Out-of-hospital cardiac arrest (OHCA) is the third-leading cause of death in developed countries1 and it is witnessed by relatives, friends or other bystanders in up to 70% of cases.2 Early cardiopulmonary resuscitation is a determining factor for survival and neurological otucomes.3 The basic cornerstone of responding to OHCA is training in basic life support (BLS) and, in this regard, training schoolchildren is one of the most effective strategies.4,5

The chain of survival (CS) was proposed by the American Heart Association (AHA) in 1991 and has been evolving to this day with the collaboration of the AHA and the European Resuscitation Council (ERC).1,2 It consists of a series of actions aimed at saving the lives of victims of cardiac arrest. These actions range from early recognition and activation of emergency services (the first link of the chain of survival) to delivery of adequate cardiopulmonary resuscitation and early use of the defibrillator.

Despite the fact that the Kids Save Lives statement3 issued by the ERC and endorsed by the World Health Organization recommends teaching cardiopulmonary resuscitation (CPR) to schoolchildren for 2 h per year from age 12,4 there is evidence that shows that the chain of survival sequence can be learned from age 6 years.5 In general, BLS training programs are not included in the early childhood education or primary education curricula in Spain.1,6–8

Although randomized controlled trials have investigated the effect of a BLS workshop in primary school9 and medical school,10 there is less evidence for children aged 5–8 years. Several studies suggest that schoolchildren aged 5–8 years retain what they have learned well, and evaluation results are not inferior to those in older children or adults.1,8 Some studies have even shown that children aged 5–8 years are able to understand the chain of survival and how to activate it,1,11–13 although the impact of BLS training at these ages has not been evaluated. In fact, to date, there is no validated questionnaire developed to assess knowledge on BLS in young children.

The purpose of our study was to assess the acquisition and retention over time of BLS knowledge and skills (mainly the first link in the chain of survival) in schoolchildren in the last year of preschool education trained with a novel CPR education methodology (RCParvulari®) compared to standard BLS training.14

Forty-one early childhood and primary education schools in Baix Llobregat agreed to participate in the study, with a cumulative student body of 1327 P-5 students; 20 schools were assigned to the IG and 21 to the CG (Fig. 2). The resulting sample included 1327 schoolchildren (79% participation rate: 746 participants in IG and 581 in CG). Of this total, 75.2% were 5 years old, and 51% (n = 648) were female.

In the preintervention evaluation, 14.6% of the sample already knew the 112 emergency number, and 10 children (0.8%) reported knowing the mouth-nose-eyes mnemonic. In the control group, a much higher proportion knew the 112 number (21.3% compared to 9.3% in IG; P < .001). In the total sample 31.6% of children had received previous training on BLS from the local/regional police or fire department: 241 in the control group and 160 in the intervention group (42.9% of CG vs 22.6% of IG; P < .001) (Table 1).

In the post-intervention evaluation, both groups exhibited significant changes in the knowledge of the 112 number and the mnemonic, with greater improvement in the IG (P < .001) (Table 1), differences that were sustained in the follow-up evaluations at 3–12 months, where 71.4% still remembered the 112 number and 19.0% the mnemonic rule in the intervention group, compared to 52.7% and 1.0%, respectively, in the control group (P < .001) (Table 1).

In the original study design, the follow-up evaluation had to be carried out 6 months after the intervention.14 In some schools, the follow-up evaluation was delayed to up to 1 year post intervention due to organizational challenges. In spite of this, the results showed that students in the intervention group remembered the 112 number and the mnemonic not only for a few months, but even after 1 year.

The results of the multivariate regression models showed that the intervention had a statistically significant effect on knowledge of the 112 number and the mnemonic rule immediately after the training and in the follow-up (P < .001) (Tables 2 and 3), with a more than 20-fold increase in the odds of knowing the 112 number and the mnemonic rule, with the exception of knowing the 112 number in the follow-up (the odds ratio of knowing the 112 number in the follow-up in the intervention group was 3.22).

Other variables, such as prior knowledge and the gossip effect, were also significantly associated with acquired knowledge in the multivariate models, depending on the outcome measure and the timing of the evaluation.

The RCParvulari® method is a novel training approach aimed at children in the last year of preschool to make them able to activate the chain of survival in the event of a medical emergency. This is achieved by adapting existing tools to the age of the students to facilitate their learning: a Power Point® presentation, a screening of drawings, cartoons, photographs, a song and role play with giant mobile phone models (Fig. 1).14

The results showed that a training lasting 30−50 min, with an eminently practical and participatory approach, significantly improved knowledge and practices related to the first link of the chain of survival in children in the last year of preschool education.

To our knowledge, there have been no previous studies in the preschool setting that made a quantitative assessment of the learning capacity for BLS (theoretical and practical) of children aged 4–6 years.

There have been previous works, such as the study by Martinez-Isasi et al.,16 which showed that, after a period of training implemented during school hours, students in years 3 and 5 of primary education and year 1 of compulsory secondary education (aged 8–12 years) were able to activate the chain of survival and initiate CPR. Similar to what we did in our study, other authors, such as Otero-Agra et al.,1 have applied their own training methodology, validating the content and suitability of the material used in the process, to train older schoolchildren on the chain of survival.

All these works show that BLS training in the school setting improves knowledge on the subject in the different age groups targeted in the research. This type of training can have a great impact on public health, as individuals of any age can save lives if they receive proper training.3 In addition, early childhood education students are open to be trained on BLS and can serve as CPR multipliers by teaching their friends and families.16

Thus, in the long-term, BLS training strategies can increase survival rates and quality of life in victims of cardiac arrest.18 Currently, in Europe, the highest bystander CPR rates are found in Scandinavian countries where education of schoolchildren in CPR has been mandatory for decades.3

Basic life support training in early childhood is a strategy that can help reduce the mortality associated to out-of-hospital cardiac arrest. Schools are the ideal setting to teach BLS if the objective is to train the entire population, as it would ensure that nearly 100% of the population in developed countries would receive the training.18,19

Educating and training children in CPR also brings social benefits, since they learn to help other people. Students and teachers are also important multipliers and can increase the proportion of individuals trained in CPR in the long term.3,17

One finding of this study concerned the variable adapted from the previous literature that we referred to as the “gossip effect”. The students answered the questionnaire in their usual environment, seated in their chairs at their desk in the classroom. We noticed that at the time of completing the questionnaire before the intervention, children who did not know how to answer copied from peers who did. This exchange of information is another way of learning, as they no longer copied answers when completing the questionnaire immediately after the intervention or in the follow-up.

There are studies, such as the one by Seki et al.,20 that, although carried out in a different setting and in adults, describe “gossip” as a way of promoting cooperation, altruism and knowledge retention.

One of the strengths of our study, the creation and evaluation of a method for BLS training in an age group in which no research had been conducted to date, is also one of its limitations: the RCParvulari® methodology has been created and tested in children in the last year of preschool education, so we do not know whether it would be valid for other age groups. We also could not assess whether training at an early age would facilitate the consolidation of knowledge about BLS at later ages, or whether acquisition of this knowledge in this age group would improve long-term survival in victims of OHCA.

Another possible limitation of the study is the significant differences we found in prior knowledge and training between the intervention and control groups. Although the results support the conclusions, they could not be fully explained in randomised groups. It is possible that this would not have been an issue if the initial groups had more homogeneous characteristics, but the study design was based on the principle of randomization.

Theoretical/practical training using an age-appropriate methodology helps students in the last year of early childhood education learn and retain knowledge about the first link in the chain of survival. The results of our study show that basic life support training could be started in early childhood with good results.

The authors declare that they have no conflict of interest.