ECG indications in pediatric patients:
1. Congenital heart disease screening (esp. if heart murmur present)
- Questionable utility in asymptomatic children , but may assist in lesion-specific diagnosis in patients with underlying pathology [2,3]
- ECG & CXR may be helpful in evaluation of heart murmur or chest pain for (1) diagnosing heart disease if exam benign & (2) ruling out lesions if possible heart disease 
2. Serial ECGs to follow disease progression & determine need for intervention in diagnosed congenital heart disease
3. Clinically-suspected arrhythmia screening
- ECG may demonstrate arrhythmia or associated findings (eg, ventricular preexcitation, prolonged QT interval)
4. Syncope screening
- ECG is cost-effective when compared to other tests 
5. Routine ECG prior to noncardiac surgery
- Not necessary in adults (unless cardiac signs/symptoms or high risk of occult heart disease)  or children (unless heart disease suspected) 
6. Medications that may alter conduction or refractoriness (eg, antiarrhythmic drugs, prokinetic agents, antidepressants, atypical antipsychotic drugs, stimulants for ADHD)
7.Pediatric emergency department:
- Chest pain: most common indication; questionable utility (esp. if reproducible on chest palpation) [8,9]
- Other indications: suspected arrhythmia, seizure, syncope, drug exposure/ingestion 
Note: relative inaccurate ECG interpretation found with pediatric residents & emergency physicians [10,11,12], which suggests the need for further education &/or overreading by pediatric cardiologists 
1. Birkebek NH, Hansen LK, Oxhoj H. Diagnostic value of chest radiography and electrocardiography in the evaluation of asymptomatic children with a cardiac murmur. Acta Paediatr 84:1379, 1995.
2. Newburger JW, Rosenthal A, Williams RG, et al. Noninvasive tests in the initial evaluation of heart murmurs in children. N Engl J Med 308:61, 1983.
3. Smythe JF, Teixeira OH, Vlad P, et al. Initial evaluation of heart murmurs: are laboratory tests necessary? [see comments]. Pediatrics 86:497, 1990.
4. Swenson JM, Fischer DR, Miller SA, et al. Are chest radiographs and electrocardiograms still valuable in evaluating new pediatric patients with heart murmurs or chest pain? Pediatrics 99:1, 1997.
5. Steinberg LA, Knilans TK. Syncope in children: diagnostic tests have a high cost and low yield. J Pediatr 146:355, 2005.
6. Goldberger AL, O’Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission. Critical review and new guidelines. Ann Intern Med 105:552, 1986.
7. von Walter J, Kroiss K, Hopner P, et al. Preoperative ECG in routine preoperative assessment of children. Anaesthesist 47:373, 1998.
8. Horton LA, Mosee S, Brenner J. Use of the electrocardiogram in a pediatric emergency department. Arch PediatrAdolesc Med 148:184, 1994.
9. Massin MM, Bourguignont A, Coremans C, et al. Chest pain in pediatric patients presents to an emergency department or to a cardiac clinic. ClinPediatr (Phila) 43:231, 2004.
10. Snyder CS, Fenrich AL, Friedman RA, et al. The emergency department versus the computer: which is the better electrocardiographer? PediatrCardiol 24:364, 2003.
11. Snyder CS, Bricker JT, Fenrich AL, et al. Can pediatric residents interpret electrocardiograms? PediatrCardiol 26:396, 2005.
12. Giuffre RM, Nutting A, Cohen J, et al. Electrocardiogram interpretation and management in a pediatric emergency department. PediatrEmerg Care 21:143, 2005.
13. Wathen JE, Rewers AB, Yetman AT, et al. Accuracy of ECG interpretation in the pediatric emergency department. Ann Emerg Med 46:507, 2005.