Weight Estimation and Dose Calculation in Resuscitation: A Systematic Review and Meta-Analysis

Background: The accuracy of instruments to estimate weight and calculate drug doses in children requiring medications during resuscitation is a critical patient safety issue. We systematically reviewed the literature to determine if length-based tapes or non-length-based measures were superior to other instruments for drug dose calculation, improved the accuracy of weight estimation or time to drug administration or drug dose accuracy or clinical outcomes during resuscitation. Methods: We searched Embase, PubMed, and the Cochrane Library from inception to December 19, 2025 (Prospero CRD42024516299). Risk of bias and Certainty of Evidence were assessed using a modified Newcastle-Ottawa tool and GRADE respectively. For weight estimation performance, the proportions of estimates within 10% (P10) of actual weight, and direct paired comparisons with pooled odds ratios were calculated. Countries classified by income level were the a-priori subgroup of interest. Findings: In the 250 included studies, only 9 enrolled children requiring active resuscitation. No studies reported patient outcomes; 16 studies reported drug dose accuracy; 2 studies reported time to drug administration; and 237 reported weight estimation accuracy. Compared to the Broselow Tape, the PAWPER tape was superior for time to drug administration, drug dose accuracy and weight estimation accuracy in all analyses. In direct paired meta-comparison, the PAWPER tape was superior to the Mercy Method (OR [95th CI] 1.81 [1.59, 2.07], 9305 patients). All age-based formulas were consistently inaccurate (P10 <50%). Findings were consistent across countries classified by income levels. In low- and middle-income countries parental estimate was superior to health care estimate for weight estimation accuracy (OR [95th CI] 3.07 [2.61, 3.60]). Interpretation: There were no studies of patient outcomes for instruments calculating drug dosing during resuscitation. Time to drug administration, drug dose and weight estimation accuracy were superior with a length-based tape with body habitus correction (i.e., the PAWPER tape) in all populations.