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

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Steps to read Pediatric Electrocardiograms :

The Wave configuration:

Evaluate P wave in lead II and V1, if P wave is >2.5 boxes wide or tall, it is suggestive of left or right atrial enlargement respectively. LAE is denoted by 'wide and notched' P-waves and RAE is denoted by 'tall and peaked' P-waves. (Table 1)
The RV hypertrophy or LV hypertrophy determination depends on the R-wave and S-wave voltages and their ratio (R/S). Tall R in V1 (R/S >1) with deep S in V6 and upright T waves in right precordial leads suggests RVH. Tall R in V5 and V6 with deep S in V1 and T wave abnormalities in V5 and V6 suggests LVH (Table 1).

Table 1. ECG criteria for ventricular and atrial hypertrophy:

Right ventricular hypertrophy

R wave greater than the 98 th percentile in lead V1

S wave greater than the 98 th percentile in lead I or V6

RSR' pattern in lead V1, with the R' height being greater than 15 mm in infants younger than 1 year of age or greater than 10 mm in children older than 1 year of age

Q wave in lead V1

Left ventricular hypertrophy ( Fig 1)

R-wave amplitude greater than 98 th percentile in lead V5 or V6

R wave less than 5 th percentile in lead V1 or V2

S-wave amplitude greater than 98 th percentile in lead V1

Q wave greater than 4 mm in lead V5 or V6

Inverted T wave in lead V6

Right atrial enlargement ( Fig 2)

Peaked P wave in leads II and V1 that is higher than 3 mm in infants younger than 6 months of age and greater than 2.5 mm in infants older than 6 months of age

Left atrial enlargement

P-wave duration greater than 0.08 seconds in a child younger than 12 months of age or greater than 10 ms in children 1 year and older

P wave minimal or plateau contour

Terminal or deeply inverted P wave in lead V1 or V3R

The presence of any of these is suspicious for hypertrophy. It is not necessary for all of the criteria to be met.

S-T and T wave changes suggest ischemia or repolarization abnormalities. The elevation of ST-segment up to 1-4mm with the concavity facing upwards is normal. Any variation in the above depicts early repolarization, pericarditis, hyperkalemia, pneumothorax or pneumopericardium. ST depression is suggestive of pressure overload/strain.

In pediatric patients, T-wave changes on the ECG tend to be non-specific and are often a source of controversy. What is agreed on is that flat or inverted T waves are normal in the newborn. In fact, the T waves in leads V1 through V3 usually are inverted after the first week of life through the age of 8 years as the so-called "juvenile" T-wave pattern. Persistence of which suggests RVHT wave inversion in leads I, V5 and V6 is seen in ischemic conditions like ALCAPA, Kawasaki Disease and pressure overload/strain. Tall T wave suggests hyperkalemia and absent T-wave with U-wave suggests hypokalemia.