Pediatric Work of Breathing
Objective: From the door, read appearance, work of breathing, and skin color. Treat a quiet, tiring child as a ventilation emergency. Support breathing before you name the disease.
Why this matters
Adults look ill when they fail. Children can look all right until they suddenly are not. The pediatric assessment triangle is appearance, work of breathing, and circulation to the skin. Use it in the first 10 seconds. Retractions, nasal flaring, grunting, and head bobbing mean the child is working hard. When the noise stops and they go limp, you are late. Breathing failure is the main path into pediatric cardiac arrest. Give oxygen, let them sit, and use a bag that does not fill the stomach. Do not spend the scene debating bronchiolitis versus asthma.
- I say whether they are working or tiring before I name a disease.
- A crying toddler with retractions is working. A quiet, pale infant who is bobbing the head is tiring.
- If they want to sit, they stay sitting. I do not lay them flat because it is easier for me.
- If the heart rate is slow, I bag first. I use a small squeeze and I watch for chest rise.
Clinical sequence
- Make the scene safe. Look before you touch. Check how they look, how hard they are working, and what color the skin is.
- If they are working hard, give oxygen in a way they will accept. Keep a parent close if that keeps them calm. Get a sat if doing it does not make them fight.
- If they are tiring, or the heart rate is slow, open the airway, suction, place an adjunct, and use a two-person bag. A slow heart rate in a hypoxic child is a breathing problem first. See the pediatric airway lesson for the breath rate.
- Do not delay the hospital for an exact diagnosis. Croup, bronchiolitis, asthma, and choking can look alike. Support the airway and move.
Teaching points
- Appearance. Look at muscle tone, whether they interact, whether they can be comforted, where they look, and their speech or cry. Floppy and vacant is a warning.
- Work of breathing. Look for retractions, nasal flaring, grunting, head bobbing, sitting forward and bracing, stridor, or wheeze. Watch the belly and the neck.
- Circulation to the skin. Pale, mottled, or blue skin matters. Cool, mottled, and tired is shock until you prove it is not.
- Quiet is not better. A child who was screaming and is now silent may be exhausted, not improved.
- You do not need the exact disease. Guidelines separate bronchiolitis and croup, but the on-scene actions are the same. Give oxygen, position them, and suction secretions. Give a bronchodilator only if your protocol and the picture fit. Not every wheeze is asthma.
Common errors
- Calling a tired infant calm.
- Using an adult-sized squeeze on a toddler.
- Laying a child flat who was sitting forward and bracing, just to get a better look.
- Waiting for a wheeze to prove asthma before you give oxygen.
Practice
One-minute check
Partner: a 14-month-old has retractions and a sat of 88% in a parent’s arms, then goes quiet. Say what you do in the first 20 seconds. Then: there is still a pulse, and the heart rate is 70. What is the emergency?
Related: Pediatric Airway Differences, Effective BVM Ventilation, Stridor: Croup vs Epiglottitis.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; follow your protocol
- AHA/AAP 2025 Pediatric BLS — respiratory problems remain the major cause of pediatric arrest; support ventilation early
- AHA/AAP 2025 Pediatric ALS — work of breathing and appearance drive the first look; protocol owns drugs
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.