Cardiac autonomic dysfunction in children and adolescents with obesity: a systematic review and meta-analysis

To evaluate the association between excess weight and cardiac autonomic modulation in children and adolescents.

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2, 2026 for observational studies comparing short-term resting heart rate variability between children and adolescents with excess weight and normal-weight controls. The protocol was registered in PROSPERO (CRD420251005501).

Eighteen studies comprising 1,590 participants were included. Random-effects meta-analyses using standardized mean differences showed lower root mean square of successive differences of RR intervals (RMSSD -1.00; 95% confidence interval [95%CI] -1.68 to -0.31), lower percentage of successive normal-to-normal intervals differing by more than 50 ms (pNN50 -0.48; 95%CI -0.68 to -0.28), and higher low-frequency/high-frequency ratio (LF/HF 0.70; 95%CI 0.30 to 1.10) in the excess weight group. No significant differences were observed for the standard deviation or mean of normal-to-normal intervals. Leave-one-out analyses supported directional robustness, and between-group body mass index difference significantly moderated LF/HF (β=-0.15; p=0.045), but not RMSSD.

Pediatric excess weight appears to be associated with impaired cardiac autonomic modulation, mainly characterized by lower parasympathetic-related heart rate variability indices. Among the evaluated parameters, pNN50 showed the most consistent reduction, whereas RMSSD showed the largest pooled effect.