Pediatric ECGs

Christine Kennedy
EM Rounds
May 20, 2010

Objectives
Highlight normal findings on a Pediatric
ECG
T waves
Q waves
ST segments

Identify some key abnormal findings on a

Pediatric ECG (case examples)

Normal Findings

T waves

2 week male with ?Apparent Life Threatening Event

Inverted T waves in V1

Take home point #1

T waves
Newborn (week 1):
may be either inverted or upright in V1

Between 8 days & 8 years

Should be inverted in V1 (if not = RVH)

Normal Findings

Q waves

1-year-old male, asymptomatic,

Mom told that child has a murmur

Q waves in inferior/lat leads

Take home point #2

Q waves
Q waves are normal in II, III, aVF, V5 & V6
Absence of Q wave: suspect a VSD

Amplitude of accepted Q wave varies with

age
Use lead III as reference
6 months: up to 7 mm
12 months: up to 5 mm
8 years: up to 3 mm

8 year old boy referred for an irregular heart rhythm

Sinus rhythm
Varied heart rate

Take home point #3

Sinus Arrhythmia
Very common in children ages 2-10
Normal variant
Associated with increased vagal tone

Need to have normal P wave morphology

and normal PR intervals*

11 year old male with chest pain

Sinus rhythm, rate 60

ST elevation I, II, V2-6

Take home point #4

ST elevation
Early Repolarization
Normal Variant, common in adolescents
ST elevation <25% of T wave height
Symmetric T waves

Now for some abnormal ECGs

3-year-old girl referred with systolic murmur

rsR in V1

Take home point #5

RSR
If R>R in V1
Suspect RVH
25% chance of having ASD

8 week male with tachypnea

Left axis deviation [30-135]

RVH: S in V6 >10 [0-10], Q wave in V1

LVH: R in V6 >21 [5-21], Q wave >4mm in V6

Left axis deviation

RVH: S in V6 >10 [0-10]

LVH: R in V6 >21 [5-21]

AVSD

Take home point #6

Left Axis Deviation
LAD in first couple of months: suspect
AVSD

9 year old male with loud systolic murmur at LUSB

Axis +130
Pure R in V1
S in V6>4 mm

Axis +130
Pure R in V1
S in V6>4 mm

Pulmonary Stenosis

Take home point #7

RVH
RV dominance & RAD in first couple
months of life is normal
Large amplitude R waves in V1, small
amplitude R waves in V5 & V6

By 5-7 years
Expect more adult norms for R waves
R in V1: 0-14
R in V6: 4-25 (4-21 by 16 years)

4-month-old infant with wheezing and cardiomegaly

ST elevation in V1-3, 5, V3R, V4R

Inverted T waves in V5-6

ALCAPA
Anomalous Left Coronary Artery
from the Pulmonary Artery

Take home point #8

ST elevation
Children do get ischemia
If child is irritable with a history of recurrent
wheeze/cough and ST elevation is present,
consider ALCAPA

Summary
1. T waves

Should be inverted in V1 between 8 days & 8

years (if not = RVH)

2. Q waves

Normal in II, III, aVF, V5 & V6

Absence of Q wave: suspect a VSD

3. Sinus Arrhythmia

Very common in children

Look for normal P wave morphology & PR
interval

Summary
4. Early Repolarization
Normal Variant, common in adolescents
ST elevation <25% of T wave height

5. RSR
If R>R in V1, suspect RVH
25% chance of having ASD

6. Left axis deviation

If present in first couple of months: suspect AVSD

Summary
7. RV dominance & RAD

Normal in first couple months of life

8. Children do get ischemia

If child is irritable with a history of recurrent

wheeze/cough and ST elevation is present,
consider ALCAPA

Table of LVH/RVH criteria

Table of Normals

References
Pediatric ECG Interpretation-An Illustrative
Guide. B.J. Deal, C.L. Johnsrude, S.H.
Buck.
The Pediatric ECG. G.Q. Sharieff, S.O.
Rao. Emerg Med Clin N Am 24 (2006).
195-208.

Other Pearls
PR interval short at birth (0.08-0.15), increases
with increasing muscle mass
QRS shorter
Abnormal If >0.08 in children <8 years

LVH
LV strain in V5&V6 (flipped Ts), mature precordial R
wave progression in newborn

Sinus tachycardia
When febrile, expect HR to increase by 10 for every
degree elevation in temperature