Perinatal Ectopic Beat Guideline
Flowchart 1 - Pathway for antenatally diagnosed ectopic beats
Flowchart 2 - Management of atrial ectopic beats
Flowchart 3 - Management of ventricular ectopic beats
Introduction
1-5% of newborns will have an abnormal heart rhythm (arrhythmia) within the first ten days of life. Most arrhythmias are premature atrial contractions (ectopic beats). The high majority of these will be benign and will disappear within the first few weeks of life without further consequences or need for follow up. 
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However, it is important to identify those that have more serious arrhythmias for appropriate investigation and treatment. 

Most often, neonates with arrhythmias will be asymptomatic and therefore present as an incidental finding at NIPE (Newborn Physical Infant Examination). Those that do have symptoms are likely to present with classical signs of heart failure (which may include colour change, poor feeding, sweating and clamminess).
Scope & Purpose
This guideline aims to differentiate between benign ectopic beats and pathological ectopic beats that require further investigation. This guideline does not replace the need for assessment by senior paediatricians or the need for discussion with tertiary cardiology colleagues where appropriate.

It is hoped that this guideline will provide:
  1. Standard framework for investigating newborn babies with antenatal/postnatal premature atrial and ventricular contractions
  2. Consistent information to parents and help reduce anxiety 
Definitions​
Arrhythmia:
Abnormal heart rhythm and can be described as benign or pathological:
  • Benign - premature atrial ectopics, premature ventricular ectopics, nodal or junctional rhythms and wandering atrial rhythms
  • Pathological - these can either be: 
  • Tachyarrhythmias - HR 240-300. Includes supraventricular tachycardia (SVT), ventricular tachycardia (VT), long QT syndrome and ventricular fibrillation (VF)
  • Bradyarrhythmias - HR <100. Includes congenital heart block and AV node dysfunction

Ectopic Beats:
Irregularly placed heart beat. Ectopic beats can be divided into premature atrial contractions (PACs) or premature ventricular contractions (PVCs). The only way to assess them is by looking at an ECG

Premature Atrial ectopic:
A premature atrial ectopic is an early P wave occurring before the next expected P wave, when in regular sinus rhythm, at a normal rate. They often have a different morphology and axis from sinus P waves and may be flattened, notched, pointed, biphasic or lost in the T wave.  Premature atrial ectopics can be unifocal (from one location) or multifocal (arising from multiple locations within the atria) so may have various P wave morphologies. A premature atrial beat can be conducted to the ventricles. This can happen in one of three ways:
  1. Normally - followed by a normal narrow QRS complex.
  2. Aberrantly - when part of the ventricular conduction system is still in its refractory period the resulting QRS will be abnormal in morphology and wide. 
BEWARE – need to differentiate from premature ventricular contraction. An aberrant conduction PAC producing a wide QRS complex will have a preceding P wave which will be different in shape to sinus P wave and may be buried in preceding T wave. 
  1. Blocked - if the conduction system is still in its refractory period there will be no following QRS complex and a pause before the next P wave. If blocked atrial ectopics alternate with normal sinus beats this will simulate a sinus bradycardia.  

Premature Ventricular Ectopic:
A premature ventricular beat has a premature and abnormal (different morphology) QRS that is not preceded by a P wave. The QRS may be of normal duration or prolonged. Ventricular ectopics can be a sign of underlying structural cardiac disease, tumours or cardiomyopathy. They can also be a sign of underlying acidosis, hypoxaemia or myocarditis. However, most ventricular ectopics are benign, with 50% having resolved by 8 weeks and 90% resolved by 12 weeks.
Overview​
General Principles
Any baby who is found to have an arrhythmia (including ectopic beats) postnatally should have a full history, examination and ECG performed. Parents should be kept fully informed throughout and an explanation provided for why the investigations are being performed. Where available, a patient information sheet should be given. 

Arrhythmias
The management of tachy- and bradyarrhythmias is outside of the scope of this guideline and APLS guidance should be followed. 

Antenatally Detected Ectopic Beats
These will have been detected antenatally on USS scans or CTGs. Their presence will be highlighted in review of the medical notes at the NIPE (Newborn Physical Infant Examination) or by the attending midwife at delivery. Management detailed in Flowchart 1.

If ectopic beats ceased prior to delivery:
If ectopic beats have ceased then no further investigations are required. An ECG is not required, unless it is clinically indicated and the baby can be discharged, with parents reassured

If present during delivery: 
The baby should be assessed by a paediatric doctor or ANNP post delivery, including:
  • Auscultation of the heart for 1 minute to assess rate and rhythm
  • Pre and post-ductal saturations
If the above examination is normal and a regular heart rate, the baby does not require an ECG and patient can be discharged. 
If any of the above are outside the expected parameters (HR <80, HR >180 or irregular rhythm on auscultation) an ECG should be performed to look for premature ventricular or atrial contractions and exclude heart block or LQTS (see below). A rhythm strip is the most helpful to assess this. 

Postnatally persisting Ectopic Beats
A 12 lead ECG should be performed in all babies with postnatal ectopics. This should be assessed carefully to exclude long QT and heart block prior to discharge from hospital.
Management of atrial ectopic beats
Management depends on the frequency of ectopics and how well the baby is clinically. 
For example, in a baby with PAC but who is otherwise well with no other clinical signs of congenital heart disease, there is no need for a routine echocardiogram. 50% of PAC will have resolved by 8 weeks.
It is important to differentiate benign PAC from paroxysmal atrial tachycardia. If the baby’s resting heart rate is more than 180bpm with either a regular or irregular rhythm then arrange a 24hr tape and consider discussion with the paediatric cardiology team.

Infrequent (<15 beats/minute)
  • If unifocal (ie similar morphology) and the baby is clinically well with a normal examination, the parents can be reassured that this usually resolves and no further follow up or investigation is required
  • If multifocal see below
Frequent (>15 beats/minute)

Clinically well:
  • If the rest of the ECG is normal, the patient can be discharged home with safety netting (e.g. to seek help if signs of heart failure or SVT, including poor feeding, being unsettled, pallor) 
  • Repeat the ECG in 4-6 weeks - if the repeat ECG continues to have frequent atrial ectopics then a 24 hour outpatient ECG should be requested. This should be done within 1-2 weeks and is primarily to exclude SVT
  • The baby will need follow up in clinic with local PEC (if available) or Paediatrician

Clinically unwell/unstable:
  • Admit to NNU for stabilisation and immediate senior review
  • Discuss with on call cardiology in Southampton or Oxford
  • Perform echocardiogram if any signs of congenital heart disease

Multifocal PACs
Regardless of frequency, multifocal PACs have a higher tendency to cause SVT or atrial tachycardias. 
Even if infrequent and clinically well, all patients with multifocal PACs should be followed up with a 24hr ECG tape within 1-2 weeks and be given the same safety netting advice as above.
Management of Ventricular Ectopics
For ventricular ectopics it does not matter whether they are frequent or infrequent - the pathway is the same:
  1. Evaluate the baby for signs and symptoms of cardiac disease
  2. Ask about family history and history of sudden death
  3. Discuss all cases with consultant or registrar
  4. Check electrolytes including calcium and magnesium 
  5. Check on the ECG there is no AV block and that QTc value is <450ms​
There are no normal QTc values for neonates so if the QTc is between 450-480ms and the baby looks well with no relevant family history then you can often discharge with a plan to repeat the ECG at 4 weeks. If the QTc is > 480ms then discuss with cardiology prior to discharge.

​If clinically well:
  • Can be discharged with safety netting advice
  • Request outpatient 24 hour ECG (request for it to be done within 2 weeks) – need to exclude complex arrhythmias (small likelihood) and assessment of VE burden
  • Referral to clinic with local PEC (if available) or Paediatrician within 6-8 weeks (if PVCs persist then they will need an echocardiogram)
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If clinically unwell:
  • Admit to NNU for stabilization and immediate senior review
  • Discuss with on call cardiology in Southampton or Oxford
  • Perform echocardiogram if any signs of congenital heart disease
Communication & Training Plans
Guideline will be made available on the PIER website, dissemination and raised awareness can occur via network leads at each centre.
Process for Monitoring Compliance
The PIER network will review problems associated with this guideline through governance process. ​

Guideline to be reviewed after three years or sooner as a result of audit findings or as any changes to practice occurs.
Appendix - Patient Information Leaflet​
Document Version: 
1.0

Lead Authors: 
Lucinda Winckworth, Consultant Paediatrician
Shankar Sadagopan, Consultant Paediatric Cardiologist
Matthew Jones, Paediatric Registrar
Approving Network:
Wessex Paediatric Cardiology Network

Date of Approval: 
December 2024

Review Due:
December 2027