Paediatric ECG lead placement

Placement of paediatric ECG leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest, at a point analogous to the left-sided V4.

Precordial leads:

• V1: 4th intercostal space, right sternal border
• V2: 4th intercostal space, left sternal border
• V3: midway between V2 and the placement of V4 in adults (5th intercostal space, left mid-clavicular line)
• V4R: 5th intercostal space, right mid-clavicular line. Use this lead for V4R, must label as such on ECG.
• V5: anterior axillary line, same horizontal plane as V4
• V6: mid-axillary line, same horizontal line as V4

Limb leads:

• Place on top part of arm or leg (less muscle interference)

Related Topics

• Paediatric ECG Basics
• Normal paediatric ECG
• Stepwise assessment of the paediatric ECG
• Common paediatric arrhythmias
• ECG approach in syncope

References

• Paediatric Electrocardiography by Steve Goodacre and Karen McLeod, from the BMJ’s “ABC of Clinical Electrocardiography” series (2002)
• O’Connor M, McDaniel N, Brady WJ. The pediatric electrocardiogram. Part I: Age-related interpretation. Am J Emerg Med. 2008 Feb;26(2):221-8
• Evans WN1, Acherman RJ, Mayman GA, Rollins RC, Kip KT. Simplified pediatric electrocardiogram interpretation. Clin Pediatr (Phila). 2010 Apr;49(4):363-72.

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Zimmerman FH. ECG Core Curriculum. 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest