What is the initial approach to a child presenting with palpitations?

Initial Approach to a Child with Palpitations

The initial approach to a child presenting with palpitations should include a detailed medical history, physical examination, family history, and a 12-lead ECG, which should be performed in all pediatric patients with palpitations. 1

Initial Evaluation

History

• Symptom characteristics:

  • Onset and offset pattern (sudden onset/offset suggests ventricular tachycardia)
  • Duration and frequency of episodes
  • Precipitating factors (exercise, emotional stress, position changes)
  • Associated symptoms (syncope, presyncope, chest pain, dyspnea)
  • Description of sensation ("shirt flapping" or "neck pounding" suggests AVNRT) 1

• Red flags in history:

  • Palpitations during exercise (suggests hypertrophic cardiomyopathy or catecholaminergic polymorphic ventricular tachycardia) 1
  • Syncope with palpitations (suggests hemodynamically significant arrhythmia) 1
  • Family history of sudden cardiac death or inheritable heart disease 1
  • Palpitations with chest pain, dyspnea, or fatigue (suggests underlying structural heart disease) 1

Physical Examination

• Vital signs (heart rate, blood pressure, respiratory rate)
• Cardiac examination (murmurs, gallops, irregular rhythm)
• Signs of structural heart disease (hepatomegaly, peripheral edema)

Initial Testing

• 12-lead ECG - mandatory first-line test 1
  • Look for:
    • Pre-excitation (WPW pattern)
    • QT interval abnormalities
    • ST-segment changes (Brugada pattern)
    • Chamber enlargement
    • Conduction abnormalities

Risk Stratification

Low Risk Features

• Normal ECG
• No family history of sudden cardiac death
• No syncope or presyncope
• No exertional symptoms
• Normal physical examination

High Risk Features

• Abnormal ECG
• Family history of sudden cardiac death or inheritable heart disease
• Syncope, especially with exertion
• Palpitations during exercise
• Abnormal physical examination suggesting structural heart disease

Additional Testing Based on Risk

For Low-Risk Patients

• Patient-activated event recorder for intermittent symptoms 1
  • Particularly useful for palpitations, as studies show arrhythmias correlate with palpitations in 10-15% of young patients 1
  • Sinus tachycardia is identified in nearly 50% of young patients with palpitations 1

For High-Risk Patients

1. Echocardiogram - to evaluate for structural heart disease 1

2. Extended monitoring based on frequency of symptoms:

   • 24-48 hour Holter monitor for frequent symptoms
   • Event recorder for less frequent symptoms
   • Implantable cardiac monitor for very infrequent but concerning symptoms 1

3. Exercise stress testing - particularly useful for:

   • Exertional symptoms
   • Suspected channelopathies (LQTS, CPVT) 1

Common Pitfalls and Caveats

• Don't dismiss symptoms as anxiety - Studies show that symptoms of SVT are frequently mislabeled as panic, anxiety, or stress (54% of patients), with women more likely to be mislabeled 1

• Don't miss red flags - Exertional palpitations or palpitations with syncope require thorough evaluation as they may indicate serious cardiac conditions 1

• Remember age-specific considerations - The mean age of symptom onset in pediatric populations is 8 years for AVRT and 11 years for AVNRT 1

• Don't overtest low-risk patients - In patients with normal ECG, no concerning symptoms, and no family history, extensive cardiac testing is usually unnecessary 1

When to Refer to Cardiology

• Abnormal ECG findings
• Exertional palpitations
• Palpitations with syncope or presyncope
• Family history of sudden cardiac death or inheritable cardiac disease
• Palpitations associated with chest pain or dyspnea
• Failed outpatient diagnostic evaluation

By following this algorithmic approach to evaluating palpitations in children, clinicians can effectively identify those patients who require more extensive evaluation while providing appropriate reassurance to those with benign causes.