Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review

Marco Chiera1,2 | Francesco Cerritelli1*| Alessandro Casini1| Nicola Barsotti1,2 | Dario Boschiero3 | Francesco Cavigioli4 | Carla G. Corti5 | Andrea Manzotti1,4,6

1Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
2Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
3BioTekna – Biomedical Technologies, Venice, Italy
4Neonatal Intensive Care Unit, “V. Buzzi” Children’s Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
5Pediatric Cardiology Unit-Pediatric Department, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
6Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy

Frontiers in Neuroscience, Volume 14, Article 561186, 25 Settembre 2020
DOI 10.3389/fnins.2020.561186

Consulta l’articolo completo LINK: https://doi.org/10.3389/fnins.2020.561186 


Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come.
When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility.
However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.


The neonatology field is growing in complexity (Biban, 2010). In essence, newborns can show many comorbidities associated with prematurity (WHO, 2016), labor complications (Tribe et al., 2018), and maternal and perinatal stress (Frasch et al., 2007; Babenko et al., 2015; Lobmaier et al., 2020), whereas the neonatal intensive care units (NICUs) are increasing the use of technology to better take care of fetuses, newborns, and infants (Biban, 2010; Chock et al., 2015).
However, many obstacles need to be overcome to efficiently assess and manage infants’ conditions: distress, pain, and sepsis need valid and reliable gauges to detect them before they happen (Cremillieux et al., 2018; Rashwan et al., 2019), but several procedures may be time-consuming (Jeng et al., 2000; Als et al., 2005; Cremillieux et al., 2018), invasive, and painful with short- and long-term negative consequences (Holsti et al., 2006; Pillai Riddell et al., 2015).
In the last 40 years, heart rate variability (HRV) has emerged as a reliable and non-invasive measure to monitor preterm and term newborns (Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology, 1996). HRV evaluates the heart rate (HR) fluctuation—the variability of the time intervals between successive heartbeats—, and during the years, more and more techniques have appeared to improve its analysis, from which several metrics can be extracted (Table 1; Bravi et al., 2011; Thiriez et al., 2015; Javorka et al., 2017; Oliveira et al., 2019b; Patural et al., 2019).
Several studies showed that HRV correlates with the newborn’s stress and stress-related behaviors (Gardner et al., 2018; Hashiguchi et al., 2020), and that it could predict the baby’s overall wellbeing and future neurological development. HRV could also accurately identify short- and long-term complications, such as the risk of sepsis (Javorka et al., 2017; Oliveira et al., 2019b; Kumar et al., 2020). HRV was also able to reveal the impact of prenatal stress on fetal brain development (Frasch et al., 2007; Lobmaier et al., 2020).
Despite these results, HRV is still underused in NICUs. Although in the 1960s, one of the first evidences published was about the alteration of HRV metrics preceding fetal distress (Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology, 1996); to date, some authors argued that there is a lack of understanding of the meaning of HRV metrics in infants: in fact, HRV has been studied especially in adults, and the autonomic nervous system (ANS) behaves differently in newborns, especially in preterm infants (Joshi et al., 2019b). Notwithstanding these contradictions, the only successful example of integration of HRV in NICUs is the Heart Rate Observation (HeRO) monitor developed by J. Randall Moorman’s team. The HeRO analyzes bedside electrocardiogram (ECG) in real-time and integrates various HRV metrics to calculate the “HRC index,” which can predict the risk of sepsis within 24 h in both preterms and very low birth weight infants (Andersen et al., 2019; Kumar et al., 2020).
However, based on the available literature and on the potential research to be developed, there is a need to further explore the use of HRV in neonatology. HRV may provide such useful insights since it correlates with the ANS development and functioning. The ANS regulates organic development and connects with the organism’s ability to cope with stressors, as well as with cognitive and emotional development (Thayer et al., 2012; Jennings et al., 2015; Schneider et al., 2018; Oliveira et al., 2019b).
To be an innovative tool useful for neonatologists, HRV measurement should rely on a technology that gives reliable metrics with a clear clinical meaning. Harnessing the positive experiences, such as the use of the HeRO monitor, it is paramount to create a system that continuously records HRV and expresses scores that could correlate with the baby’s clinical condition and help monitor its evolution (Zhao et al., 2016; Hayano and Yuda, 2019; Pernice et al., 2019b; Kumar et al., 2020).
For this purpose, modern machine learning (ML) and artificial intelligence (AI) algorithms could play a crucial role: through their computational power, they could define models capable of managing the complex physiological interactions between HRV, ANS, and the whole organism, thus boosting our ability to predict the infant’s prognosis. Indeed, we already have experiences about the clinical usefulness of ML in both neonatology (Semenova et al., 2018; Ostojic et al., 2020) and HRV analysis (Chiew et al., 2019; Lin et al., 2020).
ML/AI algorithms could also integrate clinical data of different hospital departments, i.e., obstetric, neonatal, and pediatric. Indeed, free clinical data and medical devices sharing among the departments involved in the perinatal care (from conception to the first years of life) would allow clinicians to better understand the prenatal and developmental factors underlying adverse neonatal outcomes (e.g., brain injury) and to better treat them.
Therefore, the present paper aims to address the HRV usefulness in neonatology to prospect it as an innovative tool in the years to come. This focused review is divided into three sections: (1) the first section describes briefly the HRV metrics and examines the relationship between ANS and HRV in fetuses and newborns; (2) the second section examines the technology available in the NICU, how to monitor HRV efficiently, and the usefulness of real-time HRV; and (3) the third and final section will summarize the main findings and outline future perspectives for the clinical use of real-time HRV in the neonatal field, with a brief subsection about its usefulness in low-income countries.


The present paper reviewed the use of HRV in the neonatal field and the utility of real-time HRV monitoring to assess the newborn’s clinical conditions, showing that several metrics and computed metrics change in conjunction with stress-/pain-related behaviors, inflammation, pathological conditions, such as cardiac failure, respiratory distress syndrome, hyperbilirubinemia, NEC, and sepsis, and neurological development.
The paper also reviewed the NICU technology to evaluate how to measure real-time HRV efficiently. Indeed, a system based on PPG could be the optimal solution due to being low-cost, easy-to- use, and non-invasive, although PPG-based computation seems less precise than ECG-based computation. Therefore, future studies will have to carefully assess if the outcomes reviewed in this paper might be influenced by this difference in precision between PPG and ECG.
In the next decade, introducing real-time HRV in NICUs would be a great step forward in the improvement of neonatal care, especially if supported by the advancements in bioinformatics, which could easily extrapolate accurate predicting models from all the data collected in the NICUs, although several concerns and limitations have to be overcome before fully implementing the system into a daily NICU routine care.

Keywords: autonomic nervous system, vagus, newborns, preterm infants, neonatology, NICU, photoplethysmography, HRV