Standardised formal resuscitation training programmes for reducing mortality and morbidity in newborn infants.

rationaleApproximately 10% of term newborns require resuscitation at birth. Training healthcare providers in standardised formal neonatal resuscitation training (SFNRT) programmes may improve neonatal outcomes. In the current update we focused on whether new literature confirmed our previous findings of a decrease in neonatal mortality and provided new reports of neonatal morbidity, particularly hypoxic ischaemic encephalopathy and neurodevelopmental outcomes.

objectivesTo determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve teamwork behaviour, or improve acquisition and retention of knowledge and skills. SEARCH

methodsWe searched CENTRAL, MEDLINE, three other databases, and two trial registers, together with reference checking, citation and errata/retractions checking, to identify studies for inclusion in the review. The latest search date was June 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in newborn infants that compared SFNRT with no SFNRT, with basic resuscitation training, or with SFNRT plus additional components such as booster (refresher) training. OUTCOMES: Our critical outcomes of interest were neonatal mortality (mortality in the first 28 days of life) and its components (mortality within 24 hours, within 7 days, and between 8 and 28 days of life) and neonatal morbidity. RISK OF BIAS: We assessed risk of bias in the included studies using the Cochrane RoB 1 tool. SYNTHESIS

methodsWe used the fixed-effect model for meta-analysis and reported risk ratio (RR), risk difference (RD), mean difference (MD), and number needed to treat for an additional beneficial outcome (NNTB) and number needed to treat for an additional harmful outcome (NNTH) (all with 95% confidence intervals (CI)). We analysed cluster-RCTs using the generic inverse-variance and the approximate analysis methods. Where this was precluded by the nature of the data, we summarised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included a total of 27 studies (528,366 newborns) in the review. However, only a maximum of four studies provided data for each outcome. SYNTHESIS OF

resultsSFNRT compared to no SFNRT SFNRT likely decreases 24-hour mortality (RR 0.73, 95% CI 0.66 to 0.82; I² = 0%; 2 studies, 353,527 participants; moderate-certainty evidence) and early neonatal mortality (RR 0.82, 95% CI 0.75 to 0.89; I² = 0%; 2 studies, 354,358 participants; moderate-certainty evidence). Neonatal mortality in the first 28 days, late neonatal mortality, and neonatal morbidities were not reported. SFNRT compared to basic resuscitation training SFNRT may decrease mortality in the first 28 days (RR 0.55, 95% CI 0.33 to 0.91; I² not applicable; 1 study, 3355 participants; low-certainty evidence). SFNRT likely decreases 24-hour mortality (RR 0.59, 95% CI 0.51 to 0.67; I² = 82%; 3 studies, 169,331 participants; moderate-certainty evidence) and early neonatal mortality (RR 0.88, 95% CI 0.77 to 0.99; I² = 68%; 4 studies, 69,264 participants; moderate-certainty evidence). SFNRT may not decrease late neonatal mortality (RR 0.47, 95% CI 0.20 to 1.11; I² not applicable; 1 study, 3274 participants; low-certainty evidence). Neonatal morbidities were not reported. SFNRT compared to SFNRT with boosters The evidence is very uncertain about the effect of SFNRT with boosters on mortality in the first 28 days (RR 1.23, 95% CI 0.46 to 3.27; I² not applicable; 1 study, 511 participants; very low-certainty evidence). Twenty-four-hour mortality, early neonatal mortality, late neonatal mortality, and neonatal morbidities were not reported. The overall risk of bias of the included studies was mixed due to high risk of performance bias in all RCTs. The available studies reporting mortality outcomes were conducted exclusively in low- and middle-income countries (LMICs). AUTHORS'

conclusionsSFNRT, compared with no training, likely decreases mortality at 24 hours of life and in the first 7 days of life. SFNRT, compared with basic resuscitation training, may decrease mortality in the first 28 days of life, likely decreases mortality at 24 hours and 7 days of life, but may not decrease late neonatal mortality. The evidence is very uncertain whether SFNRT with boosters affects mortality in the first 28 days of life. This update confirms our 2015 review findings of decreased neonatal mortality, but did not identify any reports on neonatal morbidity, particularly hypoxic ischaemic encephalopathy and neurodevelopmental outcomes.

fundingThis Cochrane review had no dedicated funding. REGISTRATION: Protocol (2011) DOI: 10.1002/14651858.CD009106. Original review (2015) DOI: 10.1002/14651858.CD009106.pub2.