ECG indications in pediatric patients:
1. Congenital heart disease screening (esp. if heart murmur present)

• Questionable utility in asymptomatic children [1], 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 [4]

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]

5. Routine ECG prior to noncardiac surgery

• Not necessary in adults (unless cardiac signs/symptoms or high risk of occult heart disease) [6] or children (unless heart disease suspected) [7]

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 [8]

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 [13]

REFERENCES

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.