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Elias Perez
Elias Perez

How To Read Pediatric ECG



This is Part 1 of a two-part series about the approach to pediatric ECGs. This series was developed by Eric King, a medical student at the University of Alberta. This podcast was developed with the help of pediatric hospitalist and medical educator Dr. Karen Forbes, pediatric cardiologist Dr. Joseph Atallah and the help of the PedsCases team. This series will cover how to systematically interpret a pediatric ECG, how the forces within the heart change and progress after birth, how to recognize a normal pediatric ECG at different points in childhood, and how to recognize common pediatric ECG abnormalities. Part 1 will discuss rate, rhythm, axis, and intervals, and will work through a case of a 4-week-old boy with a new murmur.




How to Read Pediatric ECG



Objectives: To assess the impact of participation in an educational presentation on electrocardiogram (ECG) interpretation in children on pediatric practitioners' ability to accurately interpret ECGs.


Study design: Pediatric healthcare providers at a pediatric clinic with >65 000 visits/year were eligible to participate. A 1-hour ECG educational module that provided a systematic approach to ECG interpretation was presented to 8 providers who consented (6 pediatricians, 2 pediatric nurse practitioners). A test on 11 ECGs (normal, normal-variant, and abnormal ECGs) was given before and 2 weeks after the educational module. Outcomes included correct interpretation of each ECG as normal or abnormal and correct identification of specific ECG findings. Data analysis was descriptive and included χ2 and Student t test.


Conclusions: Education of pediatric practitioners on ECG interpretation significantly improves their ability to distinguish normal from abnormal and to identify specific abnormalities. Limitations included small sample size and short-term follow-up.


In late 2020, the CSRC announced the establishment of a pilot project called Prevention of Sudden Cardiac Death in the Young (SCDY), which created a first-in-kind pediatric electrocardiogram (ECG) data warehouse. The intent behind the SCDY project was to help identify and overcome barriers to effective pediatric cardiac screening, a goal shared by a number of stakeholders across the biomedical community.


The FDA already utilizes an ECG data warehouse to support its cardiac safety review of therapeutic product development programs; however, there is no equivalent pediatric ECG data warehouse. Therefore, it is much more difficult to ensure comprehensive cardiac safety review for therapeutic product development for children.


Ultimately, the data warehouse and these relationships with screening partners will enable access to high-quality pediatric data on a scale that will allow research into a wide array of cardiac issues. It may even enable researchers to improve clinical guidelines for assessing cardiac risk in children, develop better pre- and post-market cardiac safety evaluation in children, and develop biomarkers for use in pediatric clinical trials.


Long QT Identification of differences in the pediatric and adult ECG aid in distinguishing potentially life-threatening abnormalities from a normal ECG, with one of the most notable and vastly overlooked conditions being prolonged QT interval.


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In order to compensate for the effect of low-frequency signals, such as those due to chest wall movement with respiration, while also minimizing the effects of extraneous high frequency on the fidelity of the recordings, various filters must be applied to the raw electrical signal. For the current digital systems in use, these low-frequency and high-frequency cutoff values are 0.5 Hz and 150 Hz, respectively, for adult ECG. In pediatric ECG, the high-frequency filter should be increased to 250 Hz. Additional guidelines are given with respect to signal amplification, compression, and storage; these are beyond the scope of this article.


Lead V1 is placed at the fourth intercostal space at the right sternal border. [16] Lead V2 is placed at the left sternal border directly across from lead V1, also in the fourth intercostal space. Lead V4 is placed in the fifth intercostal space at the mid clavicular line, and then lead V3 can be placed midway between leads V2 and V4. Lead V6 is placed in the horizontal plane of V4 at the mid-axillary line, and then lead V5 is placed in the same horizontal plane as that of lead V4 in the anterior axillary line or midway between leads V4 and V6 when the anterior axillary line is not readily discernible.


Once the ECG is completed, it should be reviewed by the operator. If significant issues with the quality of the tracing exist, the cause of the issue should be addressed and the tracing repeated. When this is impractical or impossible, the clinician ordering or reading the ECG should be notified for further guidance.


The initial review of the 12-lead electrocardiogram (ECG) should encompass the following: heart rate and rhythm, P-QRS-T morphology, presence of ST segment, and PR-QRS-QT intervals (see the image below). Each ECG should be thoroughly analyzed ("read") in a systematic fashion to avoid overlooking important abnormalities. The following steps are important to consider:


The QRS axis represents the major vector of ventricular activation, which is the overall direction of electrical activity. The electrical activity in healthy individuals starts at the sinoatrial node and spreads to the atrioventricular node down the Bundle of His, followed by conduction through the left and right bundle branches, and then to the Purkinje fibers to cause ventricular contraction. A positive deflection is when the direction of the overal electrical activity is toward that lead. Therefore, the cardiac axis may provide the overall direction of electrical activity when the ventricles depolarize. The normal cardiac axis is expected to lie between -30º and 90º, which means the overall direction of electrical activity is toward leads I, II, and III.


This article covers the core principles of ECG interpretation. In addition, we discuss the important differences in the ECG in paediatrics, and the underlying reasons for these. This should give the reader confidence in identifying the spectrum of normal ECG patterns, and the skills to diagnose the most commonly seen abnormalities.


The ECG reflects the spreading wave of electrical activity passing through the myocardium during the cardiac cycle. In sinus rhythm, the action potential travels from the sinoatrial (SA) node through the atria (P wave) to the atrioventricular (AV) node. Here the impulse is delayed, allowing synchronous atrial and ventricular contraction, before being rapidly conducted by the bundle of His, right and left bundle branches, and the Purkinje fibres (the QRS complex). The T wave is produced by ventricular repolarisation. Systematic ECG interpretation should examine each of these events in turn [1].


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