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.
This website interpretation tool makes this even easier!
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.
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)
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
- 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
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:
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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
