The Journal of Emergency Medicine, Vol. 35, No. 4, pp.

421– 430, 2008

Copyright © 2008 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/08 $–see front matter

doi:10.1016/j.jemermed.2007.09.039

Selected Topics:
Cardiology Commentary

ELECTROCARDIOGRAPHIC MANIFESTATIONS: PEDIATRIC ECG

Theodore C. Chan, MD, FAAEM, FACEP,* Ghazala Q. Sharieff, MD, FAAEM, FACEP, FAAPMD, FAAEM, FACEP,*†
and William J. Brady, MD, FAAEM, FACEP‡
*Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, California, †Department of
Emergency Medicine, San Diego Children’s Hospital and Health Center and Palomar-Pomerado Health System, San Diego, California,
and ‡Department of Emergency Medicine, University of Virginia Medical Center, Charlottesville, Virginia
Reprint Address: Theodore C. Chan, MD, Department of Emergency Medicine, University of California San Diego Medical Center,
200 West Arbor Drive # 8676, San Diego, CA 92103

e Abstract—Interpretation of pediatric electrocardiograms mal” electrocardiographic findings in adults may, in fact,

(ECGs) can be challenging for the Emergency Physician. Part
of this difficulty arises from the fact that the normal ECG
findings, including rate, rhythm, axis, intervals and morphol-
ogy, change from the neonatal period through infancy, child-
hood, and adolescence. These changes occur as a result of the
maturation of the myocardium and cardiovascular system
with age. Along with these changes, up to 20% of pediatric
ECGs obtained in the acute setting may have clinically
significant abnormal findings. This article will discuss the
approach to the interpretation of ECGs in children, the
age-related findings and alterations on the normal pediatric
ECG, and those ECG abnormalities associated with pedi-
atric cardiac diseases, including the variety of congenital
heart diseases seen in children. © 2008 Elsevier Inc.
e Keywords—electrocardiogram; pediatric; interpreta-
tion; review
INTRODUCTION
Interpretation of pediatric electrocardiograms (ECGs)
can be challenging in the Emergency Department (ED)
setting. ECGs are obtained in children in the ED for a
variety of reasons. Up to 20% of these have clinically
significant findings such as prolonged QT syndrome,
ventricular hypertrophy, or ectopy (1). Part of the chal-
lenge of pediatric ECGs is the fact that typically “abnor-
be normal or expected findings in children, depending on
the age of the patient. These differences are the result of the
changes and development of the myocardium and circula-
tory system from infancy through childhood to adulthood.
This article will review the ECG manifestations of the
normal and common clinical conditions of pediatric pa-
tients presenting to the ED. In general, we suggest the
use of a systematic approach to ECG interpretation, with
special attention to rate, rhythm, axis, ventricular and
atrial hypertrophy, and repolarization abnormalities. This
approach will assist the clinician in determining what is
normal on the pediatric ECG and what may be indicative
of an abnormal cardiac condition.
CASE REPORTS
Case 1
A 3-year-old girl was brought in to the ED by her
parents due to 3 days of poor feeding, vomiting, and
diarrhea. On examination, the patient appeared to be a
well-developed, fussy toddler with no significant physi-
cal findings other than a 2/6 systolic murmur radiating to
the base. Due to the finding of the murmur, the Emergency
Physician obtained an ECG (Figure 1). The ECG was
notable for sinus tachycardia at a rate of 112 beats/min and

RECEIVED: 9 May 2007; FINAL SUBMISSION RECEIVED: 5 September 2007;

ACCEPTED: 6 September 2007
421
422
Figure 1. 12-lead ECG of 3-year-old girl demonstrating normal sinus rhythm at a rate of 112 beats/min and inverted T waves in
leads V1, V2, and V3 normal for patient’s age.
inverted T waves in leads V1, V2, and V3. These findings
were consistent with a normal juvenile pattern appropriate
for the patient’s age. A subsequent outpatient echocardio-
gram demonstrated no significant abnormalities.
Case 2
An 11-year-boy presented to the ED complaining of chest
pain after playing baseball. The patient denied trauma,
weakness, cough, or fever, but did report transient shortness
of breath. On examination, the patient had normal vital
signs and no remarkable physical findings. An ECG dem-
onstrated a sinus rhythm at 74 beats/min with normal axis
and inverted T waves in leads V1, V2, and V3 (Figure 2).
These findings were consistent with a juvenile ECG pattern,
possibly persistent in this pre-adolescent patient. The pa-
tient workup in the ED was otherwise unremarkable.
Case 3
An 11-month-old girl was brought to the ED by her
caretakers for poor feeding, irritability, and lethargy.
Figure 2. 12-lead ECG of 11-year-old boy demonstrating juvenile ECG pattern with inverted T waves in leads V1, V2, and V3.
T. C. Chan et al.
Examination revealed a well-developed infant in mild
distress, pulse rate ⬎ 200 beats/min, but otherwise he-
modynamically stable with a clear chest on auscultation.
A 12-lead ECG was remarkable for a regular narrow
complex tachycardia at 280 beats/min (Figure 3). The
patient was diagnosed with a supraventricular tachycar-
dia (SVT) and subsequently treated with intravenous
adenosine, at which point she converted to sinus rhythm.
Case 4
A 6-week-old infant was referred to the ED by her
pediatrician for poor feeding and irritability over the past
week. On examination, the patient was hemodynamically
stable, but was noted to have rales on chest auscultation
and a grade 3/6 systolic murmur and higher pitched 2/6
diastolic murmur on cardiac examination. An ECG was
notable for an abnormal left ventricular hypertrophy
(LVH) and possible left axis deviation for her age (Fig-
ure 4). Her chest radiograph was remarkable for cardio-
megaly and increased pulmonary vascular markings. Af-
ter admission, the patient was ultimately found to have a
ventricular septal defect (VSD) on echocardiogram.
Pediatric ECG
Figure 3. 12-lead ECG from 11-month-old girl revealing supraventricular tachycardia with regular narrow QRS complex
tachycardia at a rate of 280 beats/min.
Case 5
A 1-week-old infant was brought to the ED by his parents
for lethargy, respiratory distress, and “turning blue.” On
arrival, the patient was found to be in respiratory distress
and hypotensive. Cardiac examination was notable for a
faint systolic murmur. An ECG revealed marked right ven-
tricular hypertrophy with strain abnormal for the infant’s
age (Figure 5). A subsequent echocardiogram revealed hy-
poplastic left heart syndrome. The patient was admitted to
the pediatric Intensive Care Unit and started on prostaglan-
din infusion before surgical repair.
Case 6
A 15-year-old boy presented to the ED complaining of
dizziness and weakness. Past medical history was signif-
Figure 4. 12-lead ECG from a 6-week-old infant with a large ventricular septal defect. The ECG reveals an abnormal left axis
deviation and left ventricular hypertrophy.
423
icant for repair of tetralogy of Fallot congenital heart
disease as a child and the recent addition of a diuretic to
his medication regimen. Cardiac examination was nota-
ble for a loud 3/6 systolic murmur best heard along the
base. An ECG revealed biatrial enlargement, a right axis
deviation, and intraventricular conduction delay, un-
changed from prior ECGs (Figure 6). The patient was
admitted and ultimately diagnosed with hypovolemia
from his new medication regimen.
Case 7
A 9-year-old boy presented to the ED with complaint of
palpitations, which resolved on arrival. He had a history
of recurrent palpitations associated with weakness in the
past. Physical examination was unremarkable. An ECG
revealed evidence of ventricular pre-excitation and a
424 T. C. Chan et al.

Figure 5. 12-lead ECG from a 1-week-old infant with hypoplastic left heart syndrome. The ECG demonstrates marked right
ventricular hypertrophy with strain.

delta wave before the QRS complex (Figure 7). The vealed sinus tachycardia, but no other significant ab-
patient was ultimately diagnosed with Wolff-Parkinson- normalities (Figure 8).
White syndrome with likely episodes of tachycardia.

APPROACH TO THE PEDIATRIC ECG

Case 8
A 7-month-girl was brought to the ED for 5 days of
fever, cough, and rhinorrhea. Her examination was
remarkable for bilateral conjunctivitis, injected phar-
ynx and fissured lips, cervical adenopathy, and a non-
specific rash particularly involving the hands with
periungual desquamation. After admission for the pre-
sumptive diagnosis of Kawasaki disease, an ECG re-
Electrocardiograms are obtained on children for a variety
of reasons. The most common indications include the
evaluation of chest pain, workup for possible dysrhyth-
mia, evaluation of an acute episode (i.e., syncope), or
toxicology workup after ingestion. In a review of over
1600 ECGs obtained at a pediatric ED, the most common
indications were chest pain (21%), seizure or syncope
evaluation (18%), dysrhythmia evaluation (17%), respi-

Figure 6. 12-lead ECG from adolescent with repair of tetralogy of Fallot. The ECG demonstrates biatrial enlargement, right axis
deviation, and intraventricular conduction delay.
Pediatric ECG 425

Figure 7. 12-lead ECG from a 9-year-old boy with Wolff-Parkinson-White syndrome. Note the shortened PR interval and wide
QRS complex with slurred upstroke (delta wave) consistent with ventricular pre-excitation.

ratory event or apparent life-threatening event (16%),
ingestion or toxicologic evaluation (10%), and other
cardiac evaluation (10%) (2). Although the great major-
ity of ECGs in the pediatric population are normal, a
significant percentage, as high as 20%, demonstrate sig-
nificant abnormality (1).
When evaluating a pediatric ECG, it is important to
do so in a systematic and routine manner. Although
settings can be changed to highlight certain features, the
standard 12-lead ECG set at the 10 mm/mV amplitude
standard and 25 mm/s paper speed is the one that should
be referenced against normal values. Additional right
ventricular and posterior left ventricular precordial leads
(V3R, V4R, and V7) can be included with pediatric
ECGs to provide more information on patients with
complex congenital abnormalities. Because the interpre-
tation software is often calibrated for analysis in adults,
the computer analysis on many ECG machines may
provide inaccurate interpretations in children. However,
many machines now have pediatric analysis software
that is activated when the appropriate age is entered into
the ECG machine.
AGE-RELATED PEDIATRIC ECG FINDINGS
Rapid changes occur over the first year of life as a result
of the dramatic evolution in circulation and cardiac phys-
iology. After infancy, subsequent changes are more grad-
ual until late adolescence and adulthood. In the fetus,
blood is shunted away from the lungs by the patent

Figure 8. 12-lead ECG from 7-month-old girl with Kawasaki disease. The ECG is essentially normal for age with the exception
of the sinus tachycardia.
426 T. C. Chan et al.

Table 1. Pediatric ECG Normal Intervals*

Heart Rate QRS Axis PR Interval QRS Interval

Age Beats/Min Degrees Seconds Seconds Rin V1 mm Sin V1 mm Rin V6 mm Sin V6 mm

First week 90–160 60–180 0.08–0.15 0.03–0.08 5–26 0–23 0–12 0–10
1–3 weeks 100–180 45–160 0.08–0.15 0.03–0.08 3–21 0–16 2–16 0–10
1–2 months 120–180 30–135 0.08–0.15 0.03–0.08 3–18 0–15 5–21 0–10
3–5 months 105–185 0–135 0.08–0.15 0.03–0.08 3–20 0–15 6–22 0–10
6–11 months 110–170 0–135 0.07–0.16 0.03–0.08 2–20 0.5–20 6–23 0–7
1–2 years 90–165 0–110 0.08–0.16 0.03–0.08 2–18 0.5–21 6–23 0–7
3–4 years 70–140 0–110 0.09–0.17 0.04–0.08 1–18 0.5–21 4–24 0–5
5–7 years 65–140 0–110 0.09–0.17 0.04–0.08 0.5–14 0.5–24 4–26 0–4
8–11 years 60–130 ⫺15–110 0.09–0.17 0.04–0.09 0–14 0.5–25 4–25 0–4
12–15 years 65–130 ⫺15–110 0.09–0.18 0.04–0.09 0–14 0.5–21 4–25 0–4
⬎ 16 years 50–120 ⫺15–110 0.12–0.20 0.05–0.10 0–14 0.5–23 4–21 0–4

* Reprinted with permission from reference (8): Sharieff GQ, Rao SO. The pediatric ECG. Emerg Med Clin North Am 2006;24:196.

ductus arteriosus (PDA), and systemic circulation relies
primarily on the right side of the heart. As a result, at
birth the right ventricle is larger than the left ventricle.
Subsequently, as the PDA closes during infancy, there is
increased work of the left ventricle from the systemic
circulation. The left ventricle enlarges and thickens such
that by late infancy and early childhood it is more than
twice as thick as the right ventricle (2,3).
With these changes, there is a progression of alter-
ations in the normal ECG findings, including rate, axis,
interval duration, and complex morphologies in pediatric
patients. Table 1 lists the normal pediatric ECG values
seen in the newborn, infant, child, and adolescent, in-
cluding ranges for heart rate, QRS complex axis, PR
segment and QRS complex intervals, and R and S wave
amplitudes, and their changes with age (4 – 8).
Heart Rate
Normal heart rate varies with age and is generally higher
in children than adults. Table 1 lists the normal ranges
for heart rate, which tends to peak at 3– 8 weeks and then
decreases through adolescence. Due to the smaller stroke
volume in neonates and young children, cardiac output is
maintained by the higher heart rate. With age, stroke
volume increases and contributes more significantly to
overall cardiac output. When assessing heart rate, it is
important to consider the patient’s activity and stress
levels, which can result in physiologic elevations of heart
rate. Rates significantly outside the normal range for age,
however, should be closely scrutinized for dysrhythmias.
Axis
As discussed above, the right ventricle is larger than the
left ventricle in the newborn infant, and the ECG will
show right ventricular dominance and right axis devia-
tion. Across the precordium, the R wave amplitude will
be increased in leads V1 and V2, and decreased in leads
V5 and V6. With the cardiac changes described above
occurring in the first 1–3 years of life, the left ventricle
increases in size and the QRS axis will shift from right-
ward to a more leftward axis. Across the precordium, the
R wave amplitude decreases in leads V1 and V2, and
increases in leads V5 and V6.
Intervals
QRS Complex. The normal QRS complex duration is
shorter in children than adults. This finding may be the
result of the smaller cardiac muscle mass in children. For
neonates, the normal QRS complex duration can be as
short as 30 ms and increases progressively with age
(Table 1). Accordingly, conduction abnormalities may
be present in what appears as a normal or nearly normal
QRS complex duration in young children.
PR Interval. The normal PR interval duration is shorter
in children and increases with age. Similar to the change
in normal QRS complex duration, this finding may be the
result of smaller cardiac muscle mass. In neonates, the
normal PR interval duration can be as short as 80 ms
(Table 1). As a result, AV conduction delay may be
present in young children with minimal prolongation or
a “normal”-appearing PR interval (4).
QT Interval. The QT interval duration varies with heart
rate in both children and adults. Similar to adults, the QT
interval must be corrected for heart rate (which is nor-
mally higher in children) to obtain the corrected QTc
interval. In infants, the normal QTc is longer than in
older children and, in fact, can be as long as 490 ms. This
discrepancy in the evaluation of the QTc interval in
Pediatric ECG
infants and children should be noted, particularly when
relying on computer analysis of ECG intervals.
T waves. T wave morphology can be difficult to interpret
in neonates and children. At birth, the T wave may be
upright, flat, or inverted. Within a few days after birth,
however, the T wave can become inverted normally. In
fact, upright T waves at this age may indicate right
ventricular hypertrophy (RVH). The “juvenile pattern”
of T wave inversion usually seen in the anterior leads
(leads V1–V3) typically lasts up until 8 years of age
(Case 1, Figure 1), but can persist into early adolescence
(Case 2, Figure 2).
PEDIATRIC ECG ABNORMALITIES
Tachydysrhythmias
Tachydysrhythmias are common in pediatric patients
seen in the ED. The normal range for heart rate decreases
with age and an increased rate can be normal, particu-
larly in young children (Table 1). In addition, because
cardiac output is more dependent on heart rate than
stroke volume in children, a fast heart rate can be a
normal physiologic response to stressors such as fever,
dehydration, and pain, which are often related to the
patient’s reason for presenting to the ED.
SVT. The most common pediatric tachydysrhythmia is
supraventricular tachycardia (SVT). SVT occurs with a
frequency between 1 in 250 and 1 in 1000 pediatric
patients, most commonly during the first 2 months of life
(9). Presenting symptoms are often non-specific and vary
with age, from “fussiness,” poor feeding, or lethargy in
infants to complaints of chest pain, shortness of breath,
or dizziness in older children. In infants, the heart rate is
typically ⬎ 220 beats/min, and in children the heart rate
is ⬎ 180 beats/min (10). On the ECG, the rhythm is fast
and extremely regular, and the QRS complex is narrow
with no preceding P wave activity (Case 3, Figure 3).
SVT can be episodic in infants and children, often mak-
ing the diagnosis more difficult. In neonates and young
children, the SVT is usually associated with an accessory
atrioventricular pathway. In adolescents and adults, the
most common cause of SVT is an atrioventricular nodal
reentry tachycardia (6).
SVT can be associated with Wolff-Parkinson-White
(WPW) syndrome in children, when there is an accessory
pathway between the atria and the ventricles (9). Elec-
trocardiographic findings suggestive of WPW include a
wide QRS complex with slurred upstroke or delta wave
indicative of ventricular pre-excitation from the acces-
sory pathway, short PR interval for age, and evidence of
427
repolarization ST segment/Twave abnormalities (Case 7,
Figure 7).
Although SVTs are more common in children, tachy-
cardias from a ventricular origin do occur in pediatric
patients. In fact, because the normal QRS complex is
shorter in duration in children than in adults, ventricular
tachycardias can be even more difficult to diagnose in
young children. It is important to remember that what
appears as a slightly prolonged QRS complex on ECG
may, in fact, represent a significantly prolonged or wide
complex tachycardia in infants and children. Similar to
adults, such a finding may be indicative of a sinus tachy-
cardia or SVT with bundle branch block or aberrancy,
AV reentry tachycardia (antidromic), ventricular tachy-
cardia (VT), or ventricular fibrillation (11).
VT. Ventricular tachycardia in the pediatric patient is
uncommon. VT may go unrecognized until the child
acutely decompensates, presenting with syncope, mental
status changes, congestive failure, or hemodynamic in-
stability. Because VT may lead to ventricular fibrillation
and subsequent cardiopulmonary arrest, rapid recogni-
tion of this rhythm and knowledge of its treatment is
critical (12).
Ventricular tachycardia is defined as a series of three
or more repetitive excitations originating from an ectopic
focus in the ventricle at a rate ⬎ 120 beats/min. The ECG
will reveal a QRS complex that has a different morphol-
ogy or axis from the underlying sinus rhythm. The QRS
complex duration is usually prolonged, exceeding 0.08 s
in infants and 0.09 s in children older than 3 years (6).
Importantly, the QRS complex may not be absolutely
“wide,” even after adjustment is made for the patient’s
age. This is particularly true in infants in whom the QRS
complex duration in VT may range from 0.06 s to 0.11 s.
In older children, the QRS complex is more often pro-
longed (⬎ 0.09 s). The clinician must recognize this
age-related QRS complex width variation; failure to do
so may result in misidentification of a malignant ventric-
ular dysrhythmia as a sinus tachycardia or SVT. It should
be noted that although VT is uncommon in children,
SVT with aberrancy is even more uncommon (13). In
addition to QRS complex width and morphology, other
criteria that can be helpful in distinguishing VT are
atrioventricular dissociation, intermittent fusion and cap-
ture beats, and ventricular rate.
Conduction Abnormalities
AV block—from first-degree to complete heart block—
can occur in infants and children, as well as in adults.
However, the diagnosis of first-degree AV block can be
difficult due to the normally shorter PR interval seen in
428 T. C. Chan et al.

infants and children (Table 1). Thus, normal-appearing
PR intervals may actually be abnormally prolonged and
indicative of first-degree AV block. Third-degree or
complete heart block may be congenital or acquired in
children. Congenital causes of complete heart block in-
clude transposition of the great arteries (TGA) or mater-
nal connective tissue disorders. Acquired conditions that
can present with heart block include Kawasaki disease,
Lyme disease, muscular dystrophies, and rheumatic fe-
ver (8,11). The ECG must be closely scrutinized for
complete heart block in pediatric patients presenting with
significant bradycardia. In these cases, P wave activity
will be faster and have no clear relationship to the
slower, regular QRS complexes on the ECG.
Intraventricular conduction blocks can result in vari-
able QRS complex duration, though blocks located in the
bundle branches result in abnormally prolonged QRS
complexes. In infants and young children, it is important
to remember that the normal QRS complex duration is
shorter than in adults and thus the diagnosis can be
difficult to make. In addition, incomplete right bundle
branch block (BBB) can be a normal part of the involu-
tion of right ventricular forces during infancy and early
childhood. In pediatric patients, right BBB is more com-
mon than left BBB. Right BBB can be seen with atrial
septal defects (ASDs), complete atrio-ventricular de-
fects, ventriculoseptal defects (VSDs), and after repair of
tetralogy of Fallot (ToF) and VSDs. Left BBB is rare in
children and the possibility of WPW should be consid-
ered as this syndrome can mimic a left BBB pattern on
ECG.
Prolonged QT syndrome is rare in children, and when
present, is more likely associated with a congenital cause
rather than acquired in contradistinction to adults. Al-
though there are now a number of identified congenital
long QT syndromes, the most common are Romano-
Ward syndrome (autosomal dominant) and Jervell-
Lange-Nielsen syndrome (autosomal recessive with as-
sociated with congenital deafness).
Congenital Heart Disease
Congenital heart disease (CHD) occurs in 8 of every
1000 live births, and the clinical presentation of these
patients can vary in terms of both symptomatology and
timing (14 –21). The ECG, although not diagnostic, can
provide important clues in patients suspected of having
CHD. In particular, the ECG can show the presence of
chamber enlargement or conduction abnormalities that
may be associated with specific CHDs. A number of
ECG findings can be associated with specific congenital
heart diseases (Table 2). Although abnormalities on the
ECG are found in the majority of cases, it is important to
remember that with some CHDs (such as PDA), the ECG
can appear age appropriate and normal.
Evidence of RVH on ECG (increased R wave ampli-
tude in leads V1, V2) is the most common electrocar-
diographic finding in patients with CHD. Due to the RV
predominance in the early neonatal period however, the
ECG findings for RVH may be overlooked until later
infancy. ECG findings consistent with RVH can be seen
in CHDs including pulmonary stenosis, ToF, TGA, and

Table 2. Congenital Heart Abnormalities with Timing of Onset and Typical Abnormalities that May be Seen on ECG*

CHD Onset RVH LVH RAE LAE RAD LAD RBBB

PDA 2nd–3rd weeks ⫹ (Older child)

ASD Variable ⫹ ⫹ ⫹ ⫹
VSD 2nd–12th weeks ⫹ ⫹ ⫹ ⫹
CoA 1st week ⫹ ⫹ (Older) ⫹
(Newborn) (Newborn)
ToF st th
1 –12 weeks ⫹ ⫹ ⫹ (After repair)
TGA 1st week ⫹ ⫹ ⫹
Truncus Arteriosis Variable–infancy ⫹ ⫹
Tricuspid Atresia 1st–4th weeks ⫹ ⫹ ⫹
PA Variable ⫹
HLHS 1st week ⫹
AS Variable ⫹
PS 1st–4th weeks ⫹ ⫹ ⫹
AVC 2nd–3rd weeks ⫹ ⫹ ⫹ ⫹ ⫹ ⫹
HCM Variable–adulthood ⫹ ⫹

* Modified with permission from reference (8): Sharieff GQ, Rao SO. The pediatric ECG. Emerg Med Clin North Am 2006;24:204.
CHD ⫽ congenital heart disease; RVH ⫽ right ventricular hypertrophy; LVH ⫽ left ventricular hypertrophy; RAE ⫽ right atrial
enlargement; LAE ⫽ left atrial enlargement; RAD ⫽ right axis deviation; LAD ⫽ left axis deviation; RBBB ⫽ right bundle branch block;
PDA ⫽ patent ductus arteriosus; ASD ⫽ atrial septal defect; VSD ⫽ ventricular septal defect; CoA ⫽ coarctation of aorta; ToF ⫽ tetralogy
of Fallot; TGA ⫽ transposition of great vessels; PA ⫽ pulmonary atresia; HLHS ⫽ hypoplastic left heart syndrome; AS ⫽ aortic stenosis;
PS ⫽ pulmonic stenosis; AVC ⫽ atrioventricular canal defects; HCM ⫽ hypertrophic cardiomyopathy.
Pediatric ECG
VSD with pulmonary stenosis or pulmonary hyperten-
sion, coarctation of aorta (CoA) (newborn), pulmonary
valve atresia, hypoplastic left heart syndrome (HLHS)
(Case 5, Figure 5), and atrial septal defects (ASDs).
Evidence of LVH on ECG (increased QRS complex
amplitude in the lateral leads I, avL, V5, V6) can be seen
in CHDs in lesions resulting in LV outflow tract obstruc-
tion. These CHDs include aortic stenosis and CoA. LVH
can also be seen in lesions that result in a small RV,
including tricuspid atresia and pulmonary atresia with
intact ventricular septum. LVH can also be seen with
large VSDs, AV canal defects, and PDA (older children)
(Case 4, Figure 4).
Electrocardiographic evidence of right atrial (RA) en-
largement can be seen with ASD, AV canal defects,
tricuspid atresia, Ebstein’s anomaly, and severe pulmo-
nary stenosis. These lesions result in large left-to-right
shunts causing RA volume overload and enlargement.
Similarly, left atrial (LA) enlargement can be seen with
MV stenosis or insufficiency, left heart obstruction, and
complete AV canal defects (Case 6 – Figure 6).
Abnormal axis deviations are common with CHDs.
Right axis deviation, greater than what is expected for
age, can occur with ASD, ToF, CoA, TGA, and pulmo-
nary stenosis. Left axis deviation can be seen with large
VSDs, tricuspid atresia, TGA and complete AV canal
defects (Case 4, Figure 4).
Other Pediatric Cardiac Disorders
Hypertrophic cardiomyopathy. Hypertrophic cardiomy-
opathy is an asymmetric, non-dilatated left ventricle hy-
pertrophy most prominently involving the septum. Al-
though most cases are diagnosed in adulthood, a small
percentage is found in children (22). ECG findings in-
clude LA enlargement and LVH, ST-segment abnormal-
ities, T-wave inversions, narrow Q-waves, and small R
waves in the lateral leads. Rhythm disturbances can be
seen, including PACs, PVCs, multifocal ventricular dys-
rhythmias, or new onset atrial fibrillation.
Myocarditis. Myocarditis, an acute inflammation of the
myocardium from any number of causes, can present in
children as well as adults. Signs and symptoms are often
non-specific, particularly in infants, and are due to poor
cardiac function. Multiple ECG findings may be present.
Sinus tachycardia, particularly when higher than ex-
pected for age or fever (normally 10 beats/min for each
degree of temperature elevation), is the most common
dysrhythmia (9). Other dysrhythmias include junctional
tachycardias, ventricular ectopy, and even second- and
third-degree atrioventricular blocks. Morphologically,
there may be ST segment abnormalities, T-wave flatten-
429
ing or inversion and low QRS complex voltage ⬍ 5 mm
in all limb leads. Acute pericarditis, an acute inflamma-
tion in the pericardium, can present in children and have
typical ECG findings of diffuse ST segment elevation
and PR depression (with reciprocal changes in leads aVR
and V1).
Kawasaki disease. Kawasaki disease is an acute, self-
limited vasculitis of unknown etiology that occurs in
infants and young children. Presentation is character-
ized by fever, conjunctivitis, rash, erythema of the oral
mucosa and lips, swelling of the extremities, and cer-
vical lymphadenopathy. Approximately 15–25% of
untreated children develop coronary artery aneurysms,
which may result in myocardial infarction and isch-
emic heart disease (23). Myocarditis is a common
feature early in the course of the disease and in severe
cases. In fact, Kawasaki disease has surpassed acute
rheumatic fever as the leading cause of acquired heart
disease in children (24). ECG findings in these patients
can vary from normal to classic ST segment, T wave
and Q wave changes associated with ischemia and
infarction (25) (Case 8, Figure 8). Other reported
findings include T wave flattening or peaking, and PR
and QT interval prolongation (23). These ECG abnor-
malities have been reported in up to 77– 80% of pa-
tients and may indicate more severe disease in chil-
dren (26,27).
CONCLUSION
In an ED it is necessary to quickly determine which
pediatric ECG findings are normal, which are abnor-
mal, and which must be addressed immediately. An
understanding of the pediatric ECG is essential so that
subtle abnormalities are not missed. Knowledge of the
basics of pediatric ECG interpretation, including fa-
miliarity with the age-related normal findings in terms
of heart rate, intervals, axis and waveform morpholo-
gies, is critical. In addition, clinicians should have an
understanding of the physiologic cardiac changes as-
sociated with age and maturation, particularly the ad-
aptation from right to left ventricular predominance.
Finally, it is useful to have a rudimentary understand-
ing of common pediatric dysrhythmias and findings
associated with congenital heart diseases and other
common pediatric cardiac disorders.
Acknowledgment—The authors thank Richard Harrigan, MD, for
his assistance with the manuscript.
430
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