Smartwatches in childhood: a mixed blessing?—a scoping review

Abstract

Background

Smartwatches are commonly used within the community, especially amongst its younger population. These devices have a wide range of capabilities, including measuring the heart rate, generating electrocardiographic traces, and issuing alerts when ‘abnormal’ activity is detected. This information has potential benefits but also potential risks if the health-related measurements lead to inappropriate clinical interventions. This study aimed to evaluate the current literature on the prevalence, perception and interpretation of smartwatches that document and record cardiac information as it impacts on children, adolescents and their parents.

Methods

We conducted a scoping review based on the principles of Arksey and O’Malley, which followed the scoping review checklist of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

Results

The selection criteria yielded 29 papers. They reported that smartwatch usage in children ranged from 15% to 40%, depending on the country of residence. The number of children presenting with smartwatch-based heart concerns had increased, with many false positives and few true arrhythmia diagnoses. Although there was good accuracy of heart rate measurements, there were poor automated algorithms for heart rhythm classification for the paediatric population. In addition, a few studies reported paediatric smartwatch user anxiety arising from the information generated by the devices.

Conclusions

The wearing of smartwatches has increased in children and adolescents. While they are able to record heart rates and provide corresponding electrocardiographic tracings virtually continuously and non-invasively, misinterpretation of the data arising from poor algorithms have led to increased healthcare presentations, as well as child and/or parental concern. There remains a need for ongoing education to understand the variability of the heart rate, especially in children. Furthermore, better algorithms for the interpretation of the information gleaned are required for this relatively well young population, so as to allay the anxiety that may be experienced. The issues related to medicolegal liability, privacy and cybersecurity remain to be resolved.

Highlight box.

Key findings

• Smartwatch usage has increased in children and adolescents.

• While collecting cardiac-related information is not their primary goal, it has nevertheless been used at times incorrectly to interpret the findings resulting in increased anxiety for the child/parents, resulting in medical reviews and investigations.

• Further clinical validation and education is required, as well as research on the ethical and medico-legal implications of ongoing health-related data collection by these freely available commercial devices.

What is known and what is new?

• Smartwatches can record cardiac data such as the heart rate and generate electrocardiographic traces. Alerts may be issued to notify ‘abnormal’ activity when detected. Some devices have received American Food and Drug Association approval for identifying arrhythmias in adults, which is often erroneously extended to children.

• The number of children presenting with smartwatch-based heart concerns has increased, with many false positives and few true arrhythmia diagnoses. Although heart rate measurements are usually accurate, the automated algorithms for arrhythmia detection in childhood are poor. Some pediatric smartwatch users also reported anxiety arising from the information provided by the device, with many presenting for clinical evaluation.

What is the implication, and what should change now?

• Further clinical validation of smartwatches and education regarding normal variation of heart rate aided by improved arrhythmic algorithms in childhood are required, as well as research into the ethical and medico-legal implications of the collection of health-related data by these readily available commercial devices.

Introduction

Background

Smartwatches have become increasingly prevalent especially amongst the younger population (1). These devices now come at an affordable price and have a wide range of functionalities, including global positioning system tracking to determine a child’s whereabouts, which aids its popularity amongst parents (2). Smartwatches are also able to record cardiac data such as the heart rate and generate electrocardiographic tracings (3). Alerts may be issued to notify ‘abnormal’ activity when detected (4). However, these alerts are often based on adult parameters which have led to increasing presentations to general practitioners and cardiologists because of the concern about the ‘abnormal’ heart rate or electrocardiographic trace (5). Additionally, such user-initiated screening may lead to increased healthcare burden, patient anxiety and unnecessary downstream testing (6). Benefits however have included the diagnoses of the occasional arrhythmia and the promotion of the individual’s health empowerment (7). These devices have been useful as a non-invasive provider of long-term and/or continuous cardiac data which may help clarify unresolved cardiac concerns, or generate long term physiological data (8).

Rationale and knowledge gap

Some devices, such as the Apple Watch 4 Series, have received approval by the American Food and Drug Association for identifying atrial fibrillation in adults, though of importance not in children (9). There is also limited research on the implications of smartwatches that record readily available cardiac parameters in children (10).

Objective

We conducted a scoping review to evaluate the current literature on the prevalence, perception and interpretation of smartwatches that record heart rate measurements and provide electrocardiographic traces as they impact clinically, psychologically and ethically on children, adolescents and their parents, highlighting their possible benefits but also the possible harms from their use. We present this article in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-301/rc).

Methods

We conducted a scoping review based on the principles of Arksey and O’Malley (11). This process involved the following steps: establishing a research question, conducting a systematic search for relevant studies, screening studies by abstract then full text based on the inclusion criteria, and synthesising the findings (12). Ethics approval was not required as only published data were reviewed.

Research question

How do smartwatches that record cardiac indices impact on children, adolescents and/or their parents?

Systematic search

We conducted a systematic search during the month of February 2025 using two databases: Medline/PubMed and Embase. All identified studies were transferred to EndNote for analysis. The search strategy for each database is shown in Figure S1.

Selection of studies

The following inclusion criteria were applied: studies that reported on the use of a smartwatch by a child or adolescent (18 years and under). They included reviews and retrospective studies where children were already users of smartwatches. In addition, prospective studies where children and adolescents were provided smartwatches were also included. As smartwatches are relatively new devices, all papers were reviewed irrespective of their publication date.

These exclusion criteria were applied: (I) articles without full text available; (II) articles that were not reported in the English language; (III) commentaries, editorials, letters, and preprints.

The first round of screening involved removing duplicate articles. That was followed by screening the titles and abstracts to see if they fitted within the inclusion criteria. Once selected, the article’s full text was reviewed, and a summary of the findings extracted and analyzed. Figure 1 summarizes the process.

Figure 1.

Study flowchart. Adapted from Page et al. (12).

Data extraction

A data extraction table was created in an Excel 2010 spreadsheet recording the following information from each study: authors, year of publication, study location, objectives, methodology, participants and findings. The data extraction was performed independently by the first author. A summary of the main findings has been included within the text of the paper (Table 1), with a further overview of all study findings in the supplementary files (Table S1).

Table 1. Summary of main findings.

Themes	Findings
Prevalence of smartwatches and healthcare presentations	Smartwatch usage in children ranged from 15% to 40%, depending on the country
	Increased number of children presenting with smartwatch-based heart concerns, though many false positives and few true arrhythmias have been diagnosed
Perceptions of children and parents	Up to 25% of paediatric smartwatch users experienced anxiety arising from the device
	Some parents reported their child experienced discomfort and skin reactions to the smartwatch
Accuracy of smartwatches	Heart rate and electrocardiographic readings from smartwatches correlated closely to the standard 12-lead electrocardiogram
	Smartwatch adult-based automated algorithms were inadequate to diagnose the type of arrhythmia in childhood, requiring physician interpretation

Results

Study selection

The initial search of the two databases resulted in the finding of 893 articles. Duplicate articles were removed (n=290). Further articles were excluded after their title and abstract were screened (n=494). The full text of the remaining articles were reviewed. Four additional papers were included following a review of the articles’ references, yielding a total of 29 articles for detailed analysis. Figure 1 summarizes the process. Table S1 provides a summary of the 29 studies, including their references, objectives, methods, participants and results.

Findings of retrospective studies

Prevalence of smartwatches and healthcare presentations

The prevalence of smartwatch usage in the paediatric population has been shown in a systematic review to vary globally depending on the prevailing social, economic and cultural factors, and ranged from 15% to 40% (13). Physiological data which included heart rate measurement, were often collected by smartwatches and commonly used for tracking the physical activity of the wearer (14). The availability of such data has led to increased doctor attendances. For example, the number of children presenting to a cardiologist with smartwatch-based heart concerns such as tachycardia, increased from 2 in 2017 to 57 in 2021 (5). Of these 57 children, 3 were found to have clinically significant arrhythmias. Additionally, there have been case reports of smartwatch alerts which have led to a diagnosis of an arrhythmia in children and adolescents (15,16). This demonstrates the utility of smartwatches in assisting arrhythmia diagnosis in the paediatric population. However, concerns have been raised regarding false positives generated by smartwatch heart alerts. A study found that of the paediatric patients without arrhythmias whose medical documentation indicated Apple Watch usage for recreational cardiac monitoring, 25% presented to the doctor due to heart alerts that were generated (17). This suggests a sizeable number of unnecessary healthcare visits due to false positive smartwatch heart alerts.

Perceptions of children and parents

There were limited studies exploring the perceptions of children and their parents with respect to the information provided by smartwatches. A study that focused on a subpopulation of children with attention-deficit/hyperactivity disorder reported that on first impression, most children were enthusiastic about using smartwatches to track their information (18). However, the subjects found interpretation of the variation in their heart rate concerning, with a common sentiment that a low heart rate was indicative of impending death resulting in unwarranted anxiety. Such anxiety was further supported by a study of adolescents with a cardiomyopathy who wore a Fitbit device for 3 months; 25% of the participants stated that wearing the device made them anxious (19). Despite that, the majority were still interested in continuing to wear their smartwatches to provide information for their cardiologist. Parental feedback of wearable devices that tracked heart rate was limited to reports on the comfort of wearing them and the resultant local skin reactions that were noted when worn continuously for 72 hours in a hospital setting (20).

Findings of prospective studies

There were few prospective studies that investigated the accuracy of smartwatches that recorded heart rate and/or displayed corresponding electrocardiographic traces in children. The majority showed that the heart rate and electrocardiographic readings generally correlated closely to gold standard modalities such as standard 12-lead electrocardiograms (21-23). Similar findings were noted in subjects with or without congenital heart disease (10,24,25). However, smartwatch automated algorithms to diagnose arrhythmias were generally inadequate to accurately diagnose a specific arrhythmia, with only a 66% accuracy (26). Such interpretation was left to the attending physicians to dissect out the diagnosis following further assessment and investigations (27).

Discussion

Key findings

Smartwatches have become increasingly popular over the years, with parents often purchasing them for their offspring due to their utility and aesthetics (28). Apple markets their smartwatches as a way of improving parental connectivity with their children, while at the same time encouraging increased activity and a “wristful of fun and education” (29). Having a “wristful” of easily accessible data comes with both benefits and harms. The main benefit has been the recording of the heart rate and the provision of electrocardiographic traces with the ability to provide a continuous record in varying locations, akin to that of an event monitor. This facility occasionally may pick up an arrhythmia which Holters and/or event monitors worn for a limited time often fail to do (15,16).

However, on the negative side, both children and their parents understandably may misinterpret the information gleaned from the smartwatches (5,18). Such misinterpretations tend to occur as smartwatches are generally designed with norms based on adult readings (30). The algorithms that result have led to incorrect alerts failing to take into account the variability and increased heart rate of the young child (Table 2) (31). Furthermore, the lack of standardisation of commercial wearable devices has led to heart alerts that vary from one device to another arising from their inbuilt algorithms (32). Such information wrongly interpreted have resulted in increased anxiety and healthcare presentations, despite most such patients remaining asymptomatic (5). Additionally, in paediatric patients with preexisting cardiac conditions, smartwatch heart rate measurements and alerts can result in further anxiety, though of note these studies did not use validated anxiety scales nor compared the anxiety to baseline levels (19).

Table 2. Physiological heart rates for children (31).

Age	Heart rate (beats per minute) within 5th to 95th centile
Birth to <6 months	120–170
6 months to <1 year	110–160
1 to <2 years	100–155
2 to <4 years	95–150
4 to <6 years	80–135
6 to <8 years	80–130
8 to <12 years	70–120
12 to <14 years	65–115
14 years+	60–110

Implications and actions required

These adverse and unintended outcomes raise the need for appropriate health education to inform smartwatch users as to the normal range of heart rates at different ages, as well as the clinical significance of the findings. Whether this is the responsibility of the smartwatch manufacturers to develop a relevant instructional manual, and/or for healthcare clinicians to ‘interrogate’ and explain the findings (33) remain unclear. This dilemma also encompasses the medico-legal responsibilities and their consequences as a result of misinterpreting the findings, or alternatively missing an arrhythmia which is subsequently diagnosed. Little attention has been given to the ethical and medicolegal implications of smartwatches including the possibility of invading the privacy of the user, further compounded by the variable cybersecurity of different devices (34). Additionally, further study is required to quantify healthcare costs linked to false-positive smartwatch alerts. This may more directly demonstrate the impact of false alerts leading to unnecessary visits and investigations.

Strengths and limitations

This study used a scoping review methodology to ensure a focused search of the literature. It involved the screening and analysis of a large number of articles, on a topic that is rapidly gaining momentum with novel healthcare uses of wearable devices (35). It attempted to synthesize both the utility and drawbacks of smartwatch reported cardiac readings, highlighting gaps in the current knowledge which may be the basis for future study. That included the paucity of research findings on child, adolescent and parental perceptions of smartwatch findings, with only recent attention being directed to their use in children (36).

One limitation of this study was that a single author conducted the screening process and data extraction. Additionally, most of the studies reviewed had small samples and were single-centre studies, limiting their generalizability to broader paediatric populations. There was no subgroup analysis performed on the data to categorise findings for the brand and model of smartwatch, nor the age group of the user which ranged from neonates to adolescents.

Conclusions

Smartwatch usage is now more prevalent in children and adolescents. The smartwatch’s ability to noninvasively record heart rate and provide electrocardiographic tracings have the potential to document generally accurate and continuous cardiac-related data of their wearers. While providing such information was not the primary goal of the device, it nevertheless has been incorrectly used at times to interpret the findings resulting in increased anxiety for the wearers and their family, as well as increased visits for medical assessment and investigations. Further clinical validation and education are required, such as large cohort paediatric studies to validate its use and accuracy in children and adolescents, in addition to the development of Food and Drug Administration paediatric device standards. In addition, the heart alerts are generally set for adult parameters, which fail to take into account the differences noted in childhood. Further study of child and parental perceptions is required, as well as further research on the ethical and medico-legal implications of the recording of health-related data by these readily available commercial devices with variable cybersecurity.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.