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
Be aware 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
myocarditis), post cardiac
surgery
A-arrhythmias (tachy or
bradyarrhythmia)
E-exertional symptoms
D-drugs, disease (Kawasaki)
S-syncope/seizure
E-electrolyte disturbance
C-cyanosis, contusion
(myocardial), cold
(hypothermia)
G- conGenital heart defects
 2 Fs:
◦ 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 infant’s 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

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 + 180º 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 birth-1 AGE PR (ms)

yr, then gradually
increases t/o childhood Birth 80-160

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 larger 33 weeks gestation 1.0 : 1
than LV, so Normal to
have: 36 weeks gestation 0.8 : 1

◦ Right axis deviation At birth 0.8 : 1

◦ Large precordial R 1 month 1.5 : 1
waves
◦ Upright T waves 6months 2.0 : 1

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 Depolarization Newborn +125°
process
 Birth:
1 month +90°
◦ mean QRS axis +125° with RAD
◦ up to 180° can be normal in
newborn 3 years +60°
◦ 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
Depolarization duration
time (ms)
 QRS duration
are short in the Birth < 75
young infant & 6m < 75
increases with
age. 1 yr < 75
5 yr < 80
10 yr < 85
Normal values in paediatric
electrocardiograms
R wave (S Wave)
Amplitude (mm)
Age PR QRS Lead V1 Lead V6
Interval (ms) duration
(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 Bazett’s 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 can’t calculate, shouldn’t 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 R wave (S
wave) 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
Mustard’s

 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 pulm venous  Coarctation
return ◦ < 6m: RBBB or RVH
◦ Total: RAD, RVH, RAH ◦ > 6m: LVH, N, RBBB
◦ Partial RVH or RBBB  Patent ductus arteriosus
◦ Small shunt: N
◦ Mod: LVH, +/- LAH
◦ Large: CVH, LAH
Some Congenital Heart Defects and ECG
Manifestations
 Persistent truncus Transposition
arteriosus ◦ Intact septum: RVH, RAH
◦ LVH or CVH ◦ VSD and/or PS: CVH, RAH,
 Pulm atresia (and or CAH
hypoplastic RV) Corrected transposition
◦ LVH ◦ AV blocks, WPW, LAH or
 Tetralogy of Fallot CAH, absent Q in V5/V6,
◦ RAD, RVH, +/- RAH 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 children’s 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

Sinus rate 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

1st degree 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
 Conduction pathways same,
so waveforms (P, QRS, T)
same, and waveform timing
measured the same (i.e., PR,
QRS, QT interval)
 Identical approach to ECG
analysis
DIFFERENCES
 Kids: fast HR that slows
with age, shorter N
intervals that prolong
with age, and diminution
of RV dominance
 Sinus bradycardia, sinus
arrhythmia and SVT most
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