Pediatric Echocardiographic Nomograms: Twenty Years of Advances-Do We Now Have a Complete and Reliable Tool, or Are Gaps Still Present? An Up-to-Date Review

Abstract

Echocardiography is the primary imaging modality for diagnosing cardiac disease in children, with quantitation largely based on nomograms. Over the past decade, significant efforts have been made to address the numerical and methodological limitations of earlier nomograms. As a result, robust and reliable pediatric echocardiographic nomograms are now available for most two-dimensional anatomical measurements, three-dimensional volumes, and strain parameters. These more recent nomograms are based on adequate sample sizes, strict inclusion and exclusion criteria, and rigorous statistical methodologies. They have demonstrated good reproducibility with minimal differences across different authors, establishing them as reliable diagnostic tools. Despite these advances, some limitations persist. Certain ethnic groups remain underrepresented, and data for preterm and low-weight infants are still limited. Most existing nomograms are derived from European and North American populations, with sparse data from Asia and very limited data from Africa and South America. Nomograms for preterm and low-weight infants are few and cover only selected cardiac structures. Although diastolic parameter nomograms are available, the data remain heterogeneous due to challenges in normalizing functional parameters according to age and body size. The accessibility of current nomograms has greatly improved with the development of online calculators and mobile applications. Ideally, integration of nomograms into echocardiographic machines and reporting systems should be pursued. Future studies are needed to develop broader, more comprehensive, and multi-ethnic nomograms, with better representation of preterm and low-weight populations, and to validate new parameters derived from emerging three- and four-dimensional echocardiographic techniques.

Keywords: children; echocardiography; nomograms.

Figure 1

Selection diagram according to PRISMA guidelines.

Figure 2

Percentile charts of predicted values for the mitral valve (MV) and tricuspid valve (TV) are shown for the nomograms by Lopez et al. [2], Cantinotti et al. [96], Pettersen et al. [91], and Sluysmans et al [90]. In addition, Z-score-based comparisons of predicted values from Cantinotti et al. and Pettersen et al. versus those from Lopez et al. (used as the reference standard) are presented. For example, with body surface area as the independent variable, the graphs illustrate the Z-score deviations of the mean predicted values from Cantinotti and Pettersen relative to the mean values reported by Lopez et al. Z-score calculation is performed as follows: Z-score (Cantinotti) = (predicted mean from Cantinotti et al.—predicted mean from Lopez et al.)/root mean square error (RMSE) of Lopez et al. Z-score (Pettersen) = (predicted mean from Pettersen et al.—predicted mean from Lopez et al.)/RMSE of Lopez et al.