Paeds · investigations-procedures-and-technology
Electrocardiogram acquisition and interpretation in children
Also known as Paediatric ECG · Children's ECG · 12-lead ECG in children · Neonatal ECG · Paediatric electrocardiography · ECG interpretation by age
Fellowship guide to electrocardiogram acquisition and interpretation in children. Covers the technical principles of 12-lead acquisition and electrode placement in an uncooperative infant, the age-specific normal intervals for heart rate, PR, QRS duration and axis, the right ventricular dominance of the newborn that resolves through childhood, the Bazett and alternative QTc formulae and the age-specific prolonged-QTc thresholds, the structured systematic interpretation sequence, and the high-yield abnormal patterns of long QT syndrome, pre-excitation, chamber hypertrophy, AV block and the juvenile T-wave pattern.
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Target exams
Red flags
- A QTc above 480 milliseconds in an infant or above 470 milliseconds in an older child, particularly with syncope on exertion or emotion, a family history of sudden death, or congenital deafness — long QT syndrome carries a measurable risk of torsades de pointes and sudden cardiac death and demands urgent cardiology referral
- A neonate or infant with a wide-complex tachycardia and haemodynamic compromise — ventricular tachycardia in infancy may reflect an accessory pathway, myocarditis, or a channelopathy and is not assumed to be supraventricular tachycardia simply because the child is small
- Second-degree AV block that conducts poorly, or any third-degree (complete) AV block detected in a neonate — congenital complete heart block is strongly associated with maternal anti-Ro and anti-La antibodies and needs urgent paediatric cardiology assessment and pacing evaluation
- An ECG with ST-segment elevation across multiple leads in a child with chest pain, or diffuse deep T-wave inversion beyond the normal juvenile pattern — this may represent myocarditis, pericarditis, or an anomalous coronary origin rather than benign early repolarisation
- A pre-excitation pattern (delta wave, short PR) on a routine paediatric ECG with a history of syncope — Wolff-Parkinson-White syndrome carries a small but real risk of sudden death, and asymptomatic pre-excitation requires risk stratification
- Reading a neonatal ECG with the adult normal ranges in mind — right axis deviation, dominant R waves in V1, upright T waves in V1 in the first week of life, and shorter intervals are normal in the newborn, and mislabelling them as abnormal causes unnecessary cardiology referral
Life stages
Care settings
Clinical exam formats
Board mappings
- Procedures and investigations
- Acquire and interpret a 12-lead ECG in an infant or child
- Knowledge of age-specific normal ECG intervals and axis
- Current 2026 PREP curriculum — Learning goal 11: Investigations and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Investigations and procedures
- Recognition of the abnormal paediatric ECG requiring cardiology referral
- Written Examination
- Clinical Applications
- Cardiology and cardiac emergencies requiring ECG interpretation
- Short Cases
- Investigation interpretation and procedural skills
- Communication and patient-safety scenarios
- 11. Investigating and managing paediatric presentations
- Level 2: Acquires and interprets a paediatric ECG with appropriate supervision
- Patient safety: recognising age-specific normal ranges and the abnormal ECG
- Applied Knowledge in Practice (AKP)
- Foundations of Practice (FOP)
- Cardiology: ECG acquisition, age-specific normal intervals and the abnormal paediatric ECG
- Clinical
- Investigation interpretation scenarios
- Safe procedural and assessment skills
- General Pediatrics Content Outline — Cardiology: ECG interpretation by age
- General Pediatrics Content Outline — Procedural skills: ECG acquisition
- General Pediatrics EPA: Acquire and interpret a paediatric ECG
- Patient Care 3: Procedural skills
- Medical Knowledge 1: Clinical knowledge
- Systems-Based Practice: safe investigation and appropriate referral
- Medical Expert
- Communicator
- Pediatrics: Core EPA — Acquire and interpret a paediatric ECG
Overview & Definition
Picture the six-week-old infant brought in with poor feeding and a fast heart rate, the eight-year-old who has fainted during a swimming lesson, or the teenager referred by the GP for an "abnormal ECG" after a routine check. In each case the question the ECG must answer is whether the electrical activity of the child's heart is normal for their age, and that question cannot be answered with adult ranges. That is the territory this page owns. [1] [2]
A 12-lead electrocardiogram (ECG) is the non-invasive recording, from ten surface electrodes (four limb and six precordial), of the summed electrical potentials generated by the myocardium over time and displayed as twelve different spatial views or leads. In a child the same physical principles apply as in the adult, but the normal ranges for heart rate, the PR and QRS intervals, the QRS axis, and the T-wave morphology all change with age, and the newborn ECG in particular is dominated by the right ventricle because the right heart has been working against the high pulmonary vascular resistance of fetal life. The discipline of the paediatric ECG is therefore to acquire a clean tracing and to interpret it against age-specific norms. [1] [9]
What distinguishes the paediatric ECG from the adult is a combination of a small, fast, often uncooperative patient and an electrical anatomy that is still maturing. The neonatal right ventricle is dominant, the intervals shorten with faster heart rates and lengthen as the heart grows, the T waves in V1 to V3 are normally inverted through childhood, and a number of channelopathies and congenital arrhythmias declare themselves on the surface ECG long before they declare themselves clinically. The fellowship skill being tested is acquiring a technically adequate tracing, interpreting it systematically against the correct age ranges, and recognising the patterns that demand urgent cardiology referral. [2] [6]
References12ShowHide
- [1]Miliaraki M, Germanakis I Pediatric Electrocardiogram in Preparticipation Screening: Narrative Review of Normal Values in Key Features Children (Basel), 2026.PMID 41749567
- [2]Sharieff GQ, Rao SO The pediatric ECG Emerg Med Clin North Am, 2006.PMID 16308120
- [3]Wathen JE, Rewers AB, Yetman AT, et al. Accuracy of ECG interpretation in the pediatric emergency department Ann Emerg Med, 2005.PMID 16308065
- [4]Gandhi S, Lin M, Smith SR, et al. Predictors of abnormal electrocardiograms in the pediatric emergency department Ann Pediatr Cardiol, 2018.PMID 30271014
- [5]Schwartz PJ, Moss AJ, Vincent GM, Crampton RS Diagnostic criteria for the long QT syndrome. An update Circulation, 1993.PMID 8339437
- [6]Zareba W, Moss AJ Long QT syndrome in children J Electrocardiol, 2001.PMID 11781951
- [7]Schwartz PJ, Stramba-Badiale M, Segantini A, et al Prolongation of the QT interval and the sudden infant death syndrome N Engl J Med, 1998.PMID 9624190
- [8]Saul JP, Schwartz PJ, Ackerman MJ, et al Rationale and objectives for ECG screening in infancy Heart Rhythm, 2014.PMID 25239430
- [9]Pærregaard MM, Kock J, Pihl C, et al. The Evolution of the Neonatal QRS Axis during the First Four Weeks of Life Neonatology, 2021.PMID 33691309
- [10]Park J, Kimata C, Young J, et al. Fine Tuning ECG Interpretation for Young Athletes: ECG Screening Using Z-score-based Analysis Sports Med Open, 2024.PMID 39441450
- [11]Pinsky AM, Kulkarni VK, Bos JM, et al. Proceed with caution: Standard protocol exercise stress tests fail to replicate the diagnostic utility of supine-stand tests for long QT syndrome Pacing Clin Electrophysiol, 2024.PMID 38348899
- [12]Gotta V, Donner B QT interval prolongation: clinical assessment, risk factors and quantitative pharmacological considerations J Pharmacokinet Pharmacodyn, 2025.PMID 41204044