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Meta-Analysis
. 2025 Jun 3;14(11):e039783.
doi: 10.1161/JAHA.124.039783. Epub 2025 May 26.

Holter Monitor Rhythm Parameters in Healthy Infants, Children, and Adolescents: Defining Reference Limits With Meta-Analysis

James J Joyce  1 , Soujanya Bogarapu  2 , Collins Odhiambo  3 , Sunita J Ferns  2 , Harold L Kennedy  4   5
Affiliations
Meta-Analysis

Holter Monitor Rhythm Parameters in Healthy Infants, Children, and Adolescents: Defining Reference Limits With Meta-Analysis

James J Joyce et al. J Am Heart Assoc. .

Abstract

Background: Ambulatory electrocardiography has been in clinical use for 5 decades. However, reference limits for rhythm parameters in healthy infants, children, and adolescents have not been adequately defined. We sought to determine these reference ranges using meta-analysis of existing published studies of 24-hour Holter monitoring in healthy pediatric populations.

Methods: Multiple literature databases were searched from 1969 to May 2024 for relevant studies. Data extraction and analysis were completed according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. The prevalence of cardiac ectopy and conduction delays along with mean±SD of heart rates were obtained and grouped by the following age ranges: neonates (birth to 4 weeks), older infants (1-12 months), younger children (1-6 years), older children (7-12 years), and adolescents (13-18 years). Ninety-five percent reference ranges for all rhythm variables were estimated in each age group.

Results: Forty-five studies including 3886 participants were identified and analyzed. Minimum, average, and maximum heart rates during Holter monitoring decreased with age as expected. Prevalence of transient first-degree atrioventricular block and Wenckebach second-degree atrioventricular block increased with age to around 14% in adolescence. Prevalence rates for any premature atrial complexes and premature ventricular complexes were also highest in adolescence at 50% and 29%, respectively. The upper limits for the number of premature atrial complexes per day were 150 in infants and 50 in the older age groups and for premature ventricular complexes were 50 in all age groups.

Conclusions: Holter monitor age-related reference limits for healthy infants, children, and adolescents are proposed.

Keywords: Holter monitor; cardiac rhythm; reference range.

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Conflict of interest statement

None.

Figures

Figure 1
Figure 1. Forest plot of minimum heart rates.*
HR indicates heart rate. *References , , , , , , , , , , , , , , , , , , , , , , , , , , , .
Figure 2
Figure 2. Forest plot of second‐degree atrioventricular block.*
AV indicates atrioventricular. *References , , , , , , , , , , , , .
Figure 3
Figure 3. Forest plot of >150 premature atrial complexes per day.
* PAC indicates premature atrial complex. *References , , , , , , , , , , , , , .
Figure 4
Figure 4. Forest plot of >50 premature ventricular complexes per day.*
PVC indicates premature ventricular complex. *References , , , , , , , , , , , , , , , , .
See this image and copyright information in PMC

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