Tap the infant on the heel or the sole of the foot, or flick the outer sole, and watch for a response; if there is none, immediately check breathing and pulse and start CPR. The heel is preferred because it is far from the face and airway, it is easy to expose, and it produces a clear sensory signal without risking injury to the neck or chest. Do not shake the baby. For anything beyond a momentary check, use the formal pediatric assessment sequence taught in Basic Life Support.
Why the Heel Is the Default Site and How Infant Arousal Works
The choice of tapping site is not arbitrary. Infant responsiveness testing works by delivering a controlled sensory stimulus and observing a behavioral or physiological reaction. The heel is rich in nerve endings and is a standard site for painful stimulation in newborns, so a firm flick or tap there produces a reliable withdrawal, cry, or grimace in a responsive infant.
Arousal in infants is mediated by brainstem and cortical circuits that respond to noxious or tactile input. A tap generates a brief mechanical signal that travels through peripheral nerves to the spinal cord and upward. In a responsive infant, this triggers a startle, a cry, a change in muscle tone, or eye opening. In an unresponsive infant, none of these appear. The test is therefore about detecting a reaction, not about the intensity of the tap itself.
The heel also keeps the examiner away from the face and airway. That matters because the next step after an absent response is airway and breathing assessment, and you do not want to be positioned over the mouth while checking. A heel tap lets you observe the whole body at once.
What the Numbers and Guidelines Actually Say
Infant CPR guidelines from major resuscitation bodies describe checking responsiveness by tapping the infant and shouting, then assessing breathing and pulse. The American Heart Association and the American Academy of Pediatrics frame the sequence as: verify scene safety, check responsiveness, check breathing and pulse, then begin compressions and breaths. The heel flick is a recognized method for stimulating a newborn in delivery-room and nursery settings.
Normal infant heart rates are much faster than adult rates. A newborn typically has a resting heart rate of about 100 to 160 beats per minute, and a young infant about 100 to 160 as well, drifting toward 90 to 150 by the end of the first year. A pulse below about 60 beats per minute with signs of poor perfusion is the threshold that triggers compressions in pediatric BLS. These numbers matter because responsiveness and circulation are assessed together.
Compression depth for infants is about one-third the depth of the chest, roughly 4 centimeters or 1.5 inches, delivered at a rate of 100 to 120 compressions per minute. The ratio for a single rescuer is 30 compressions to 2 breaths, and for two rescuers 15 to 2. These figures are stable across current guidelines.
Edge Cases: Premature Infants, Newborns, and Special Situations
Premature and low-birth-weight infants have thinner skin, less subcutaneous fat, and more fragile capillaries. A tap that would be harmless on a term infant can bruise a preterm heel. Use a flick rather than a firm press, and avoid the very center of the heel where the bone sits close to the surface.
Newborns in the first minutes after birth are often assessed with a different protocol. Delivery-room teams use stimulation such as drying and rubbing the back or flicking the sole to encourage breathing. That is a distinct context from a community responder checking an infant who has collapsed.
Infants with known conditions change the calculus. A baby with a bleeding disorder, a skeletal dysplasia, or recent heel-stick testing may have tender or injured heels. In those cases, tap the sole gently or use a shoulder tap instead. A shoulder tap is an acceptable alternative when the heel is inaccessible, for example if the infant is fully clothed and you cannot expose the foot quickly.
Misconceptions That Lead Rescuers Astray
The most dangerous misconception is that shaking an infant is an acceptable way to check responsiveness. Shaking an infant can cause abusive head trauma and is never appropriate. A tap or flick is sufficient and far safer.
A second misconception is that you must tap a specific "pressure point" to get a response. There is no secret spot. Any adequate sensory stimulus works; the heel is chosen for convenience and safety, not because it is uniquely sensitive.
A third misconception is that a crying infant is automatically fine. Crying indicates responsiveness but not adequate breathing or circulation. An infant can cry and still be in respiratory distress or shock. Assess breathing and pulse regardless.
A fourth misconception is that a lack of response to a single tap means the infant is unresponsive. Repeat the tap once and shout, then move immediately to breathing and pulse checks if there is still no reaction. Delaying CPR to keep tapping wastes critical seconds.
Practical Steps and Thresholds for a Real Check
Approach in a fixed order so you do not freeze. The steps below assume you have confirmed the scene is safe.
Tap the heel or flick the sole firmly and shout the infant's name or a loud "Are you okay?" If there is no response, look for chest rise, listen for breath sounds, and feel for a pulse at the brachial artery within 10 seconds. If breathing is absent or the pulse is below 60 beats per minute with poor perfusion, start CPR at 100 to 120 compressions per minute. Call emergency services or direct someone to call while you begin compressions. Continue until the infant responds, breathes normally, or advanced help arrives.
The 10-second limit on the pulse check is important. Prolonged pulse checks delay compressions and worsen outcomes. If you cannot clearly feel a pulse in 10 seconds, assume there is none and begin CPR.
Reconciling the Thresholds and the Limits of This Guidance
Different sources phrase the responsiveness check differently. Community CPR courses say "tap and shout." Newborn resuscitation programs emphasize stimulation by drying and rubbing. Pediatric BLS emphasizes checking breathing and pulse together. These are not contradictory. They reflect different contexts: a collapsed infant in the community, a newborn in the delivery room, and a child in cardiac arrest.
The unifying principle is this: use a brief, safe stimulus, observe for a reaction, and move quickly to the airway-breathing-circulation assessment. The heel tap satisfies the first part. It does not substitute for the rest.
One professional caveat deserves emphasis. A single tap can miss a deeply obtunded infant who responds only to stronger stimulation. If the history suggests a serious event, such as a fall, choking, or a known heart condition, err toward starting the assessment and calling for help even if the first tap produces a weak reaction.
This article is general educational information about infant responsiveness checks, not a diagnosis, treatment plan, or substitute for certified CPR training. It does not promise any outcome. For hands-on instruction, take a course from a qualified local provider such as the American Red Cross or American Heart Association. If an infant is in immediate danger, call local emergency services right away.