When giving breaths to a child, use the head tilt-chin lift maneuver to open the airway. This involves pushing down gently on the forehead with one hand while lifting the chin upward with two fingertips of the other hand. The goal is to move the tongue away from the back of the throat so air can pass through to the lungs.
How the Head Tilt-Chin Lift Works
When a child is unconscious and lying on their back, the tongue can fall backward and block the airway. The head tilt-chin lift physically pulls the tongue and the small flap that covers the windpipe (the epiglottis) forward and away from the airway opening, creating a clear path for air.
To perform it, place one hand on the child’s forehead and press down gently to tilt the head back. With your other hand, place the tips of your index and middle fingers under the bony part of the chin and lift upward. Only pull on the bone of the jaw, not the soft tissue underneath, as pressing into the soft area can actually push the tongue back and make the obstruction worse.
How Far to Tilt a Child’s Head
Children’s airways are not simply smaller versions of adult airways. A child’s head is proportionally much larger than an adult’s, so when a child lies flat on their back, the head naturally rolls forward and flexes the neck. This alone can partially block the airway before you even begin. The upper airway in children also sits higher and more forward than in adults, which means tilting the head too far back can actually compress the airway rather than open it.
For children ages 1 through puberty, tilt the head back to what’s called the “sniffing position,” as if the child were leaning forward slightly to sniff a flower. A practical way to check your positioning: the ear canal should line up roughly with the notch at the top of the breastbone. You want moderate extension, not the full head-back tilt you might use for an adult.
For infants under age 1, the head stays in a neutral or only very slightly extended position. Their large heads make the sniffing position happen almost naturally once you compensate for the forward neck flexion. Place a small folded towel under the shoulders (not the head) to counteract the way the oversized head pushes the neck forward. Research on sedated infants from birth to 4 months found that a head-tilt angle of roughly 144 to 150 degrees provided the best airway opening, which corresponds to just a slight extension.
Giving the Rescue Breaths
Once you have the head tilted and chin lifted, maintain that position throughout the breaths. Pinch the child’s nose closed, seal your mouth over theirs, and deliver two initial breaths. Each breath should last about one second and be just enough to make the chest visibly rise. Watch the chest as you blow. If you see it rise, your airway positioning is correct and air is reaching the lungs.
Avoid blowing too hard or too fast. A child’s lungs are smaller, and forcing too much air can push it into the stomach, which causes vomiting and further complications.
If the Chest Doesn’t Rise
When you give a breath and the chest doesn’t move, the most likely problem is head positioning. Re-tilt the head by adjusting the forehead hand and chin lift, then try another breath. The airway may not have been fully open on the first attempt, and a small repositioning often fixes it.
If the chest still doesn’t rise after repositioning, suspect that something is physically blocking the airway. Look inside the mouth for any visible object you can remove. Do not do a blind finger sweep, as this can push an object deeper.
Breath Timing During CPR
The number of breaths you give depends on whether the child has a pulse.
- Child has a pulse but isn’t breathing: Give one breath every 2 to 3 seconds, which works out to about 20 to 30 breaths per minute. Check for a pulse every 2 minutes and continue rescue breathing as long as the heart is still beating.
- No pulse, one rescuer: Perform cycles of 30 chest compressions followed by 2 breaths.
- No pulse, two rescuers: Switch to cycles of 15 compressions followed by 2 breaths.
In every case, you re-open the airway with the head tilt-chin lift before each set of breaths. It’s common for the head to shift during compressions, so repositioning before ventilating is a consistent part of the cycle.
When to Use the Jaw Thrust Instead
If there’s any chance the child has a neck or spinal injury, such as after a fall, car accident, or diving injury, avoid tilting the head. Instead, use the jaw thrust maneuver. Stand or kneel above the child’s head, place your palms on the temples, and use your fingers to hook under the angles of the jawbone on both sides. Push the jaw forward and upward until the lower teeth sit higher than the upper teeth. This opens the airway without moving the neck.
The jaw thrust is harder to perform and maintain, but it protects the cervical spine. If you can’t get a breath in using the jaw thrust alone, the American Heart Association guidelines allow adding a careful head tilt, because getting air into the lungs takes priority.