A Practical Guide to Paediatric ECG Interpretation for General Practitioners: From Age-Related Normality to Recognition of Pathology

Abstract

The electrocardiogram (ECG) is a vital diagnostic tool in children presenting with syncope, chest pain, palpitations, and suspected heart conditions. However, paediatric ECG interpretation presents unique challenges due to significant age-related physiological changes affecting heart rate, axis, intervals, and wave morphology; hence, what is normal for a neonate may be abnormal for an adolescent. General practitioners (GPs) are often the first point of contact for children with these presentations, yet many report limited confidence in interpreting paediatric ECGs. Recent evidence from a 2025 study demonstrated a mean accuracy of 76.6% among clinicians, with notable misdiagnosis rates in emergency and resource-limited settings.

This article presents a practical, evidence-informed framework for paediatric ECG interpretation, developed through synthesis of peer-reviewed literature, published normative data, and established cardiology guidelines. We provide an overview of developmental physiology, a structured five-step approach to ECG analysis, and discussions of common arrhythmias and red flags requiring urgent cardiology referral. Reference tables offer age-adjusted normal parameters, and a summary algorithm supports clinical decision-making. Technical considerations, including lead placement, motion artefact, and the limitations of automated interpretations, are addressed to reduce misdiagnosis. The goal is to bolster GPs' confidence in distinguishing benign from dangerous conditions, enhance patient safety, and optimise the utilisation of specialist care.