Published:  2021-02-16

Maturation of the Cardiac Autonomic Nervous System Activity in Children and Adolescents

Authors:  Lisette M. Harteveld, Ineke Nederend, Arend D. J. ten Harkel, Nienke M. Schutte, Susanne R. de Rooij, Tanja G. M. Vrijkotte, Helena Oldenhof, Arne Popma, Lucres M. C. Jansen, Jill Suurland, Hanna Swaab, Eco J. C. de Geus, Martin Prätzlich, Katharina Ackermann, Rosalind Baker, Molly Batchelor, Sarah Baumann, Anka Bernhard, Roberta Clanton, Dimitris Dikeos, Roberta Dochnal, Lynn Valérie Fehlbaum, Aranzazu Fernández‐Rivas, Karen Gonzalez, Maider González de Artaza‐Lavesa, Silvina Guijarro, Malou Gundlach, Beate Herpertz‐Dahlmann, Amaia Hervas, Linda Kersten, Gregor Kohls, Angeliki Konsta, Helen Lazaratou, Iñaki Kerexeta‐Lizeaga, Anne Martinelli, Tisse van Nimwegen, Ignazio Puzzo, Nora Maria Raschle, Jack Rogers, Réka Siklósi, Areti Smaragdi, Martin Steppan, Stephane De Brito, Graeme Fairchild, Meinhard Kieser, Kerstin Konrad, Christine Freitag, Christina Stadler

Tags:  autonomic nervous system, development, heart rate variability, pediatrics, sympathetic nerve activity

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Despite the increasing interest in cardiac autonomic nervous activity, the normal development is not fully understood. The main aim was to determine the maturation of different cardiac sympathetic‐(SNS) and parasympathetic nervous system (PNS) activity parameters in healthy patients aged 0.5 to 20 years. A second aim was to determine potential sex differences.

Methods and Results

Five studies covering the 0.5‐ to 20‐year age range provided impedance‐ and electrocardiography recordings from which heart rate, different PNS‐parameters (eg, respiratory sinus arrhythmia) and an SNS‐parameter (pre‐ejection period) were collected. Age trends were computed in the mean values across 12 age‐bins and in the age‐specific variances. Age was associated with changes in mean and variance of all parameters. PNS‐activity followed a cubic trend, with an exponential increase from infancy, a plateau phase during middle childhood, followed by a decrease to adolescence. SNS‐activity showed a more linear trend, with a gradual decrease from infancy to adolescence. Boys had higher SNS‐activity at ages 11 to 15 years, while PNS‐activity was higher at 5 and 11 to 12 years with the plateau level reached earlier in girls. Interindividual variation was high at all ages. Variance was reasonably stable for SNS‐ and the log‐transformed PNS‐parameters.


Cardiac PNS‐ and SNS‐activity in childhood follows different maturational trajectories. Whereas PNS‐activity shows a cubic trend with a plateau phase during middle childhood, SNS‐activity shows a linear decrease from 0.5 to 20 years. Despite the large samples used, clinical use of the sex‐specific centile and percentile normative values is modest in view of the large individual differences, even within narrow age bands.