https://doi.org/10.1177/30502225251319883 Sage Open Pediatrics Volume 12: 1–14 © The Author(s) 2025 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/30502225251319883 journals.sagepub.com/home/gph Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Review Introduction In the last few decades, international efforts have been made to reduce infant and neonatal mortality. The mor- tality rate for children under 5 has significantly declined; it went from 93 deaths per 1000 live births in 1990 to 39 deaths per 1000 in 2018. But low- and middle-income countries (LMICs), especially those in Africa, continue to have high rates of infant death. The overall child mor- tality rate in these areas is still 76 fatalities for every 1000 live births, although there is wide regional varia- tion in this rate.1,2 Improving pediatric emergency care has become a priority in low-resource settings since many newborn deaths might be avoided with easy, affordable, and successful interventions. Every year, almost 1 million 1319883 GPHXXX10.1177/30502225251319883Global Pediatric HealthDel Castillo Miranda et al review-article2025 1 Universidad Peruana Cayetano Heredia, Lima, Peru 2 College of Medicine, Hebron University, Hebron, West Bank, Palestine 3 Tanta University, Tanta, Egypt 4 Al-Quds University, Jerusalem, Palestine 5 Menoufia University, Shebin El-Kom, Egypt 6 Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra state, Nigeria 7 Al-Thawara Modern General Hopsital, Sana’a, Yemen Corresponding Author: Mohammed Alsabri, Emergency Department, Al-Thawara Modern General Hopsital, Sana’a, Yemen. Email:
[email protected] Enhancing Pediatric Emergency Care in Low-Resource Settings Through Simulation-Based Training: A Narrative Review Jose Carlos Del Castillo Miranda, MD, MPH1 , Majd Oweidat, MD2 , Eslam Abady, MD3 , Mohammad Hakam Shehadeh, MD4, Mayam Mohamed Aziz, MBBS5 , Chibuike Daniel Onyejesi, MBBS6 , and Mohammed Alsabri, MD, FAAP, FISQUA7 Abstract Background. Low- and middle-income countries (LMICs) face persistent challenges in reducing pediatric mortality, particularly in emergency settings. Simulation-based training (SBT) offers a practical solution to improve pediatric emergency care by enhancing healthcare providers’ skills and clinical decision-making. Objective. This narrative review explores the effectiveness, challenges, and implementation strategies of SBT for pediatric emergency care in LMICs. Methods. A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar databases and 36 selected articles were included. Results. Findings highlight significant improvements in clinical skills, teamwork, and decision-making through SBT, with low-fidelity and in-situ simulations emerging as cost-effective alternatives for these settings. Case studies from Ghana, India, and Uganda showcase innovative, affordable models, including task-trainers and homemade mannequins, which address local barriers. Despite its potential, further research is needed to evaluate long-term outcomes and establish standardized assessment metrics. Conclusion. SBT represents a scalable and impactful strategy to strengthen pediatric emergency care and reduce child mortality in LMICs. Keywords simulation training, child, emergency medical services, resource-limited settings Received November 9, 2024. Received revised January 15, 2025. Accepted for publication January 27, 2025.
2 Sage Open Pediatrics babies pass away on their first day of life, followed by another million within the first week and nearly 2 mil- lion more during the up to 28-day neonatal period. Furthermore, there are about 3 million stillbirths world- wide each year.3 For a long time, simulation has been a practical teaching method to reduce mortality associated with resuscitation.1 The World Health Organization (WHO) has advised adding simulation-based training to these programs to enhance care in low-resource settings. The specific requirements of low-resource environments have led to the development of programs like Saving Children’s Lives, Helping Babies Breathe (HBB), the Emergency Triage, Assessment, and Treatment (ETAT and ETAT+) Essential Steps in Managing Obstetrical Emergencies (which includes neonatal care) in South Africa, and others.1 This review will focus on simulation in pediatric emergency care as an effective way of enhancing it, especially in low-resource settings such as Africa and the Middle East. Finally, we are going to address the challenges of implementing it with some recommenda- tions from international guidelines and success cases to further scale into LMICs. Materials and Methods This narrative review aimed to evaluate the literature in English related to pediatric emergency care in low- resource settings, specifically focusing on the role of simulation-based training. An electronic search was conducted using PubMed, Scopus, and Google Scholar databases. The search covered studies published from January 2013 up to October 2024. The key search terms used were combinations of “simulation” or “simulation training,” or “simulation-based training” and “low resource” and “countries,” “settings,” or “nations,” as well as “pediatrics,” “child,” and “emergency.” The inclusion criteria for the studies focused on original research, systematic reviews, other narrative reviews, literature reviews, and case studies that spe- cifically addressed simulation training for pediatric emergency care in low-resource settings. Studies that did not provide specific information about pediatric emergency care, which includes trauma care, simula- tion training, or the targeted low-resource environ- ments were excluded. We further applied exclusion criteria for papers with inadequate sample size, unclear methodology, or not meeting quality control standards regarding design and statistical rigor. 100 abstracts were initially screened, and 36 full- text articles were selected for detailed evaluation. One independent reviewer conducted the selection process. In cases of disagreement, a second reviewer was consulted, and their decision was considered final. The final articles selected were reviewed for key themes related to the effectiveness, challenges, and outcomes of simulation-based training in pediat- ric emergency care in low-resource settings. Relevant data were systematically extracted and categorized into thematic subgroups. Ethical Approval and Informed Consent Ethics approval and Informed Consent were not required for this narrative review The Role of Simulation in Pediatric Emergency Training The practice of simulation, by definition, is creating a virtual reality where a situation or an environment repre- sents a real-life event to learn, practice, evaluate, test, or acquire a skill. There has been an exceptional expansion in using simulation-based training (SBT) in health care over the past 2 decades as simulation-based training expanded to be used as a tool to uplevel clinical skills and teamwork in addition to evaluating the competency of medical and trauma management in the pediatric pop- ulation and across all other specialties.4 Types of Simulation: High-Fidelity Versus Low- Fidelity Versus In-Situ Low-fidelity simulations have been used for decades to represent clinical events or for basic life support training, using simple manikins and traditional mock codes. Vise versa, high-fidelity simulations are more recent, offering more realistic experiences through computer-controlled simulators. Advanced manikins can simulate breathing and heart sounds, chest move- ments, palpable pulses, and airway changes, for exam- ple, swelling and spasms. Additionally, they feature advanced monitors that show vital signs and ECG rhythms and can be programed to mimic real-life responses to interventions.4 An overview of the key features, advantages, challenges, and recommended settings for different simulation techniques in pediat- ric resuscitation is provided in Table 1. Benefits of Simulation in Pediatric Emergency Settings Simulation training in pediatric critical care has proven benefits in increasing clinical proficiency and
4 Sage Open Pediatrics support, a trained team, and smart sourcing can facilitate successful adoption. Efforts to integrate simulation into existing curricula and raise awareness of its benefits are crucial for enhancing pediatric emergency care. Institutional leadership drives these changes and sup- ports simulation-based initiatives.6 Task Trainers and Their Applications in Low- Resource Settings In low-resource settings, task trainers have proven highly effective in enhancing medical training, especially for specific technical skills like surgery and obstetrics. A review of healthcare simulation in developing countries revealed that hand-made task trainers were used in most studies, demonstrating significant improvements in par- ticipants’ technical abilities and satisfaction. These low- cost models, some costing as little as 15 dollars, allow for the widespread adoption of simulation-based training, even in areas with minimal resources, making them cru- cial tools for healthcare education in such settings.7 For example, the Helping Babies Breathe (HBB) pro- gram in Kenya demonstrated the transformative impact of task trainers. Prior to training, only 36% of non- breathing infants received adequate stimulation during resuscitation, and the effectiveness of bag-mask ventila- tion (BMV) was just 20%. Following the introduction of low-cost neonatal mannequins as task trainers, these figures rose to 100% for both adequate stimulation and BMV effectiveness.1 This underscores the critical role of task trainers in improving neonatal outcomes in resource-limited contexts. Similarly, the PediSTARS Initiative in India utilized locally modified, low-cost mannequins for skill training in neonatal resuscitation and airway management. These cost-effective models provided high-realism training opportunities, leading to significant improvements in provider confidence and procedural skills.8 Homemade Mannequins for Basic Skill Training Cost is a significant barrier to implementing SBT in low-resource settings. PediSTARS innovatively addressed this challenge by utilizing and modifying low-cost mannequins to create effective training tools. These modifications achieved high-realism simula- tions, demonstrating that valuable simulation experi- ences can be provided even in resource-limited settings. This strategy is particularly relevant for basic skill training, where low-cost or homemade mannequins offer practical, hands-on learning without expensive technology or infrastructure.8 Integration of Low-Cost Simulation Techniques Into Training Programs Integrating low-cost simulation techniques into regular training requires overcoming barriers like time con- straints and resource shortages. The study highlighted that a flexible approach to debriefing, including “flash debriefs” in time-constrained environments, allowed for more efficient use of simulation training. Leadership support and team building were identified as crucial enablers for successfully embedding simulation-based learning into routine training, which could improve health outcomes in low-resource settings.9 Simulation for Pediatric Resuscitation Training Simulation-based training has emerged as a vital com- ponent in equipping healthcare professionals for pediat- ric resuscitation, where timely interventions are essential. A growing body of research highlights the positive impact of simulation on clinical performance and decision-making in critical situations.10 The use of simulation techniques in pediatric resusci- tation scenarios is pivotal for optimizing response times and enhancing the standard of care in emergencies involving children. Importance of Simulation in Pediatric Resuscitation Care The COVID-19 pandemic necessitated rapid adapta- tions in pediatric emergency care to ensure patient safety and healthcare worker protection. Regular multidisci- plinary simulation sessions were employed to refine processes, enhance communication, and develop proto- cols for critical situations. These simulations effectively disseminated new practices and optimized workflows, underscoring the vital role of simulation in improving care for critically ill children while minimizing risks during unforeseen emergencies.11 Key Techniques Used in Pediatric Resuscitation Simulation Training Pediatric residency programs increasingly utilize sim- ulation to enhance trainees’ procedural and resuscita- tion skills, addressing the gap in their training. A review of the literature highlights the effectiveness of simulated procedural and resuscitation scenarios, though results vary across studies. Techniques such as video-assisted debriefings, mock resuscitation scenar- ios, and structured evaluations are crucial.12 Despite
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