Utility of An Automatic and Patient-Triggered Cardiac Event Recorder: Experience in Children

Utility of An Automatic and Patient-Triggered Cardiac Event Recorder: Experience in Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Utility of An Automatic and Patient-Triggered Cardiac Event Recorder: Experience in Children Özlem Elkıran, Mehmet Öncül This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9199287/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Objective This study aimed to evaluate the diagnostic yield of an event recorder capable of automatic and manual recording in children with possible arrhythmia related symptoms. Methods We evaluated retrospectively 81 children monitored with Novacor event recorder system between September 2021 and September 2024. All of the patients performed 12-lead electrocardiogram (ECG), 24-hour-Holter monitoring, and echocardiography before the cardiac event recording. Results The indications included palpitation in 59 (72.8%) patients, chest pain and palpitations in 19 (23.5%) patients, palpitation and pre-syncope in 3 (3.7%) patients. After a mean monitoring period of 14.40 ± 7.79 days, 65 children described symptoms and 41(%63) children had automatically or manually recorded arrhythmias. 63% of these arrhythmias were correlated with the symptoms. Of the 16 patients who were asymptomatic during the enrollment period, 9 (56%) had arrhythmia recorded with automatic arrhythmia detection property only. A total of 107 arrhythmia episodes were registered; forty-six (43%) episodes were patient triggered, and 61 (57%) were automatically recorded. While 24-hour-Holter monitoring detected a clinical diagnosis in 13 patients (16.7%), event recorder diagnosed the clinical arrhythmia in 41 children (63%). Based on the event recorder and findings, 10 patients received an electrophysiology study/ablation. Conclusion We found that the automatic mode of the device provided additional clinical and therapeutic consequences. For this reason, a cardiac event recorder capable of automatically and manually recording may be a more preferable method in children with potentially arrhythmia related symptoms. Studies with larger patient series may provide illuminating data in this area. Arrhythmia Children Cardiac event recorder Holter Figures Figure 1 Figure 2 Figure 3 The Key Messages Automatic event recorders can help detect palpitations in pediatric patients presenting with palpitations. The device's automatic arrhythmia detection mode has provided additional clinical and therapeutic results, especially in young children with intermittent palpitations who cannot use triggered event recorders. Automatic event recorders appear to be more advantageous than 24-hour Holter monitoring. Introduction Rhythm problems and palpitations are frequent complaints in patients who refer to pediatric cardiology clinics. Due to reasons such as tachycardia attacks being short termed and rare most of the time and the fact that sometimes infants and children cannot realize palpitation themselves, it is quite difficult to assess these complaints in childhood [ 1 – 3 ]. The 12-lead electrocardiogram (ECG) has been used as the gold standard for arrhythmia diagnosis for more than 100 years. Recording ECG during the period in which the patient referring with palpitation is symptomatic is very important for the diagnosis. However, the most important limitation of ECG is the fact that ECG records are limited to the short time in which ECG is taken. Again, since cardiac arrhythmias are generally intermittent and sometimes asymptomatic, resting ECG can be insufficient in diagnosis[ 1 , 4 , 5 ]. Non-invasive ambulatory ECG device, which is also called Holter monitoring was begun to be used in the early 1940s and it is also widely used today [ 6 , 7 ]. Holter devices generally record 24–48 hours of ECG. For this reason, they have a higher diagnostic value than ECG in patients who have intermittent symptoms during the day. However, 24-h-Holter is insufficient in diagnosis in patients who have infrequent symptoms. In pediatric and adult patients who have complaints of intermittent palpitations, syncope and chest pain, the diagnostic value of 24-h-Holter has been shown to be low. Difficulties are experienced in making a diagnosis due to reasons such as the difficulty children experience in describing their complaints, frequent shortness of palpitation attacks and the termination of these attacks before ECG is taken and 24-h-Holter records not coinciding with the moment of palpitation [ 8 , 9 ]. Event recorder has begun to be used increasingly in the diagnosis of cardiac arrhythmias. In adult patients who have arrhythmia-related complaints such as palpitation, chest pain and syncope so infrequent that they cannot be recorded with ECG or 24-h-Holter, event recorder use has been reported to be very useful. Due to its longer recording than 24-h-Holter, the rate of diagnosis is higher with event recorder. Normal sinus rhythm in recordings during the patient’s symptoms is also important in terms of showing that the symptoms are not related with arrhythmia [ 10 – 14 ]. However, the use of patient-activated event recorder which is widely used can cause difficulties especially for children due to problems of compliance. With the development of recent event recorders which can also detect arrhythmia automatically, this problem has been overcome [ 15 , 16 ]. However, literature data about event recorder use in children are very limited. In addition, to our knowledge there is no study about the use of event recorder which can make both automatic and patient-triggered recording in children. In our study, we would like to present a first experience with event-recording system capable of automatic and manual recording in children with possible arrhythmia related symptoms. Patients and Methods A total of 81 children with complaints of sporadic palpitation, chest pain, and pre-syncope referred to Pediatric Cardiology Department, Medical School of Inonu University between September 2021 and September 2024 were included in this study. Before event recorder was fitted, all children routinely underwent a detailed history collection, physical examination, laboratory assessment, 12-lead ECG, 24-h-Holter monitoring and echocardiography. Exclusion criteria were age ˃18 years and the presence of a pacemaker or implantable defibrillator. Prior to the study, approval was obtained from the Inonu University Faculty of Medicine Ethics Committee, dated 2025 and numbered 8502, in accordance with the Helsinki Declaration. The parents of the participants were informed about the study and their written informed consent was obtained. Device A commercially available Novacor (R-Test™Evolution 4, Novacor, France) device was used for monitoring in all children. It has both automatic and patient-triggered record options and the clinician can choose either one of these or both. This device has a maximum duration of monitoring for automatic mode up to 32 days and for manual mode up to 60 days. Total duration of recording for ECG events is 60 minutes. Both manual and automatic monitoring recordings can be scheduled for pre-and post- triggering delay. The device is able to distinguish up to 8 subcategories of rapid events and additionally able to recognize pauses, bradycardia, sinus tachycardia, ST-T-segment analysis and atrial fibrillation analysis in automatic mode. We used both automatic and patient-triggered record options in our patients. Thus, the problems that can occur in case of patients’ not being able to press the record button due to problems of compliance at the moment of symptoms were avoided. Based on the recording protocol set previously, record number, date and period were recorded to the memory of the device for a specific period of time (e.g.,30 second before and 1 minute after the event). The fact that the records could directly be transferred into the computer allowed digital quality electrocardiogram records. Since the device consist of a unit weighing about 40 grams and it can be worn to the patient by a system of electrodes and a neck cable (Fig. 1 ), patient compliance and comfort were better. Statistical Analysis Statistical Package for Social Sciences (SPSS) for Windows 15.0 (SPSS, Inc., Chicago, IL, USA) program was used to assess the data statistically. All values were expressed as percentages of the total or the mean±standard deviation. Data availability The data associated with the paper are not publicly available but are available from the corresponding author on reasonable request. Data are located in controlled data storage at İnonu University. Results Patient population consisted of 81 patients. Average age was 11.30 ± 3.87. Indications for fitting event recorder were palpitation in 59 patients (72.8%), chest pain and palpitation in 19 patients (23.5%) and palpitation and pre-syncope in 3 patients (3.7%) (Table 1 ). In 24-h-Holter monitoring before cardiac event recorder, ventricular extrasystole was found in 2 patient, supraventricular extrasystole was found in 5 patients and benign sinus tachycardia was found in 6 patients (Table 2 ). All patients had normal ECG. Table 1 The clinical characteristics and indications for monitoring in patients Variable Value, n (%) Number of patients Age (years) Male/Female 81 11.30 ± 3.87 37/44 Indications for monitoring Palpitations Palpitation and chest pain Palpitation and pre-syncope 59 (72.8) 19 (23.5) 3 (3.7) Echocardiographic findings MVR (Mild) MVP BAV ASD (Transcatheter or surgically closed) CAA 2 (2.78) 6 (8.33) 3 (4.17) 4 (5.56) 1 (1.39) Monitoring time (days) 14.40 ± 7.79 Data are presented as mean value±standard deviation. MVR: Mitral valve regurgitation; MVP: Mitral valve prolapses; BAV: Bicuspid aortic valve; ASD: Atrial septal defect; CAA: Cervical aortic arch After a mean monitoring period of 14.40 ± 7.79 days, 65 patients described symptoms (57 patients had palpitations, 6 patients had palpitations and chest pain, and 2 patients had palpitations and pre-syncope). Of these 65 patients, 41 (63%) were detected automatically or manually recorded arrhythmias. Various arrhythmias were detected in 9 of the 16 patients who said they did not feel any symptoms. A total of 107 arrhythmia episodes were registered; 53 episodes of sinus tachycardia, 25 episodes of supraventricular tachycardia (Fig. 2 ), 6 episodes of ventricular tachycardia, 10 episodes of ventricular extrasystole, and 13 episodes of supraventricular extrasystole. Forty-six (43%) episodes were patient triggered, and 61 (57%) were automatically recorded (Table 2 ). 63% of these arrhythmias were correlated with the symptoms. A total of 47 episodes patient-triggered normal sinus rhythm were detected in 24 Table 2 Registered arrhythmias episodes in patients Event recorder 24h-Holter Automatically recorded Manually recorded Total Arrhythmias Patient Episodes Patient Episodes Patient Episodes Patient Symptomatic/asymptomatic 34 61 16 46 41/9 107 12 ST 15 30 8 23 23 53 6 SVT 7 15 4 10 11 25 VT 1 3 1 3 2 6 VES 5 6 2 4 7 10 2 SVES 6 8 1 5 7 13 5 Data are presented as numbers of patients. n: Number of patients; ST: Sinus tachycardia; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; VES: Ventricular extrasystole; SVES: Supraventricular extrasystole patients who were symptomatic. Of the 16 patients who were asymptomatic during the enrollment period, 9 (56%) had arrhythmia recorded with automatic arrhythmia detection property only 5 patients had supraventricular extrasystole, 3 patients had ventricular extrasystole and 1 patient had SVT. Only 12 episodes (8%) could not be evaluated because of artifact. As a result, of the 50 patients recorded with the event recorder, 23 (46%) had sinus tachycardia, 11 (22%) had supraventricular tachycardia, 7 (14%) had ventricular extrasystoles, 7 (14%) had supraventricular extrasystoles, and 2 (4%) had ventricular tachycardia. (Table 2 , Fig. 3 ). Two of the patients with supraventricular tachycardia had pre-syncope complaint. Two patients with ventricular extrasystole in the 24-h-Holter were found to have also ventricular extrasystole and no ventricular tachycardia with event recorder. However, two of the patients who were found to have supraventricular extrasystole with 24-h-Holter, were found to have supraventricular tachycardia with event recorder. While the 24-h-Holter records of two patients were found to be normal, event recorder showed VT attacks. Patient outcomes Clinical characteristics of patients are shown in Table 1 . Ablation was applied in 9 patients diagnosed with supraventricular tachycardia and in 2 patients diagnosed with ventricular tachycardia. Beta-blocker was started in one patient who had supraventricular extrasystole and in one patient who had ventricular extrasystole since they had high arrhythmia frequency and they were symptomatic. 2 patients with ventricular extrasystole and 3 patients with supraventricular extrasystole were monitored without any treatment. No organic pathology was found in patients with sinus tachycardia and they were not started any treatment. During the follow-up period of patients who had normal event recorder findings, supraventricular tachycardia was found in one patient and the patient was planned ablation treatment. Discussion Palpitation, chest pain and syncope are the most common symptoms which require pediatric cardiology consultation. While ECG record taken during symptom is the gold standard in identifying underlying arrhythmia, most of the time this is not possible in patients who have intermittent symptoms [ 1 , 2 ]. Since patients are frequently asymptomatic during 24-h-Holter recordings which can record for 24–48 hours, diagnostic value of this test is also low [ 9 ]. Ayabakan et al. examined a total of 2017 24-h-Holter records of 1500 children in their large-scale study. In this study, while arrhythmic findings were reported in 24-h-Holter records of only 5.3% of these patients, asymptomatic patients were found to have more arrhythmic findings. Thus, it was concluded that 24-h-Holter monitoring had low diagnostic value in terms of symptom-rhythm correlation [ 17 ]. In their study, Hegazy et al. found that the diagnostic value of 24-h-Holter monitoring was 57% in palpitation complaint and only 0.04% in patients with syncope. In the concerned study, abnormal findings were not found in 24-h-Holter records of any patient who referred with a complaint of chest pain [ 8 ]. In the large-scale study they conducted, Sulfi et al. reported that 93.1% of the patients who had a complaint of palpitation and 95.3% of the patients who had changes in consciousness had normal 24-h-Holter records. The results of the study emphasized that 24-h-Holter monitoring had very low diagnostic value especially in young patients and alternative diagnostic tools need to be used in these patients [ 9 ]. In our study, arrhythmias were found only in 12 (16.7%) children (ventricular extrasystole was found in 2, supraventricular extrasystole was found in 4 and benign sinus tachycardia was found in 6) with 24-h-Holter monitoring. The most obvious advantages of event recorders are being smaller devices, enabling longer periods of recording and providing almost simultaneous information analysis. In addition, their diagnostic yield is reported to be higher [ 7 ]. In a study involving 43 adult patients who had palpitation complaint, cardiac event recorder was shown to have higher diagnostic value and to be more economic when compared with 24-h-Holter[ 13 ]. In another study conducted with 184 adult patients who had complaints of palpitation, pre-syncope and syncope, cardiac event recorder was reported to be quite useful and cost efficient in the assessment of patients who did not have underlying cardiac disease[ 12 ]. Similarly, in a large-scale study conducted by Asmundis et al., while the rate of diagnosis with 24-h-Holter was only 8% in patients who had arrhythmic symptoms, this rate was found as 89% with event recorder [ 18 ]. However, the number of studies researching the diagnostic yield with cardiac event recorder use in pediatric population is in fact quite limited. In a study they conducted on a wide range of patient group, Saygı et al. reported that the diagnosis rate was higher in children who were fitted event recorder when compared with 24-h-Holter and found symptom–rhythm correlation as 39%. As a result of the study, it was concluded that event recorders could be primary diagnostic tool in children who had symptoms related with arrhythmia. In their study they conducted on children between the ages of 4 and 16 by using leadless Omron® event recording system which required patient activation, Park et al. reported symptom–rhythm correlation in all patients. In this study, supraventricular tachycardia was found in 4 patients, while benign sinus tachycardia was found in the remaining patients. It was concluded that symptom–rhythm correlation was very high with this system since all the patients had palpitation complaint and in addition one of the patients had pre-syncope history. Although event recorder is a more advantageous diagnostic tool when compared with ECG and 24 h Holter, the main limitation of most of routinely used event recorders is the fact that used the manually activated mode only. Device activation may be a major problem especially for small children and patients those who had mental and physical problems. These factors can limit the diagnostic value of the device[ 5 , 19 , 20 ]. Saygi et al. reported that although one fourth of the patients were trained, they had difficulties in activating the device during symptom and concluded that this factor may decreased the diagnostic value of the test [ 4 ]. Park et al. also reported that patients who were too young to activate the device and those who had mental and physical problems were excluded from their study [ 5 ]. These problems can be overcome with the use of cardiac event recorders capable of both automatic and manual recording. However, there is very limited data available in the literature about the clinical relevance of combined automatically and patient-triggered event recorders in adult patients. In addition to, there is no study in literature conducted on children by using this system. Roche F. et al. showed in adult patients that the patient-triggered and automatic event recorder had a clinical advantage, especially when investigating patients with unexplained rare events such as palpitations, pre-syncope, syncope, or in patients inconsistent [ 15 ]. Similar to this study, Balmelli et al. used an event recorder capable of both automatic and manual activation in 101 adults’ patients and reported that the usage of patient triggered mode alone had less reliability while automatic arrhythmia detection had an additional contribution to diagnosis and treatment. Since the system that we used had automatic activation, no problems were found related with patient non-compliance. During the symptoms, in cases when ECG records could not be taken with event recorder, implantable loop recorders can be tried as an alternative method [ 21 ]. In patients with palpitation and syncope, the diagnostic value of loop recorders has been reported to be between 50 and 90% [ 19 , 21 – 25 ]. In another study conducted on children, arrhythmic symptoms were found in 6 out of 12 children who had recurrent syncope attacks that could not be explained with other non-invasive diagnostic methods [ 21 ]. However, when compared with other non-invasive diagnostic tests, despite its higher diagnostic value, loop recorder indications should be kept limited. Significant disadvantages of loop recorders are requiring invasive procedure in stages of both implantation and explantation, risk of potential wound site infection, higher cost when compared with other non-invasive diagnostic tests and causing a scar on the implantation area. For this reason, loop recorder should be used only in finding out the reason for primary cardiac electrical diseases and the syncope reason that cannot be explained with other diagnostic tests, in patients who have only structural cardiac disease, and in case of high risk and life-threatening arrhythmia [ 21 , 22 , 24 ]. In our study, arrhythmias were detected in some form in 50 (61.7%) of 81 patients with normal ECG and 24-hour Holter recordings. Severe arrhythmias, including SVT in 11 and VT in two of these patients, were detected. In 34 of these 50 patients, the event recorder automatically detected these arrhythmic events, even though the patients were unaware of them. Only in 16 of these patients did the device manually trigger when they experienced symptoms. Patient-symptom correlation was found to be high, approximately 63%. Therefore, we believe that automatic event recorders should be considered as an alternative diagnostic tool, especially in symptomatic patients who are not detected by 24-hour Holter monitoring. In our study, if the patients who were found to have supraventricular tachycardia and ventricular tachycardia also had clinical indication, catheter ablation treatment was applied. If normal sinus rhythm was found in the event recorder recordings in the period when the patients were symptomatic, no advanced examination was made. Normal sinus rhythm in symptomatic periods is important in terms of both preventing the time and expenses required for advanced examination and resolving the anxieties of the patient and the family. Sinus tachycardia was found in 23 patients. Although sinus tachycardia is typically benign, it may be associated with underlying conditions such as anemia, hypovolemia, shock, hypoxia, hyperthyroidism, myocardial ischemia, hypocalcemia, pulmonary oedema, medication, and illicit drug use. No etiological reason was found in our patients who were found to have sinus tachycardia. In conclusion, to our knowledge, there is no study in literature conducted on children by using Novacor (R-Test™Evolution, Novacor, France) system which can record both automatically and manually. It was found in our study that, the automatic arrhythmia detection mode of the device provided additional clinical and therapeutic consequences. For this reason, the event recorder capable of automatic and manual recording may be a more preferable method than only manually-triggered system in children with potentially arrhythmia related symptoms. However, we believe that comparative studies with larger pediatric population may provide illuminating data in this area. Limitations of the study Our study is a non-randomized and non-blind study. In addition, other limitation of our study is the relatively small sample size of patients examined in a tertiary center. However, we think that the number of our patients is significant when compared to recent literature. Declarations Compliance with Ethical Standards Conflict of interest statement: All authors declared no conflicts of interest including any financial, personal respect to the research, authorship, and/or publication of this article or other relationships. Authors’ contribution All authors meet the authorship and contribution criteria established by the ICMJE. “All authors read and approved the final version of the manuscript”. Conflicts of interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript Funding The authors did not receive any funding for conducting this study Informed consent The parents of the participants were informed about the study and their written informed consent was obtained. The study was approved by the Ethics Committee of İnönü University Faculty of Medicine in accordance with the Helsinki Declaration, with approval number 8502 dated 04.11.2025. References Usadel L, Haverkamper G, Herrmann S, Lober R, Weiss K, Opgen-Rhein B, Berger F, WillJC. Arrhythmia Detection in Pediatric Patients: ECG Quality and Diagnostic Yield of a Patient-Triggered Einthoven Lead-I Event Recorder (Zenicor EKG-2). Pediatr Cardiol. 2016;37:491–6. 10.1007/s00246-015-1304-4 . Hoefman E, Bindels P, van Weert H. Efficacy of diagnostic tools for detecting cardiac arrhythmias: systematic literature search. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9199287","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621493576,"identity":"17fcabf0-0f90-492a-870b-2a263eedd57e","order_by":0,"name":"Özlem Elkıran","email":"","orcid":"","institution":"Inonu University","correspondingAuthor":false,"prefix":"","firstName":"Özlem","middleName":"","lastName":"Elkıran","suffix":""},{"id":621493577,"identity":"2666bccd-ef89-41c4-aa1f-5bcca7435f8a","order_by":1,"name":"Mehmet Öncül","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYDCCA2DSgsH+eDOIKSFDrBYJBoYzxxJADB4StNzIMQCxCGvhu3342IOfbRLRjD1nPr+6UWPBw8B++OgGfFokz6WlG/a2SeQ2s/dus845BnQYT1raDXxaDM7wmEkzArW08ZzdZpzDBtQiwWNGnJYeiZxnxjn/SNEyQyKH+XFuGxFaJM+wpUn2nJPI3cBzzIw5t0+Ch42QX/jOMB+T+FFmk7uBvfnx55xvdXL87IeP4dWCDNgkwCSxykGA+QMpqkfBKBgFo2DkAACahUZSKEkqAwAAAABJRU5ErkJggg==","orcid":"","institution":"Inonu University","correspondingAuthor":true,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Öncül","suffix":""}],"badges":[],"createdAt":"2026-03-23 10:39:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9199287/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9199287/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107247034,"identity":"f3e5885b-2fef-448b-b4a5-515f1480faad","added_by":"auto","created_at":"2026-04-19 08:11:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":279441,"visible":true,"origin":"","legend":"\u003cp\u003eA view of event recording system (R-Test™Evolution 4, Novacor, France)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9199287/v1/232ce5435f36d027f2e45cd2.png"},{"id":107484422,"identity":"a4ef89ff-161b-45a6-ac98-bd56eee2c2a6","added_by":"auto","created_at":"2026-04-22 02:31:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":178151,"visible":true,"origin":"","legend":"\u003cp\u003eAn example of supraventricular tachycardia recording with the event recorder system\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9199287/v1/5511c74e2341c0608a6158c2.png"},{"id":107247036,"identity":"2f13d48e-38bd-4b26-b22d-df34b3d33041","added_by":"auto","created_at":"2026-04-19 08:11:33","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":279711,"visible":true,"origin":"","legend":"\u003cp\u003eArrhythmias identified with cardiac event recorder\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9199287/v1/198a8ba6eb1d4abaca56d0e6.jpeg"},{"id":107486836,"identity":"d6540e70-3b06-4e10-b4b5-fd2b63360d8c","added_by":"auto","created_at":"2026-04-22 02:39:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1153721,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9199287/v1/c6a65bca-0672-43e1-95e5-feaa4e3628e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utility of An Automatic and Patient-Triggered Cardiac Event Recorder: Experience in Children","fulltext":[{"header":"The Key Messages","content":"\u003cp\u003eAutomatic event recorders can help detect palpitations in pediatric patients presenting with palpitations.\u003c/p\u003e \u003cp\u003eThe device's automatic arrhythmia detection mode has provided additional clinical and therapeutic results, especially in young children with intermittent palpitations who cannot use triggered event recorders.\u003c/p\u003e \u003cp\u003eAutomatic event recorders appear to be more advantageous than 24-hour Holter monitoring.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eRhythm problems and palpitations are frequent complaints in patients who refer to pediatric cardiology clinics. Due to reasons such as tachycardia attacks being short termed and rare most of the time and the fact that sometimes infants and children cannot realize palpitation themselves, it is quite difficult to assess these complaints in childhood [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 12-lead electrocardiogram (ECG) has been used as the gold standard for arrhythmia diagnosis for more than 100 years. Recording ECG during the period in which the patient referring with palpitation is symptomatic is very important for the diagnosis. However, the most important limitation of ECG is the fact that ECG records are limited to the short time in which ECG is taken. Again, since cardiac arrhythmias are generally intermittent and sometimes asymptomatic, resting ECG can be insufficient in diagnosis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNon-invasive ambulatory ECG device, which is also called Holter monitoring was begun to be used in the early 1940s and it is also widely used today [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Holter devices generally record 24\u0026ndash;48 hours of ECG. For this reason, they have a higher diagnostic value than ECG in patients who have intermittent symptoms during the day. However, 24-h-Holter is insufficient in diagnosis in patients who have infrequent symptoms. In pediatric and adult patients who have complaints of intermittent palpitations, syncope and chest pain, the diagnostic value of 24-h-Holter has been shown to be low. Difficulties are experienced in making a diagnosis due to reasons such as the difficulty children experience in describing their complaints, frequent shortness of palpitation attacks and the termination of these attacks before ECG is taken and 24-h-Holter records not coinciding with the moment of palpitation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvent recorder has begun to be used increasingly in the diagnosis of cardiac arrhythmias. In adult patients who have arrhythmia-related complaints such as palpitation, chest pain and syncope so infrequent that they cannot be recorded with ECG or 24-h-Holter, event recorder use has been reported to be very useful. Due to its longer recording than 24-h-Holter, the rate of diagnosis is higher with event recorder. Normal sinus rhythm in recordings during the patient\u0026rsquo;s symptoms is also important in terms of showing that the symptoms are not related with arrhythmia [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the use of patient-activated event recorder which is widely used can cause difficulties especially for children due to problems of compliance. With the development of recent event recorders which can also detect arrhythmia automatically, this problem has been overcome [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, literature data about event recorder use in children are very limited. In addition, to our knowledge there is no study about the use of event recorder which can make both automatic and patient-triggered recording in children.\u003c/p\u003e \u003cp\u003eIn our study, we would like to present a first experience with event-recording system capable of automatic and manual recording in children with possible arrhythmia related symptoms.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eA total of 81 children with complaints of sporadic palpitation, chest pain, and pre-syncope referred to Pediatric Cardiology Department, Medical School of Inonu University between September 2021 and September 2024 were included in this study. Before event recorder was fitted, all children routinely underwent a detailed history collection, physical examination, laboratory assessment, 12-lead ECG, 24-h-Holter monitoring and echocardiography. Exclusion criteria were age ˃18 years and the presence of a pacemaker or implantable defibrillator. Prior to the study, approval was obtained from the Inonu University Faculty of Medicine Ethics Committee, dated 2025 and numbered 8502, in accordance with the Helsinki Declaration. The parents of the participants were informed about the study and their written informed consent was obtained.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDevice\u003c/h2\u003e \u003cp\u003eA commercially available Novacor (R-Test\u0026trade;Evolution 4, Novacor, France) device was used for monitoring in all children. It has both automatic and patient-triggered record options and the clinician can choose either one of these or both. This device has a maximum duration of monitoring for automatic mode up to 32 days and for manual mode up to 60 days. Total duration of recording for ECG events is 60 minutes. Both manual and automatic monitoring recordings can be scheduled for pre-and post- triggering delay. The device is able to distinguish up to 8 subcategories of rapid events and additionally able to recognize pauses, bradycardia, sinus tachycardia, ST-T-segment analysis and atrial fibrillation analysis in automatic mode. We used both automatic and patient-triggered record options in our patients. Thus, the problems that can occur in case of patients\u0026rsquo; not being able to press the record button due to problems of compliance at the moment of symptoms were avoided. Based on the recording protocol set previously, record number, date and period were recorded to the memory of the device for a specific period of time (e.g.,30 second before and 1 minute after the event). The fact that the records could directly be transferred into the computer allowed digital quality electrocardiogram records. Since the device consist of a unit weighing about 40 grams and it can be worn to the patient by a system of electrodes and a neck cable (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), patient compliance and comfort were better.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical Package for Social Sciences (SPSS) for Windows 15.0 (SPSS, Inc., Chicago, IL, USA) program was used to assess the data statistically. All values were expressed as percentages of the total or the mean\u0026plusmn;standard deviation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData availability\u003c/h3\u003e\n\u003cp\u003eThe data associated with the paper are not publicly available but are available from the corresponding author on reasonable request. Data are located in controlled data storage at İnonu University.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient population consisted of 81 patients. Average age was 11.30\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87. Indications for fitting event recorder were palpitation in 59 patients (72.8%), chest pain and palpitation in 19 patients (23.5%) and palpitation and pre-syncope in 3 patients (3.7%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 24-h-Holter monitoring before cardiac event recorder, ventricular extrasystole was found in 2 patient, supraventricular extrasystole was found in 5 patients and benign sinus tachycardia was found in 6 patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All patients had normal ECG.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe clinical characteristics and indications for monitoring in patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003cp\u003eMale/Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003cp\u003e11.30\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e \u003cp\u003e37/44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndications for monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalpitations\u003c/p\u003e \u003cp\u003ePalpitation and chest pain\u003c/p\u003e \u003cp\u003ePalpitation and pre-syncope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (72.8)\u003c/p\u003e \u003cp\u003e19 (23.5)\u003c/p\u003e \u003cp\u003e3 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiographic findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVR (Mild)\u003c/p\u003e \u003cp\u003eMVP\u003c/p\u003e \u003cp\u003eBAV\u003c/p\u003e \u003cp\u003eASD (Transcatheter or surgically closed)\u003c/p\u003e \u003cp\u003eCAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.78)\u003c/p\u003e \u003cp\u003e6 (8.33)\u003c/p\u003e \u003cp\u003e3 (4.17)\u003c/p\u003e \u003cp\u003e4 (5.56)\u003c/p\u003e \u003cp\u003e1 (1.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMonitoring time (days)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eData are presented as mean value\u0026plusmn;standard deviation. MVR: Mitral valve regurgitation; MVP: Mitral valve prolapses; BAV: Bicuspid aortic valve; ASD: Atrial septal defect; CAA: Cervical aortic arch\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAfter a mean monitoring period of 14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79 days, 65 patients described symptoms (57 patients had palpitations, 6 patients had palpitations and chest pain, and 2 patients had palpitations and pre-syncope). Of these 65 patients, 41 (63%) were detected automatically or manually recorded arrhythmias. Various arrhythmias were detected in 9 of the 16 patients who said they did not feel any symptoms. A total of 107 arrhythmia episodes were registered; 53 episodes of sinus tachycardia, 25 episodes of supraventricular tachycardia (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), 6 episodes of ventricular tachycardia, 10 episodes of ventricular extrasystole, and 13 episodes of supraventricular extrasystole. Forty-six (43%) episodes were patient triggered, and 61 (57%) were automatically recorded (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 63% of these arrhythmias were correlated with the symptoms. A total of 47 episodes patient-triggered normal sinus rhythm were detected in 24\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegistered arrhythmias episodes in patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eEvent recorder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24h-Holter\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAutomatically recorded\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eManually recorded\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEpisodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEpisodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEpisodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptomatic/asymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eData are presented as numbers of patients. n: Number of patients; ST: Sinus tachycardia; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; VES: Ventricular extrasystole; SVES: Supraventricular extrasystole\u003c/em\u003e \u003c/p\u003e \u003cp\u003epatients who were symptomatic. Of the 16 patients who were asymptomatic during the enrollment period, 9 (56%) had arrhythmia recorded with automatic arrhythmia detection property only 5 patients had supraventricular extrasystole, 3 patients had ventricular extrasystole and 1 patient had SVT. Only 12 episodes (8%) could not be evaluated because of artifact.\u003c/p\u003e \u003cp\u003eAs a result, of the 50 patients recorded with the event recorder, 23 (46%) had sinus tachycardia, 11 (22%) had supraventricular tachycardia, 7 (14%) had ventricular extrasystoles, 7 (14%) had supraventricular extrasystoles, and 2 (4%) had ventricular tachycardia. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Two of the patients with supraventricular tachycardia had pre-syncope complaint. Two patients with ventricular extrasystole in the 24-h-Holter were found to have also ventricular extrasystole and no ventricular tachycardia with event recorder. However, two of the patients who were found to have supraventricular extrasystole with 24-h-Holter, were found to have supraventricular tachycardia with event recorder. While the 24-h-Holter records of two patients were found to be normal, event recorder showed VT attacks.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePatient outcomes\u003c/h3\u003e\n\u003cp\u003eClinical characteristics of patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Ablation was applied in 9 patients diagnosed with supraventricular tachycardia and in 2 patients diagnosed with ventricular tachycardia. Beta-blocker was started in one patient who had supraventricular extrasystole and in one patient who had ventricular extrasystole since they had high arrhythmia frequency and they were symptomatic. 2 patients with ventricular extrasystole and 3 patients with supraventricular extrasystole were monitored without any treatment. No organic pathology was found in patients with sinus tachycardia and they were not started any treatment. During the follow-up period of patients who had normal event recorder findings, supraventricular tachycardia was found in one patient and the patient was planned ablation treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePalpitation, chest pain and syncope are the most common symptoms which require pediatric cardiology consultation. While ECG record taken during symptom is the gold standard in identifying underlying arrhythmia, most of the time this is not possible in patients who have intermittent symptoms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Since patients are frequently asymptomatic during 24-h-Holter recordings which can record for 24\u0026ndash;48 hours, diagnostic value of this test is also low [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Ayabakan et al. examined a total of 2017 24-h-Holter records of 1500 children in their large-scale study. In this study, while arrhythmic findings were reported in 24-h-Holter records of only 5.3% of these patients, asymptomatic patients were found to have more arrhythmic findings. Thus, it was concluded that 24-h-Holter monitoring had low diagnostic value in terms of symptom-rhythm correlation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In their study, Hegazy et al. found that the diagnostic value of 24-h-Holter monitoring was 57% in palpitation complaint and only 0.04% in patients with syncope. In the concerned study, abnormal findings were not found in 24-h-Holter records of any patient who referred with a complaint of chest pain [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the large-scale study they conducted, Sulfi et al. reported that 93.1% of the patients who had a complaint of palpitation and 95.3% of the patients who had changes in consciousness had normal 24-h-Holter records. The results of the study emphasized that 24-h-Holter monitoring had very low diagnostic value especially in young patients and alternative diagnostic tools need to be used in these patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, arrhythmias were found only in 12 (16.7%) children (ventricular extrasystole was found in 2, supraventricular extrasystole was found in 4 and benign sinus tachycardia was found in 6) with 24-h-Holter monitoring.\u003c/p\u003e \u003cp\u003eThe most obvious advantages of event recorders are being smaller devices, enabling longer periods of recording and providing almost simultaneous information analysis. In addition, their diagnostic yield is reported to be higher [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In a study involving 43 adult patients who had palpitation complaint, cardiac event recorder was shown to have higher diagnostic value and to be more economic when compared with 24-h-Holter[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In another study conducted with 184 adult patients who had complaints of palpitation, pre-syncope and syncope, cardiac event recorder was reported to be quite useful and cost efficient in the assessment of patients who did not have underlying cardiac disease[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, in a large-scale study conducted by Asmundis et al., while the rate of diagnosis with 24-h-Holter was only 8% in patients who had arrhythmic symptoms, this rate was found as 89% with event recorder [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the number of studies researching the diagnostic yield with cardiac event recorder use in pediatric population is in fact quite limited. In a study they conducted on a wide range of patient group, Saygı et al. reported that the diagnosis rate was higher in children who were fitted event recorder when compared with 24-h-Holter and found symptom\u0026ndash;rhythm correlation as 39%. As a result of the study, it was concluded that event recorders could be primary diagnostic tool in children who had symptoms related with arrhythmia. In their study they conducted on children between the ages of 4 and 16 by using leadless Omron\u0026reg; event recording system which required patient activation, Park et al. reported symptom\u0026ndash;rhythm correlation in all patients. In this study, supraventricular tachycardia was found in 4 patients, while benign sinus tachycardia was found in the remaining patients. It was concluded that symptom\u0026ndash;rhythm correlation was very high with this system since all the patients had palpitation complaint and in addition one of the patients had pre-syncope history.\u003c/p\u003e \u003cp\u003eAlthough event recorder is a more advantageous diagnostic tool when compared with ECG and 24 h Holter, the main limitation of most of routinely used event recorders is the fact that used the manually activated mode only. Device activation may be a major problem especially for small children and patients those who had mental and physical problems. These factors can limit the diagnostic value of the device[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Saygi et al. reported that although one fourth of the patients were trained, they had difficulties in activating the device during symptom and concluded that this factor may decreased the diagnostic value of the test [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Park et al. also reported that patients who were too young to activate the device and those who had mental and physical problems were excluded from their study [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These problems can be overcome with the use of cardiac event recorders capable of both automatic and manual recording. However, there is very limited data available in the literature about the clinical relevance of combined automatically and patient-triggered event recorders in adult patients. In addition to, there is no study in literature conducted on children by using this system. Roche F. et al. showed in adult patients that the patient-triggered and automatic event recorder had a clinical advantage, especially when investigating patients with unexplained rare events such as palpitations, pre-syncope, syncope, or in patients inconsistent [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similar to this study, Balmelli et al. used an event recorder capable of both automatic and manual activation in 101 adults\u0026rsquo; patients and reported that the usage of patient triggered mode alone had less reliability while automatic arrhythmia detection had an additional contribution to diagnosis and treatment. Since the system that we used had automatic activation, no problems were found related with patient non-compliance.\u003c/p\u003e \u003cp\u003eDuring the symptoms, in cases when ECG records could not be taken with event recorder, implantable loop recorders can be tried as an alternative method [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In patients with palpitation and syncope, the diagnostic value of loop recorders has been reported to be between 50 and 90% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In another study conducted on children, arrhythmic symptoms were found in 6 out of 12 children who had recurrent syncope attacks that could not be explained with other non-invasive diagnostic methods [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, when compared with other non-invasive diagnostic tests, despite its higher diagnostic value, loop recorder indications should be kept limited. Significant disadvantages of loop recorders are requiring invasive procedure in stages of both implantation and explantation, risk of potential wound site infection, higher cost when compared with other non-invasive diagnostic tests and causing a scar on the implantation area. For this reason, loop recorder should be used only in finding out the reason for primary cardiac electrical diseases and the syncope reason that cannot be explained with other diagnostic tests, in patients who have only structural cardiac disease, and in case of high risk and life-threatening arrhythmia [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, arrhythmias were detected in some form in 50 (61.7%) of 81 patients with normal ECG and 24-hour Holter recordings. Severe arrhythmias, including SVT in 11 and VT in two of these patients, were detected. In 34 of these 50 patients, the event recorder automatically detected these arrhythmic events, even though the patients were unaware of them. Only in 16 of these patients did the device manually trigger when they experienced symptoms. Patient-symptom correlation was found to be high, approximately 63%. Therefore, we believe that automatic event recorders should be considered as an alternative diagnostic tool, especially in symptomatic patients who are not detected by 24-hour Holter monitoring.\u003c/p\u003e \u003cp\u003eIn our study, if the patients who were found to have supraventricular tachycardia and ventricular tachycardia also had clinical indication, catheter ablation treatment was applied. If normal sinus rhythm was found in the event recorder recordings in the period when the patients were symptomatic, no advanced examination was made. Normal sinus rhythm in symptomatic periods is important in terms of both preventing the time and expenses required for advanced examination and resolving the anxieties of the patient and the family. Sinus tachycardia was found in 23 patients. Although sinus tachycardia is typically benign, it may be associated with underlying conditions such as anemia, hypovolemia, shock, hypoxia, hyperthyroidism, myocardial ischemia, hypocalcemia, pulmonary oedema, medication, and illicit drug use. No etiological reason was found in our patients who were found to have sinus tachycardia.\u003c/p\u003e \u003cp\u003eIn conclusion, to our knowledge, there is no study in literature conducted on children by using Novacor (R-Test\u0026trade;Evolution, Novacor, France) system which can record both automatically and manually. It was found in our study that, the automatic arrhythmia detection mode of the device provided additional clinical and therapeutic consequences. For this reason, the event recorder capable of automatic and manual recording may be a more preferable method than only manually-triggered system in children with potentially arrhythmia related symptoms. However, we believe that comparative studies with larger pediatric population may provide illuminating data in this area.\u003c/p\u003e\n\u003ch3\u003eLimitations of the study\u003c/h3\u003e\n\u003cp\u003eOur study is a non-randomized and non-blind study. In addition, other limitation of our study is the relatively small sample size of patients examined in a tertiary center. However, we think that the number of our patients is significant when compared to recent literature.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement:\u0026nbsp;\u003c/strong\u003eAll authors declared no conflicts of interest including any financial, personal respect to the research, authorship, and/or publication of this article or other relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors meet the authorship and contribution criteria established by the ICMJE.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;All authors read and approved the final version of the manuscript\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any funding for conducting this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe parents of the participants were informed about the study and their written informed consent was obtained. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of İn\u0026ouml;n\u0026uuml; University Faculty of Medicine in accordance with the Helsinki Declaration, with approval number 8502 dated 04.11.2025.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUsadel L, Haverkamper G, Herrmann S, Lober R, Weiss K, Opgen-Rhein B, Berger F, WillJC. 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Pediatr Int. 2015;57:359\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ped.12530\u003c/span\u003e\u003cspan address=\"10.1111/ped.12530\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRossano J, Bloemers B, Sreeram N, Balaji S, Shah MJ. Efficacy of implantable loop recorders in establishing symptom-rhythm correlation in young patients with syncope and palpitations. Pediatrics. 2003;112:e228\u0026ndash;233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.112.3.e228\u003c/span\u003e\u003cspan address=\"10.1542/peds.112.3.e228\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshby DT, Cehic DA, Disney PJS, Mahar LJ, Young GD. 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Pacing and Clinical Electrophysiology, 32: 1422\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1540-8159.2009.02486.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1540-8159.2009.02486.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Arrhythmia, Children, Cardiac event recorder, Holter","lastPublishedDoi":"10.21203/rs.3.rs-9199287/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9199287/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the diagnostic yield of an event recorder capable of automatic and manual recording in children with possible arrhythmia related symptoms.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe evaluated retrospectively 81 children monitored with Novacor event recorder system between September 2021 and September 2024. All of the patients performed 12-lead electrocardiogram (ECG), 24-hour-Holter monitoring, and echocardiography before the cardiac event recording.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe indications included palpitation in 59 (72.8%) patients, chest pain and palpitations in 19 (23.5%) patients, palpitation and pre-syncope in 3 (3.7%) patients. After a mean monitoring period of 14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79 days, 65 children described symptoms and 41(%63) children had automatically or manually recorded arrhythmias. 63% of these arrhythmias were correlated with the symptoms. Of the 16 patients who were asymptomatic during the enrollment period, 9 (56%) had arrhythmia recorded with automatic arrhythmia detection property only. A total of 107 arrhythmia episodes were registered; forty-six (43%) episodes were patient triggered, and 61 (57%) were automatically recorded. While 24-hour-Holter monitoring detected a clinical diagnosis in 13 patients (16.7%), event recorder diagnosed the clinical arrhythmia in 41 children (63%). Based on the event recorder and findings, 10 patients received an electrophysiology study/ablation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found that the automatic mode of the device provided additional clinical and therapeutic consequences. For this reason, a cardiac event recorder capable of automatically and manually recording may be a more preferable method in children with potentially arrhythmia related symptoms. Studies with larger patient series may provide illuminating data in this area.\u003c/p\u003e","manuscriptTitle":"Utility of An Automatic and Patient-Triggered Cardiac Event Recorder: Experience in Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 08:11:29","doi":"10.21203/rs.3.rs-9199287/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-14T09:24:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T15:51:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T06:28:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289679816144105667186078697383504622707","date":"2026-04-23T18:53:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283402724011002109093990633808368134494","date":"2026-04-23T06:44:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T04:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139910056267675057010443980409840240046","date":"2026-04-09T02:33:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-09T02:31:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T17:52:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T02:26:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-27T02:26:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-03-23T10:35:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7523eaef-a1cd-44da-9e64-944c6196fdae","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-14T09:24:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T15:51:55+00:00","index":64,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T06:28:49+00:00","index":63,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T09:39:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 08:11:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9199287","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9199287","identity":"rs-9199287","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}