The Patient: This ECG was obtained from a seven-year-old girl who was complaining of mild, non-specific chest pain. A medical workup found no structural or electrical abnormalities, and her pain resolved without treatment. This is a good ECG to illustrate some of the ECG findings that are normal at this age, which might not be normal in adults or in infants.
The ECG: A general description of this ECG would include:
· Normal sinus rhythm at 87 bpm
· Normal frontal plane QRS axis at 60 degrees
· PR interval: .132 second (132 ms)
· QRS duration: .082 second (82 ms)
· QTc: .391 second (391 ms)
· Predominantly negative V1 and positive V2
· Slightly irregular rhythm with no apparent changes in P wave morphology
· Very subtle J point elevation in V1 through V3
The Normal ECG in Children It is not really possible to state exact parameters for pediatric ECGs by age alone. ECG findings are affected by age, but also by race, gender, body size, and puberty. There are some findings in this ECG that can be considered to be normal for this child without being necessarily normal for an infant, or for an adult.
· The slightly irregular sinus rhythm is very common in children
· T wave inversion in V1 is normal for a 7-year-old. In infants older than one week, T waves are usually inverted in V1 – V3. The right precordial T waves will become upright during early childhood, with V3 becoming upright before V2.
· RSR’ pattern in V1 resembles right bundle branch block without the QRS widening.
· Tall R waves in mid-precordial leads may appear to meet voltage criteria for LVH. However, there is no “strain” pattern in the ST segments. In this example, there is also no left axis deviation and aVL has low voltage (normal). This appearance of high voltage is due to the child’s small chest wall, which makes the heart’s voltage readily measurable by the surface leads. (The ECG, in general, is not the best way to diagnose LVH – imaging is much better).
· Slightly peaked (rather than rounded) P waves, less than 3 mm in height.
Some findings that might be normal in a seven-year-old that are NOT present in this ECG include:
· Ventricular or supraventricular ectopy
· Slightly rightward frontal plane axis
· Dominant R wave in V1 (although the R wave in V2 might be taller than expected in an adult).
· Short PR interval and QRS duration.
· PR interval variations.
References: For more information, go to:
Heart. 2005 Dec; 91(12):1626-1630. Doi: [10.1136/hrt.2004.057307]
Life In The Fast Lane Paediatric ECG Interpretation
Many thanks to Alan Vinyets for donating this ECG to the ECG Guru.