Pediatric Echocardiographic Nomograms: Twenty Years of Advances—Do We Now Have a Complete and Reliable Tool, or Are Gaps Still Present? An Up-to-Date Review

: Echocardiography is the primary imaging modality for diagnosing cardiac disease in children, with quantitation largely based on nomograms. Over the past decade, significant efforts have been made to address the numerical and methodological limitations of earlier nomograms. As a result, robust and reliable pediatric echocardiographic nomograms are now available for most two-dimensional anatomical measurements, three-dimensional volumes, and strain parameters. These more recent nomograms are based on adequate sample sizes, strict inclusion and exclusion criteria, and rigorous statistical methodologies. They have demonstrated good reproducibility with minimal differences across different authors, establishing them as reliable diagnostic tools. Despite these advances, some limitations persist. Certain ethnic groups remain underrepresented, and data for preterm and low-weight infants are still limited. Most existing nomograms are derived from European and North American populations, with sparse data from Asia and very limited data from Africa and South America. Nomograms for preterm and low-weight infants are few and cover only selected cardiac structures. Although diastolic parameter nomograms are available, the data remain heterogeneous due to challenges in normalizing functional parameters according to age and body size. The accessibility of current nomograms has greatly improved with the development of online calculators and mobile applications. Ideally, integration of nomograms into echocardiographic machines and reporting systems should be pursued. Future studies are needed to develop broader, more comprehensive, and multi-ethnic nomograms, with better representation of preterm and low-weight populations, and to validate new parameters derived from emerging three- and four-dimensional echocardiographic techniques.