Abstract. Background: Critical pediatric illness or injury occurs infrequently in out-of-hospital settings, making it difficult for paramedics to maintain physical assessment, treatment, and procedure skills. Objectives: To document the ability of paramedics to retain clinical knowledge over a one-year interval after completing a pediatric resuscitation course and to determine whether clinical experience or retesting improves retention. Methods: This was a randomized controlled study assessing retention of knowledge in pediatric resuscitation soon after, six months after, and 12 months following completion of a pediatric anvanced life support course. Forty-three parmedics participated in pre- and post-pediatric resuscitation course testing and were randomly assigned to one of four groups. Group 1 received a knowledge examination (KE) and mock resuscitation scenarios (MR) at six months. Group 2 received only the KE at six months. Groups 3 received the MR only at six months. Group 4 received no intermediate testing. All groups were reassessed at 12 months. Results; Pediatric clinical knowledge (as measured by KE) rose sharply immediately after the course but returned to baseline levels within six months. There was no difference between the groups in knowledge scores at 12 months, despite the interventions at six months. Conclusions: Although intensive out-of-hospital pediatric education enhances knowledge, that knowledge rapidly decays. Emergency medical services programs need to find novel ways to increase retention and ensure paramedic readiness.