Background <p>Pediatric emergencies demand rapid, accurate, and coordinated clinical responses; however, healthcare students often have limited opportunities to gain hands-on experience in such high-risk situations during training. High-fidelity simulation (HFS) has emerged as a widely adopted educational strategy to bridge this gap by providing realistic, safe, and controlled learning environments. Despite its increasing use, the magnitude and consistency of its effectiveness across different educational outcomes remain unclear.</p> Methods <p>A comprehensive systematic search was conducted across PubMed, Scopus, Web of Science, CINAHL, Embase, Cochrane CENTRAL, and ProQuest for studies published between January 2012 and December 2025. Randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs), and mixed-methods studies evaluating high-fidelity simulation (HFS) in pediatric emergency training among healthcare students were included. Outcomes of interest included knowledge, psychomotor skills, clinical performance, decision-making, teamwork, confidence, and other learner-related outcomes. The methodological quality of included studies was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for RCTs, the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool for non-RCTs, and the Mixed Methods Appraisal Tool (MMAT) for mixed-methods studies. Meta-analyses were conducted using a random-effects model for studies reporting comparable outcomes, while studies with non-comparable outcomes were synthesized narratively. The certainty of the evidence for each meta-analyzed outcome was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.</p> Results <p>A total of 23 studies involving 2,734 healthcare students were included. The meta-analysis demonstrated a statistically significant improvement in knowledge scores favouring HFS (mean difference = 3.03; 95% CI: 0.34–5.73; <i>p</i> = 0.03), although substantial heterogeneity was observed (I² = 93%). Skill-related outcomes, pooled from two studies, showed a large and statistically significant effect favouring HFS (mean difference = 8.74; 95% CI: 7.98–9.50; <i>p</i> &lt; 0.001), with no observed heterogeneity (I² = 0%). Narrative synthesis revealed consistent improvements in clinical decision-making, critical thinking, teamwork, self-confidence, and learner satisfaction. Overall, the certainty of evidence was rated as low due to methodological limitations and variability across studies.</p> Conclusion <p>High-fidelity simulation is an effective educational approach for improving pediatric emergency preparedness among healthcare students. While the findings support its use in enhancing both technical and non-technical competencies, further high-quality studies are required to strengthen the evidence base and evaluate long-term educational and clinical outcomes.</p> Trial registration <p>The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (CRD42025631603).</p>