Normative values for cardiopulmonary exercise testing in the pediatric population - an updated systematic review

Normative data for cardiopulmonary exercise testing (CPET) provide benchmarks of aerobic fitness that change throughout the lifespan, with new scaling techniques often developed and differing between adults and children/adolescents. Considering the recent interest in the pediatric population for CPET studies, this systematic review aimed to update pediatric-specific CPET reference values.

A systematic review was performed according to the PRISMA guidelines from February 1, 2019, to December 31, 2025, from 6 scientific databases. Observational studies in any language, presenting data from maximal CPET, and conducted only on healthy participants <18 years old were included. Primary outcomes included reference values for peak oxygen uptake (V̇O2peak), and secondary outcomes included other variables assessed during CPET. Risk of bias was assessed with the 14-point ATS/ACCP statement for CPET and the 8-point JBI Critical Appraisal Tool. 15 studies conducted on 12,083 participants (5,886 [49.4%] females) were included, of which recruitment was hospital-based in 6 studies, community-based in 8 studies, and athlete-specific in 1 study. 6 studies reported ethnicity, with most participants classified as white, while 1 investigation presented exclusive data for obese/overweight or pediatric athletic cohorts. Normative V̇O2peak ranged between 26.0-56.3 mL·kg-1·min-1, peak heart rate between 175-199 bpm, and peak ventilation between 52.2-96.0 L·min-1. Reference equations were developed in 11 studies, with 5 of these studies validating the derived equations. A high heterogeneity was observed between studies of high- (n=2), moderate- (n=9), and low-quality (n=4), with ATS/ACCP statement and JBI Critical Appraisal Tool often disregarded - although quality level did not influence study outcomes.

Updated normative values for CPET varied significantly in pediatric cohorts. While female representation matched male, and more studies considering pediatric athletes, showing a positive trend change from previous investigations, obese and overweight children/adolescents, as well as non-white participants, remained underrepresented. Considering the differences in normative data between pediatric cohorts of differing characteristics, clinicians should use reference values derived from cohorts closely matching their patients' characteristics.

CRD420251137402.