Pediatric Advanced Life Support, commonly called PALS, is a set of clinical guidelines and a training course designed to help healthcare professionals recognize and treat life-threatening emergencies in infants and children up to 18 years of age. Published by the American Heart Association and the American Academy of Pediatrics, PALS covers everything from cardiac arrest to dangerously fast or slow heart rhythms, breathing failures, and shock. The most recent guidelines were updated in 2025.
PALS is not a single procedure. It’s a structured framework that teaches medical teams how to assess a deteriorating child quickly, intervene with the right tools, and manage care after the crisis has passed. High-quality CPR is the foundation of the entire system.
How PALS Differs From Basic Life Support
Basic Life Support (BLS) covers the fundamentals: recognizing cardiac arrest, performing chest compressions, delivering rescue breaths, and using an automated defibrillator. PALS builds on all of that with advanced interventions that require specialized training and equipment. These include managing a child’s airway with advanced devices like breathing tubes, establishing access to the bloodstream through an IV or directly into bone, administering emergency medications, using manual defibrillators, and interpreting heart rhythm monitors in real time.
BLS proficiency is actually a prerequisite for PALS training. Think of BLS as the floor: it keeps blood and oxygen moving. PALS adds the tools to diagnose the underlying problem and treat it.
What PALS Covers in a Cardiac Arrest
The core of PALS is a set of algorithms, essentially step-by-step decision trees, that guide a medical team through a pediatric cardiac arrest. The first branch point is whether the child’s heart rhythm is “shockable” or “non-shockable.” Shockable rhythms, like ventricular fibrillation or pulseless ventricular tachycardia, can potentially be reset with a defibrillator. Non-shockable rhythms require a different approach focused on CPR and medication.
Regardless of the rhythm, the team starts high-quality CPR immediately and administers epinephrine (adrenaline) every 3 to 5 minutes through an IV or a needle placed into bone. For shockable rhythms that don’t respond to the first two defibrillator shocks, the guidelines call for additional medications to help stabilize the heart’s electrical activity. Throughout the process, the team cycles between two-minute rounds of CPR, rhythm checks, and targeted interventions.
Managing Dangerous Heart Rates
Cardiac arrest isn’t the only emergency PALS addresses. Children can develop critically slow or fast heart rates that compromise blood flow to the brain and organs.
For bradycardia, a dangerously slow heart rate, the PALS algorithm instructs providers to start CPR if the rate drops below 60 beats per minute in a child showing signs of poor blood flow, such as altered consciousness, low blood pressure, or shock. If the slow rate is caused by overstimulation of the vagus nerve (which can happen during certain medical procedures or with specific heart conditions), atropine is the targeted medication. Epinephrine is used when the heart itself isn’t generating an adequate rate.
For tachycardia, an abnormally fast heart rate, the approach depends on whether the rhythm is stable or unstable, and whether it originates from the upper or lower chambers of the heart. Unstable children with tachycardia may need electrical cardioversion, a synchronized shock that resets the rhythm.
Gaining Emergency Access to the Bloodstream
One of the unique challenges in pediatric emergencies is that children’s veins are small and often difficult to access, especially when blood pressure is dropping. PALS training emphasizes intraosseous (IO) access, a technique where a specialized needle is inserted through bone into the marrow cavity, as a rapid alternative.
IO lines can deliver fluids and medications just as effectively as a standard IV. In critically ill children without measurable blood pressure, IO success rates are roughly twice as high as IV placement. The guidelines are clear: IO access should not be delayed in favor of repeated failed IV attempts. In infants, the most common insertion sites are the shinbone (just below the knee), the lower shinbone (near the ankle), and the thighbone (just above the knee). One important consideration in children is avoiding the growth plates near the ends of bones, since damage there can affect long-term bone development.
Care After the Heart Restarts
Getting a child’s heart beating again is only half the battle. PALS devotes significant attention to post-cardiac arrest care, the period immediately after a pulse returns. The goals during this phase are to protect the brain, support the heart, and prevent a second arrest.
Oxygen levels are monitored continuously, with a target range of 94 to 98 percent (or whatever is normal for that particular child). Blood pressure is maintained above the 10th percentile for the child’s age and sex using IV fluids, and if needed, medications that support the heart’s pumping strength and keep blood vessels from relaxing too much. Temperature management, blood sugar monitoring, and careful respiratory support all factor into the post-arrest checklist.
Who Needs PALS Certification
PALS certification is designed for healthcare professionals who may encounter pediatric emergencies. This includes physicians, nurses, paramedics, respiratory therapists, and other personnel working in emergency departments, intensive care units, pediatric wards, and ambulance services. Some hospitals and healthcare systems require PALS certification as a condition of employment for anyone who regularly treats children.
The American Heart Association offers the PALS Provider Course, which combines online learning modules with hands-on skills sessions. Upon passing, providers receive a certification card valid for two years, after which they must complete a renewal course to stay current. The two-year cycle ensures providers stay up to date as guidelines evolve, since recommendations around compression techniques, medication timing, and airway management are periodically revised based on new evidence.
Why Pediatric Emergencies Need Their Own Approach
Children are not simply small adults. The causes of cardiac arrest in children differ fundamentally from those in adults. In adults, the heart itself is usually the problem, often a sudden electrical malfunction caused by coronary artery disease. In children, cardiac arrest most often results from respiratory failure or shock that progressively worsens until the heart can no longer compensate. This means PALS places heavy emphasis on recognizing and treating breathing problems and circulatory collapse before they escalate to full cardiac arrest.
Drug dosing in children is weight-based, which adds complexity. Equipment sizes vary dramatically between a 3-kilogram newborn and a 70-kilogram teenager. Anatomy differs too: a child’s airway is narrower, more anterior, and more easily obstructed. PALS training accounts for all of these variables, giving providers the mental frameworks and practiced reflexes to adapt quickly under pressure.