From Referral to Retention: A Systematic Review of Access, Equity, and Participation Across the Pediatric Cardiac Rehabilitation Care Cascade

Abstract Background: Pediatric cardiac rehabilitation may improve function, confidence, and quality of life, but its benefit depends on whether eligible children can access, initiate, and remain in care. We synthesized evidence across a care cascade spanning program availability, referral, enrollment, initiation, adherence, and retention, with equity examined at every transition. Methods: Seven databases were searched through July 2026 without date, language, or publication-type restrictions. We included original quantitative, qualitative, and mixed-methods studies of structured, multi-session, non-acute cardiac rehabilitation, cardiac fitness, or exercise-therapy programs for pediatric or explicitly young-person cardiac populations. Two reviewers independently screened records and reports. Multiple reports were linked into study families, appraised with design-specific tools, and synthesized narratively. Results: Searches identified 19,204 records; 14,864 remained after deduplication, and 191 reports underwent eligibility assessment. Sixty-five reports representing 45 study families were included. Evidence addressed availability or access in 32 families, referral in nine, enrollment in 26, initiation in 15, attendance or adherence in 30, and retention or completion in 28. Equity-relevant pathway findings were explicit in 22 families and contextual in 20. Travel, program scarcity, school and caregiver schedules, cost or insurance, developmental needs, and digital requirements shaped participation. Home, hybrid, and virtual delivery reduced travel burden but could transfer workload and supervision demands to families. Twenty-two families had high methodological concern or risk. Conclusion: Pediatric cardiac rehabilitation evidence remains concentrated among participants who enter programs, obscuring earlier cascade losses. Services and future studies should use stable stage-specific denominators, standardized transition measures, equity-stratified reporting, and supported flexible delivery models.