Palpitations are a common presenting symptom in the paediatric population and generate understandable anxiety around issues regarding the heart and the possible consequences of an underlying cardiac arrhythmia. That said, many patients will be describing a benign sensation with no associated underlying cardiac pathology. This article aims to provide a practical framework when encountering children with palpitations to assess the likelihood of an underlying arrhythmia and to determine whether further investigation and/or referral to specialist paediatric cardiac services is required.

A 10-year-old boy has been referred to the local paediatric outpatient clinic by his general practitioner. He has experienced three episodes of palpitations, each lasting around 10–15 min, over the past couple of months. These have come without warning and stopped spontaneously. He is otherwise fit and well, with no significant medical or family history. His parents are concerned about the possibility of an underlying arrhythmia.

Palpitations vary in sensation between individuals, but collectively describe an unpleasant awareness of one’s own heartbeat due to speed, strength and/or irregularity. Often children will report feeling a more rapid and forceful heartbeat, although for others it can be a single ‘thump’ in the chest or ‘skipped beats’. Sometimes parents will report having felt this through the chest wall or seen pulsations in the neck. They may occur in isolation, or in association with a variety of other symptoms, including shortness of breath, chest pain, abdominal pain, neck pain, feeling weak, visual disturbance, headache and dizziness.

When presenting acutely with continuing symptoms, assessment of heart rate and contemporaneous ECG can usually accurately identify the presence of an underlying arrhythmia and need for further management. Often, however, as in the scenario above, the encounter is following a symptomatic episode (or episodes) that has since resolved spontaneously prior to evaluation. Baseline cardiac examination and ECG are …