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