Pediatric Electrocardiogram ECG Reading Steps-Normal Variation,Values

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Pediatric Electrocardiogram - The Basics

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PEDIATRIC ELECTROCARDIOGRAM- THE BASICS

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Introduction and Basics of Recording and Interpretation of Pediatric ECG

Sumitra Venkatesh, Shakuntala Prabhu
Div. of Pediatric Cardiology,
Dept. of Pediatrics,
B.J.Wadia Hospital for Children, Mumbai

Corresponding address: Shakuntala Prabhu, Div. of Pediatric Cardiology, Dept. of Pediatrics, B.J.Wadia Hospital for Children, Mumbai.
Email : ssprabhu1@hotmail.com

Continue....

Steps to read Pediatric Electrocardiograms:

Normal variations to be considered in children (Table 2):

Normal heart rate in the neonates varies between 120-230/min and gradually decreases over the first 6 months. Resting heart rate is about 120 beats/min at 1 year, 100 at 5 years and reaches adult values by 15 years.
Appearance of secondary 'r' waves (r' or R') in right chest leads is normal in neonates.
At birth, right axis deviation of the mean QRS vector is the rule. The axis becomes normal by 1 year of age. Hence, normal or leftward QRS axis is abnormal in the neonatal period and early infancy. Common conditions with leftward axis of QRS vector are tricuspid atresia and AV canal defects.
The PR-interval varies with age. Neonates - 0.08-0.15, adolescents - 0.12-0.20 seconds. This normal variation must be kept in mind when considering diagnosis of conduction abnormalities or AV-blocks in children. Other pathological causes of short PR interval are Pompe's Disease, Fabry's disease, Mannosidosis, WPW syndrome, ectopic atrial pacemaker from lower right atrium.
Dominant R in right precordial leads can persist up to 6 months to 8 years; in the majority, the R/S ratio in lead V1 becomes less than 1 by 4 years of age.
Q waves are normally seen in leads II, III, aVF, V5 and V6 due to the clockwise loop of the QRS vector and are seen in majority of the congenital heart diseases. Q-waves in leads I and aVL suggest a counter-clockwise loop of the initial QRS vector and is seen in cases of Tricuspid atresia, Endocardial cushion defect and inlet VSD. Deep Q waves in lateral leads might point towards underlying anomalous origin of left coronary artery from pulmonary artery (ALCAPA).
The QRS complex duration varies with age. In children, the QRS complex duration is shorter, possibly because of decreased muscle mass, and gradually increases with age. The QRS complex measures 0.03-0.08 seconds in neonates and 0.05-0.10 seconds in adolescents. As a result, slight prolongation of what may appear as a normal QRS complex can indicate a conduction abnormality or bundle branch block in children .
QT interval is highly variable in the first 3 days of life and in early infancy may be as high as 0.49seconds. Corrected QT (calculated by Bazett's formula) of more than 0.44 seconds is abnormal thereafter. The common causes of prolonged QTc are hypokalemia, hypocalcemia, hypothermia and cerebral injury. Certain drugs also prolong the QT-interval, viz. Cisapride, Macrolide antibiotics, etc.
Preterms of < 28 weeks of gestation may not have right ventricular dominance. Chest leads may show LV dominance with normal or leftward QRS axis.
Sinus pauses or junctional escapes (narrow QRS complex without preceding P waves) may occasionally occur during sleep, feeding and defecation.

Table 2: Normal values in Pediatrics:

Age	HR (bpm)	QRS axis (degrees)	PR interval (sec)	QRS interval (sec)	R in V1 (mm)	S in V1 (mm)	R in V6 (mm)	S in V6 (mm)
wk	HR (bpm)	QRS axis (degrees)	PR interval (sec)	QRS interval (sec)	R in V1 (mm)	S in V1 (mm)	R in V6 (mm)	S in V6 (mm)
1st wk	90-160	60-180	0.08-0.15	0.03-0.08	5-26	0-23	0-12	0-10
1-3 wk	100-180	45-160	0.08-0.15	0.03-0.08	3-21	0-16	2-16	0-10
1-2 mo	120-180	30-135	0.08-0.15	0.03-0.08	3-18	0-15	5-21	0-10
3-5 mo	105-185	0-135	0.08-0.15	0.03-0.08	3-20	0-15	6-22	0-10
6-11 mo	110-170	0-135	0.07-0.16	0.03-0.08	2-20	0.5-20	6-23	0-7
1-2 yr	90-165	0-110	0.08-0.16	0.03-0.08	2-18	0.5-21	6-23	0-7
3-4 yr	70-140	0-110	0.09-0.17	0.04-0.08	1-18	0.5-21	4-24	0-5
5-7 yr	65-140	0-110	0.09-0.17	0.04-0.08	0.5-14	0.5-24	4-26	0-4
8-11 yr	60-130	-15-110	0.09-0.17	0.04-0.09	0-14	0.5-25	4-25	0-4
12-15 yr	65-130	-15-110	0.09-0.18	0.04-0.09	0-14	0.5-21	4-25	0-4
>16 yr	50-120	-15-110	0.12-0.20	0.05-0.10	0-14	0.5-23	4-21	0-4
Ref- Ra'id Abdullah, MD, University of Chicago , Illinois .

Summary:

Interpreting pediatric ECG is easy if a systematic approach of heart rate, intervals, axis and waveform morphologies is applied. Knowing what is normal in pediatric age group helps to easily identify what is abnormal.

Suggested Reading:

Sharieff GQ, Rao SO. The Pediatric ECG Emergency Medicine Clinics of North America. February 2006; 24(1):195-208.
H.D. H.P. E.B. Moss and Adams' heart disease in infants, children, and adolescents 6th edition. 2001Philadelphia: Lippincott, Williams and Wilkins,
Park M.K., George R., Pediatric cardiology for practitioners. St. Louis: Mosby, 2002. p. 34-51
Savitsky E., Alejos J., Votey S., Emergency department presentations of pediatric congenital heart disease. J Emerg Med (2003) 24: 239-245.
Sharieff G., Wylie T., Pediatric cardiac disorders. J Emerg Med (2004) 26 : 65-79
Schwartz PJ, Garson A, Paul T et al. Guidelines for the interpretation of the neonatal electrocardiogram. European Heart J 2002; 23:1329-44.
Horton L., Mosee S., Brenner J., Use of the electrocardiogram in a pediatric emergency department. Arch Pediatr Adolesc Med (1994) 148: 184-188.

Last Updated 1 - 3 - 2007 Vol 4 Issue 3 Art # 9

How to cite this url :

Venkatesh S, Prabhu S .Pediatric Electrocardiogram The Basics. Pediatric Oncall [serial online] 2007 [cited 2007 March 1];4. Art # 9. Available from: