PEDIATRIC ECGs

OBJECTIVES

1. Review Pediatric ECG

Indications
2. Discuss some similarities
and differences between
Pediatric and Adult ECGs
3. Discuss pediatric
arrhythmias
Successful use of
Pediatric
Electrocardiography
Beaware of age related differences in
ECG indications

Know N ranges for ECG variables

Recognize typical differences in

infants/children
 Syncope/seizure Electrolyte disturbance
Exertional symptoms Kawasaki disease
Drug ingestions Rheumatic fever
Tachyarrhythmia Myocarditis
Bradyarrhythmia Myocardial contusion
Cyanotic episodes
Pericarditis
Heart Failure
Post cardiac surgery
Hypothermia
Congenital heart defects

Indications for a Pediatric ECG

PAEDS ECG + 2 Fs
P- pericarditis (or E-electrolyte
myocarditis), post disturbance
cardiac surgery C-cyanosis, contusion
A-arrhythmias (tachy or (myocardial), cold
bradyarrhythmia) (hypothermia)
E-exertional symptoms G- conGenital heart
D-drugs, disease defects
(Kawasaki)
2 Fs:
S-syncope/seizure
Fever (rheumatic)
Failure (heart)
Rarely cardiac in origin

ECG NOT usually helpful in diagnosis

Consider ECG for parent reassurance

Chest Pain in Kids

ECG Recording
Distract child
Limb electrodes proximal, less movement
artifact
Standard adult positions, but add V3R or
V4R to detect right ventricular or atrial
hypertrophy
Standard paper speed (25 mm/s) and
deflection (10 mm/mV)
AGE RELATED CHANGES
IN NORMAL ECGs
The famous 1 complex, 2
segments, 2 intervals and 5
waves.
Heart development during infancy and
childhood causes differences in HR,
interval durations, and ventricular
dominance

Abnormal adult ECG features may be

Normal age-related changes in pediatrics
Pediatric ECG findings
that may be Normal
HR > 100 bpm
Right precordial T wave inversion
Dominant RPLs R waves
Short PR and QT intervals
Short P wave and short QRS duration
Inferior and lateral Q waves
Approach in reading
Paediatric ECG
Heart Rate
CO = SV X HR
Higher rate for infants high metabolic
needs, small ventricle size cannot
compensate by increasing SV (newborn
commonly 120-160 bpm)
As heart grows, SV increases. Higher
rate no longer needed to produce
adequate CO
Rate gradually declines with age
RESTING HR
Birth 140 bpm

1 yr: 120 bpm

5 yr: 100 bpm

10 yr: adult values

Amplitude varies little with age
Best evaluated in II, V1, or V4R
Wide P waves: L atrial hypertrophy
Tall P waves (> 2.5 mm) in II: R atrial
hypertrophy
Abnormal P patterns (ie inversion in II or
aVF): atrial activation from site other than
sinoatrial node

P wave
P axis in range 0 to +90
P waves upright in I, II & aVF
P wave duration 0.06s +/- 0.02s in children
Max P duration 0.1s in children & 0.08s in
infants.
E.g if P axis is in range of +90 to + 180 what
would u suspect in a normal healthy child?

P wave
P wave + physiologic delay in AV node
(PQ segment)
Varies with age & HR.
Age increases, HR decreases & PR interval
increases in duration
With the exception the PR interval is
longer in duration at Birth than at infants
period

PR Interval
PR Interval

Decreases from AGE PR (ms)

birth-1 yr, then
Birth 80-160
gradually increases
t/o childhood 6m 70-150

1 yr 70-150

5 yr 80-160

10 yr 90-170
Ventricle Dominance
Fetal heart pumps blood to high resistance
pulmonary circuit, so RV pressure high
After birth:
Pulmonary vascular resistance falls
RV muscularity recedes
RV contribution to ECG diminishes
Systemic vascular resistance changes:
increased LV size until > than RV (1 month)
6 months: RV/LV ratio similar to adults
Shift from newborn RV dominance to LV
dominance by 1 yr
RV dominance: R wave is larger than S wave
in V1
Heart Changes
LV/RV Weight Ratio

30 weeks gestation 1.2 : 1

Neonates: RV 33 weeks gestation 1.0 : 1
larger than LV, so
36 weeks gestation 0.8 : 1
Normal to have:
Right axis deviation At birth 0.8 : 1
Large precordial R 1 month 1.5 : 1
waves
6months 2.0 : 1
Upright T waves
Alduts 2.5 : 1
D3oL baby
RAD
Dominant R
in V4R/V1
Upright T in
V1
Upright T
persistence
in RPLs > 1st
wk: sign of
RVH
12 year old
ECG
Normal adult
axis
R wave no
longer
dominant in R
precordial
leads
QRS axis
Mean vector of Vent Newborn +125
Depolarization process
Birth:
1 month +90
mean QRS axis +125 with
RAD
up to 180 can be normal in 3 years +60
newborn
R waves prominent in R
precordium adult +50
S waves prominent in L
precordium
Axis moves to Left as child
ages
QRS
Ventricular AGE QRS
Depolarizati duration
on time (ms)
QRS
duration are Birth < 75
short in the 6m < 75
young infant
& increases 1 yr < 75
with age.
5 yr < 80
10 yr < 85
 Normal values in paediatric
electrocardiograms
R wave (S Wave) Amplitude
(mm)
Age PR QRS duration Lead V1 Lead V6
Interval (ms) (ms)

Birth 80160 < 75 526(123) 012 (010)

6 months 70150 < 75 320 (117) 622 (010)

1 year 70150 < 75 220 (120) 623 (07)

5 years 80160 < 80 116 (222) 825 (05)

10 years 90170 < 85 112 (325) 926 (04)

Q waves
Depolarization of Ventricular Septum
Commonly in I,II,III & aVF
Almost always in V5 & V6 but absent in
V4R & V1
Duration is 0.02s & not > 0.03s
In aVF & V5, max amplitude <6mm
In V6, should be <5mm
R/S Progression
In patient > 3 years of age
Progressive increase in R wave amplitude
toward V5
Progressive decrease in S wave amplitude
toward V6
1st month of life, complete reversal of R/S
progression
Btw 1mont & 3 years, partial reversal
present with dominant R in V1 as well as in
V5 & V6
T waves
Ventricular repolarization
T axis is more anterior with upright T
wave in V1
T wave in V1 inverts (Posterior) by 7 days,
stays inverted until 5 to 7 years then
progressively more anterior in later years
Upright T waves in right precordial leads
(V1-V3) between 7d and 7yrs are
ABNORMAL, usually RVH
QT interval
Varies with HR but not age, except in infancy
Must interpreted by Bazetts formula QTc
Important in recognition of congenital
prolonged QT syndrome, and medication
effects (ie hyperK+, hypoCa++, dig, quinidine,
procainaminde, Li+, tricyclics, phenothiazides)
QTc should not exceed 0.44, except in infant
where QTc of up to 0.49s may be normal for
the 1st 6months of life.
(if cant calculate, shouldnt be > half R-R
distance)
Occur at the end of T wave
Should not be included in QTc
Represents the repolarization of Purkinje
fibers
Present in hypokalemia

U wave
Long QT syndrome in 3 yr old
 ABNORMAL
PAEDIATRIC ECGs
Ventricular Hypertrophy
Voltage Criteria: Depend on age adjusted
values for R and S wave amplitudes
R wave (S wave) R wave (S wave)
amplitude (mm) amplitude (mm)

AGE V1 V6
Birth 5-26 (1-23) 0-12 (0-10)
6m 3-20 (1-17) 6-22 (0-10)
1 yr 2-20 (1-20) 6-23 (0-7)
5 yr 1-16 (2-22) 8-25 (0-5)
10 yr 1-12 (3-25) 9-26 (0-4)
RVH

Useful ECG Features

qR or rSR in V1
Upright T in RPLs: 7d-7yrs

Marked right axis deviation (esp if with right

atrial enlargement)

Complete reversal of adult precordial pattern

of R and S waves
Pediatric RVH
13 yr old
Transposition of
great arteries,
previous Mustards

RV systemic
ventricle: RVH
RAD
Dominant R in R
precordial leads
Case: 6 m old with Cyanotic Episodes:
ToF and RVH

Tall R in
V1,
reciprocal
S in V6
qR in V3R
and V4R
RAD 120*
Upright T
V1-V3
(should be
inverted)
LVH
Useful ECG Features
Deep Qs in L precordial leads
Lateral ST depression and T wave inversion
Some Congenital Heart
Defects and ECG
Manifestations
Anomalous L coronary Aortic Stenosis
artery LVH
Anterolat MI
Anomalous Coarctation
pulm
venous return < 6m: RBBB or RVH
Total: RAD, RVH, RAH > 6m: LVH, N, RBBB
Partial RVH or RBBB Patentductus
arteriosus
Small shunt: N
Mod: LVH, +/- LAH
Large: CVH, LAH
Some Congenital Heart
Defects and ECG
Manifestations
Persistent truncus Transposition
arteriosus Intact septum: RVH,
LVH or CVH RAH
Pulmatresia (and VSD and/or PS: CVH,
hypoplastic RV) RAH, or CAH
LVH Corrected
Tetralogy of Fallot transposition
RAD, RVH, +/- RAH AV blocks, WPW, LAH
or CAH, absent Q in
V5/V6, and qR in V1
ABNORMALITIES OF
RATE AND RHYTHM
Abnormal HR

Consider systemic illness in any child

with an abnormal HR

Sinus tachycardia in babies and infants

can be up to 240 bpm

Bradycardia: consider hypoxia, sepsis,

acidosis, intracranial lesions
Pediatric Arrhythmias
Any adult arrhythmia can occur in peds

Major difference in pediatric ECGs is

type of abN rhythms usually seen
Most common pediatric dysrhythmias:
SVT, bradycardia, and sinus arrhythmia

AF, atrial flutter, VT, or VF rare

BUT: kids with congenital heart
disease may have any arrhythmia
What should be done about
this ECG?
Nothing!

Sinus arrhythmia common in childrens

ECGs
Often quite marked
Sinus Arrhythmia

Inspiration: increased blood flow to heart

decreases vagal tone: increased HR
Expiration: increased vagal tone: lower HR
Marked in asthma, upper airway obstruction,
increased ICP, and premature infants (immature
autonomic innervation)
Must differentiate from AF
Rarely in infants but N in many kids/athletes,
normally insignificant
Sinus Bradycardia

Sinusrate below N for age: 80 in

newborn is sinus brady; 50 in athletic
teenager is N

Common in severe distress:

hypoxia*/drugs

Can be asymptomatic/insignificant (ie

sleep/well-conditioned), treat if signs of
poor systemic perfusion
SVT
Most common paeds arrhythmia
Can occur in healthy infants and children
Different
from sinus tach by unusually fast rate
and patient presentation:
ST usually physiologic: fear, fever,
hypovolemia
SVT: vague hx, child irritable, lethargic,
feeding poorly, may present with signs of CHF

Regular rhythm > 220 (infants up to 280-320)

AV Blocks
Uncommon: atrial enlargement, surgical
damage to AV nodal tissue, or congenital
Same classification as adults

1stdegree AV block: must account for PR

change with age. Can be N, or occur in
rheumatic carditis, diphtheria, digoxin OD, and
congenital heart defects
Other Arrhythmias
AF/flutter: rare in children
Flutter: rheumatic heart dz, congenital
defects, cardiac surgery, in utero, or N
neonates
VT: RARE, extremely abN: monomorphic
associated with heart surgery; polymorphic
(torsades) with long QT syndrome
Aids to diagnose tachycardias (ie AV
dissociation and capture/fusion beats) LESS
common in kids
Other Arrhythmias
Atrial
and Ventricular extrasystoles very
common, usu benign if structurally N heart

VF: RARE, only ~ 10% of terminal rhythm;

congenital heart dz, prolonged resuscitation
efforts, prolonged QT or long QT syndrome

Asystole: common, least successfully resolved

lethal peds arrhythmia; hypoxia and acidosis
damage myocardium beyond repair
1. Indications for Pediatric ECGs
2. Some differences between Pediatric
and Adult ECGs
3. Common pediatric arrhythmias

What I Hope We Covered

What You Should TRY to
Remember
Kids n Adults

SIMILARITIES DIFFERENCES
Conduction Kids:fast HR that
pathways
same, so waveforms slows with age,
(P, QRS, T) same, and shorter N intervals
that prolong with
waveform timing age, and diminution
measured the same of RV dominance
(i.e., PR, QRS, QT
interval) Sinusbradycardia,
sinus arrhythmia
Identical
approach to and SVT most
ECG analysis common
arrhythmias in kids
Findings that may be N
HR > 100 bpm
Right precordial T wave inversion
Dominant R precordial R waves
Short PR and QT intervals
Short P wave and short QRS duration
Inferior and lateral Q waves
REFERENCES
ABC of clinical electrocardiograpy. Paediatric
electrocardiography. Goodacre S, McLeod K. BMJ Volume
324. June 8, 2002. Pgs 1382-1385
ECG INTERPRETATION: WHAT IS DIFFERENT IN CHILDREN?
Mowery, Bernice, Suddaby, Elizabeth C., Pediatric Nursing,
0097-9805, May 1, 2001, Vol. 27, Issue 3.
How to interpret Paediatric ECG by Gunneroth