Paediatric ECG

Use the following chart as a quick checklist to review what’s normal and what’s not in a paediatric ECG.

Remember:

Lead V4R in under5’s
Manually calculate QTc
WPW needs referral for ablation – increase risk of sudden death

If in any doubt discuss with paediatric registrar/senior. If in need of urgent interven:on then contact the paediatric cardiology team in LGI.

1. Placement of Leads: Precordial Leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest at a point analogous to the left sided V4.

2. P Waves:

3. Axis:

In utero- high pulmonary pressures and a relatively thick Right Ventricle (RV) -> Initial Right Axis on ECG is normal and resolves after the first 6 months of life

QRS Axis Deviation

Chest leads in wrong position

RAD:

Newborns
RVH secondary to Right ventricular outflow tract obstruction eg: Pulmonary
Stenosis ,Tetralogy Of Fallot, Noonans (characterized by mildly unusual facial features, short stature, heart defects, bleeding problems, skeletal malformations, and many others)
RBBB

LAD:

LBBB
LVH secondary to LVOTO (Left Ventricular Outflow Tract Obstruction) e.g. Aortic Stenosis, HOCM

Superior Axis

AVSD (Atrio ventricular septal defect – Trisomy 21)

4. QTc:

Manually calculate QTc – HERE

Normal QTc:

Infants less than 6 months = < 0.49 seconds.
Older than 6 months = < 0.44 seconds.

QTc is prolonged in:

Hypocalcaemia
Myocarditis
Long QT syndromes such as Romano-Ward Drugs

QTc is short in:

Hypercalcaemia
Congenital short QT syndrome

5. Ventricular Hypertrophy

6. T waves:

The precordial T-wave configuration changes over time
For the first week of life, T waves are upright throughout the precordial leads.
After the first week, the T waves become inverted in V1-3 (= the “juvenile T-wave pattern”)
This T-wave inversion usually remains until ~ age 8; thereafter the T waves become upright in V1-3.
However, the juvenile T-wave pattern can persist into adolescence and early adulthood (= “persistent juvenile T waves”).

Tall, peaked T waves are seen in:

Hyperkalaemia, Dilated LV (volume overload), Benign early repolarisation

Flat T waves are seen in:

Normal newborns, Hypothyroidism, Hypokalaemia, Pericarditis, Myocarditis

7. ST Segment:

Some ST changes may be normal:

Limb lead ST depression or elevation of up to 1mm (up to 2mm in the left precordial leads).
J-point depression: the J point is depressed without sustained ST depression, i.e. upsloping ST depression
Benign early repolarisation in adolescents: the ST segment is elevated and concave in leads with an upright T wave.

Others are pathological:

A downward slope of the ST followed by a inverted T.
A sustained horizontal ST segment depression

Pathological ST segment changes are commonly associated with T wave changes and occur in:

Pericarditis.
Myocardial ischaemia or infarction.
Severe ventricular hypertrophy (ventricular strain pattern)

Thanks to the paediatric dept for supplying the guidance – trust PDF here