up: involve developmental and rehabilitative services once the child is stabilized.
• Emotional support and clear guidance are vitally important to help families deal with the recovery process of the child.

Read More: Importance of PALS Certification: An Introduction to Online Learning

Renewal and Update of Your PALS Certification

The AHA PALS provider card is good for two years. Prior to the end of this time, providers must undergo renewal training to remain certified. With the 2025 update, AHA offers both a full PALS course and shorter PALS Update courses.

After October 2025, training centers will offer classes labeled for the 2025 guidelines (often released in early 2026). Courses are available instructor-led or via HeartCode (blended learning). Check with AHA training centers or online portals to enroll in the refreshed PALS course. Keeping your certification up to date ensures your skills and knowledge match the newest recommendations.

Read More: How long is my ACLS/PALS certification good for?

Preparing for the Future of Pediatric Resuscitation!

The 2025 PALS guidelines introduce several key changes to further improve outcomes in pediatric resuscitation. Key takeaways include unified guidance for all ages, new choking protocols, updated CPR techniques for infants, and refined post-arrest care strategies. Healthcare providers should review these updates and incorporate them into practice. Renewing PALS certification or taking an update course will help clinicians learn the new recommendations. By staying current with the latest PALS science, providers can deliver the best possible emergency care to infants and children. Sign up for our PALS training today and learn how to respond confidently in pediatric emergencies!

FAQs

1.  Who should learn the updated PALS?

Anyone who cares for sick infants or children: nurses, doctors, paramedics, respiratory therapists, and advanced trainees. If pediatric emergencies are part of your job or on-call duties, you should review the new guidance and refresh skills regularly.

2. What changed with choking and CPR steps?

The update simplifies what to do and stresses quick recognition, high-quality compressions, and age-appropriate actions. Follow the age-specific sequences you learn in class. Practice until it feels automatic, and always follow your local protocol and instructor.

3. Do I still need BLS if I have PALS?

Yes. PALS builds on BLS; it doesn’t replace it. Most hospitals and EMS services require an up-to-date BLS card plus PALS. Keep both current so your compression, ventilation, and team skills stay sharp and aligned with policy.