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Approach to the child with palpitations

Authors
Robert Mazor, MD
Suzan Mazor, MD
Section Editors
George A Woodward, MD
Jan E Drutz, MD
Deputy Editor
James F Wiley, II, MD, MPH

INTRODUCTION

Palpitations describe perception of the heartbeat that is usually concerning to the patient. In adults, palpitations occasionally herald serious underlying cardiac events [1]. However, palpitations in children typically arise from physiologic stimuli, such as fever, exercise, anxiety, or anemia, rather than life-threatening causes (eg, cardiac arrhythmia). In addition, children with serious arrhythmias may report no palpitations. This topic will review the differential diagnosis and approach to the child with palpitations.

The differential diagnosis of tachycardia in children who do not have palpitations is discussed elsewhere. (See "Approach to the child with tachycardia".)

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of palpitations encompasses rare etiologies that are life-threatening and common causes (algorithm 1 and table 1).

Life-threatening causes — Children with a serious underlying cause for their palpitations often have a history of syncope, congenital heart disease, or cardiac surgery (table 1) [2-6].

Arrhythmias — Arrhythmias are a very uncommon cause of palpitations in children with structurally normal hearts but are frequently seen in children with surgically corrected structural heart disease [6]. Arrhythmias may be broadly classified as fast or slow. The child with tachyarrhythmia and shock should be triaged and managed per the American Heart Association (AHA) guidelines for assessment of cardiopulmonary instability espoused in the Pediatric Advanced Life Support (PALS) course [7]. (see "Approach to the child with tachycardia")

A key component of this assessment requires categorization of the QRS complex from the cardiorespiratory (CR) monitor or 12-lead ECG as narrow or wide (algorithm 2) [2]. A 12-lead ECG before and after intervention is preferable if patient status allows. Supraventricular tachycardia (SVT) is the most common non-sinus tachyarrhythmia of childhood and often presents with palpitations in verbal children [2,8]. Most infants with SVT are asymptomatic although feeding problems, pallor, or dyspnea, especially with feeding, may occur [8]. Ventricular tachycardia is rare in children with structurally normal hearts. (see "Management of supraventricular tachycardia in children" and "Management and evaluation of wide QRS complex tachycardia in children" and "Sustained monomorphic ventricular tachycardia: Diagnosis and evaluation")

Symptomatic sinus bradycardia in children often arises from respiratory failure with hypoxemia. Sick sinus syndrome, Mobitz type II atrioventricular blockage, and complete atrioventricular dissociation are usually seen in children with structural heart disease, including children with pacemaker malfunction. (see "Bradycardia in children")

                      

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Literature review current through: Nov 2016. | This topic last updated: Mon Jun 20 00:00:00 GMT+00:00 2016.
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