Pediatric ECGs

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A excellent description of the neonatal electrocardiogram has been made by Schwarz et al.[1][2]

Heart Axis

Normal heart axis values[3]
Age QRS Axis Normal Values Abnormal Values Description
Adult -30° to 90°
<-30°
-30° to -45°
-45° to -90°
90° to 120°
90° to 180°
Left-axis deviation
Moderate left-axis deviation
Marked left-axis deviation
Moderate right-axis deviation
Marked right-axis deviation
8 to 16 years 0° to 120° >120° Right-axis deviation
5 to 8 years 0° to 140° >140°

<0°

Right-axis deviation

Left-axis deviation

1 year to 5 years 5° to 100° >100° Right-axis deviation
1 mo to 1 y 10° to 120° >120°

<10° to -90°

Right-axis deviation

Left-axis deviation

Neonate 30° to 90° >190° to -90°

<30° to <-90°

Extreme right axis deviation

Left axis deviation

Conduction: definition of LBBB and RBBB in children

  • RBBB: if consistent morphology and if QRS width >90ms in children < 4 years and >100ms in children 4-16 years[3]
  • LBBB: if consistent morphology and QRS width >90ms in children < 4 years and >100ms in children 4-16 years[3]

Normal neonatal ECG standards

Normal neonatal ECG standards[1]
Age group Heart rate
(beats . min-1)
Frontal plane
QRS axisa
(degrees)
P wave
amplitude
(mm)
P-R
intervala
(s)
QRS
durationa
V5
Q IIIc (mm) QV6c (mm) RV1b (mm) SV1b (mm) R/S V1c RV6b (mm) SV6b (mm) R/S V6c SV1 + RV6c (mm) R + SV4c (mm)
0–1 days 93–154 (123) +59 to +192 (135) 2·8 0·08–0·16 (0·11) 0·02–0·08 (0·05) 5·2 1·7 5–26 0–22·5 9·8 0–11 0–9·8 10 28 52
1–3 days 91–159 (123) +64 to +197 (134) 2·8 0·08–0·14 (0·11) 0·02–0·07 (0·05) 5·2 2·1 5–27 0–21 6 0–12 0–9·5 11 29 52
3–7 days 90–166 (129) +77 to +187 (132) 2·9 0·08–0·14 (0·10) 0·02–0·07 (0·05) 4·8 2·8 3–24 0–17 9·7 0·5–12 0–9·8 10 25 48
7–30 days 107–182 (149) +65 to +160 (110) 3·0 0·07–0·14 (0·10) 0·02–0·08 (0·05) 5·6 2·8 3–21·5 0–11 7 2·5–16 0–9·8 12 22 47
1–3 months 121–179 (150) +31 to +114 (75) 2·6 0·07–0·13 (0·10) 0·02–0·08 (0·05) 5·4 2·7 3–18·5 0–12·5 7·4 5–21 0–7·2 12 29 53
  • a 2nd–98th percentile (mean)
  • b 2nd–98th percentile (1 mm=100 µV)
  • c 98th percentile (1 mm=100 µV)

Distinguishing tachyarrhythmias in infants

Distinguishing tachyarrhythmias in infants[1]
  Sinus tachycardia SVT Atrial flutter VT
History Sepsis, fever, hypovolaemia, etc. Usually otherwise normal Most have a normal heart Many with abnormal heart
Rate Almost always <230 b/min Most often 260–300 b/min Atrial 300–500 b/min. Vent. 1:1 to 4:1 conduction 200–500 b/min
R-R interval variation Over several seconds may get faster and slower After first 10–20 beats, extremely regular May have variable block (1:1, 2:1, 3:1) giving different ventricular rates Slight variation over several beats
P wave axis Same as sinus almost always visible P waves 60% visible P waves, P waves do not look like sinus P waves Flutter waves (best seen in LII, LIII, aVF, V1) May have sinus P waves continuing unrelated to VT (AV dissociation), retrograde P waves, or no visible P waves
QRS Almost always same as slower sinus rhythm After first 10–20 beats, almost always same as sinus Usually same as sinus, may have occasional beats different from sinus Different from sinus (not necessarily ‘wide’)
  • SVT = Supraventricular tachycardia
  • VT = ventricular tachycardia

References

  1. Schwartz PJ, Garson A Jr, Paul T, Stramba-Badiale M, Vetter VL, Wren C, and European Society of Cardiology.. Guidelines for the interpretation of the neonatal electrocardiogram. A task force of the European Society of Cardiology. Eur Heart J. 2002 Sep;23(17):1329-44. PubMed ID:12269267 | HubMed [schwarz1]
  2. Schwartz PJ, Paul AG Jr, Stramba-Badiale M, Vetter VL, Villain E, Wren C, and Task Force of the Comittee for Practice Guidelines and Policy Conferences of the European Society of Cardiology.. Report from the Task Force of the European Society of Cardiology for the interpretation of the neonatal electrocardiogram. Cardiol Young. 2002 Dec;12(6):592-608. PubMed ID:12739597 | HubMed [schwarz2]
  3. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, Hancock EW, Josephson M, Kligfield P, Kors JA, Macfarlane P, Mason JW, Mirvis DM, Okin P, Pahlm O, Rautaharju PM, van Herpen G, Wagner GS, Wellens H, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology., American College of Cardiology Foundation., and Heart Rhythm Society.. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2009 Mar 17;119(10):e235-40. DOI:10.1161/CIRCULATIONAHA.108.191095 | PubMed ID:19228822 | HubMed [aha]
All Medline abstracts: PubMed | HubMed