The Normal P-R Interval in Infants

and Children
By MARIANO M. ALIMURUNG, M.D., AND BENEDICT F. MASSELL, M.D.
The value of the P-R interval in the study and evaluation of treatment of rheumatic carditis, a
disease predominantly of the younger ages, has prompted a re-examination of the normal P-R
standards for infants and children. This study reports these data as obtained from 506 normal
infants and children. The data reveal that both age and heart rate exert a significant influence on
the P-R interval. The minimum, average, and maximum values are given as related to different
ages and different heart rates.

IN previous papers'-4 we have reported Parkinson-White syndrome. In thyrotoxicosis

various data on the normal electrocardio- the P-R may also be shortened.
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gram in infants and children. The same
electrocardiographic material offered a valu-
able source for other analyses, such as the
P-R interval.
The P-R interval has been the subject of
much interest for many reasons. While not
specific for rheumatic carditis, changes in the
P-R interval are of significant clinical value
in the study of this disease. Thus a prolonged
P-R has been described as the most common
electrocardiographic finding5-7 in active rheu-
matic carditis and occasionally the only evi-
dence of this condition.8 A marked prolonga-
tion is considered by some observers as an
indication of a poor prognosis.9 Shortening of
the P-R interval to within normal limits is
also valuable in determining subsidence of
the rheumatic activity'0 and, therefore, in
assessing the success of therapy." In a recent
review of 66 patients given corticotropin
(ACTH) or cortisone, a prolonged P-R was
found to reverse to normal during therapy in
54 instances although in some the P-R pro-
longation reappeared after the discontinuation
of treatment.'2
A short P-R interval is a characteristic
feature of nodal rhythm and of the Wolff
From the House of the Good Samaritan (Children's
Medical Center) and the Department of Pediatrics,
Harvard Medical School, Boston, Mass.
Supported by Research Grant H-956 from the
National Institutes of Health, Public Health Service,
Bethesda, Md.
257
Physiological factors likewise play an im-
portant role in determining the P-R interval.
Prolongation may be caused by vagotonia;
whereas shortening is associated with sympa-
thicotonia.
It is obvious that the normal values of the
P-R interval are important in order that the
aforementioned clinical applications of P-R
changes can be correctly made. Particular em-
phasis must be placed on the values for children
because of the current interest in certain forms
of treatment of rheumatic carditis, a disease
predominantly of the younger ages.
While there are published data on the normal
P-R in children,'3-27 the need for a re-analysis
of the subject seems indicated. In many re-
ports attention is mainly directed to the aver-
age values of the P-R interval. In others,
although the upper limits are specified, the
lower limits of normal are not given. In some
reports the age grouping followed seems so
wide that the existing peculiarities due to age
are not clearly appreciated. On the other hand
there are reports in which the use of too many
age groups makes it difficult to apply the data
clinically. Again, there are studies which are
limited to infancy alone or which, though con-
cerned with all ages in childhood, are based
on a relatively small number of observations;
such studies fail to present an adequate pic-
ture of the P-R interval for the entire span
of infancy and childhood.
In view of the foregoing considerations, the
present study was undertaken.
Circulation, Volume XIII, February, 1956
 258 NORMAL P-R INTERVAL IN INFANTS AND CHILDREN
CLINICAL MATERIAL AND METHOD AVERAGE P-R INTERVAL AT DIFFERENT AGES

OF STUDY
0.1 8

0 17

In this study, a total of 506 electrocardiograms of 0.16

normal infants and children ranging in age from 0.1 5

birth to 13 years were analyzed. The source of the 0.14

clinical material and the method used for obtaining 0.13

0.12
the electrocardiographic tracings have been de- 0.11
scribed in our previous publications on other aspects 0.10
of the normal electrocardiogram in children.'-' 0.09
For greater accuracy a special reflectoscope was oze

often used in making the measurements. This o.0r

reflectoscope magnified the tracing to approximately AGE
AGE
..
f
'O'
oi'I 2
'2 3 '4 '6 '7 829s
3 45s67 91 o00la2I
1a 22 3 12
04 1161
5 6 7 6 9 001t 2 0s
MONTHS
ten times its actual size. In this manner the difficulty YEARS

of detecting a tiny Q wave was greatly minimized. FIG. 2. The average P-R is shown here in relation
Particular attention was paid to this point because to age alone, with the first year of life analyzed by
nonrecognition of a tiny Q wave will lengthen er- months.
roneously the P-R measurement. AWhile often called
the P-R interval, it is really the P-Q interval that is
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measured whenever a Q wave is present.

second for an average heart rate of 65 per
The data herein presented were taken from lead minute and an average P-R of 0.103 second
II since nearly all available P-R data in the medical for an average heart rate of 185 per minute.
literature are based on lead II measurements. In Figure 2 presents the relation between the
cases with sinus arrhythmia the average figures for average P-R and age, irrespective of the heart
both the P-R interval and the heart rate were the rate in each age. As with the heart rate, there
ones considered.
seems to be definite evidence that age also
RESULTS exerts a significant influence on the P-R inter-
In the first part of this study the average val. In spite of certain fluctuations in the curse
P-R interval was analyzed first in relation corresponding to the first twelve months of
to heart rate and then in relation to age. life, the figures for this age period are still
Figure 1 shows the influence of heart rate significantly shorter than those in succeeding
on the average P-R for the entire group of years. Moreover, as the child grows older, it is
506 infants and children. There appears to be evident that the average P-R interval like-
an almost linear trend as the P-R interval wise lengthens progressively from an average
shortens with increasing heart rate. At the value of 0.114 second at 1 year of age to 0.15
two extremes are an average P-R of 0.146 second at 13 years.
It is generally supposed that a relationship
exists between the P-R interval on the one
0.18 _

0.17 0.18r
0.16 0.17p

0.1 5 0.16F

0.14 0.15

0.13 0.14 Ive.,-.

z 0.12
4
0.13
111 O6. - --* i

cc
z 0.12
11.
0.11 _
_

0.10 0.11

0.10
_ 111 0,
1(O)_'~~~~_ _ V
~~.s 1b
I~1b)
0.09
1(o)
0.08 0.09 _

0.07 0.08 _

0.06rs L
uVM06^ 1 0.07
50 60
1^
70
1 on
80 90n M040HA
120
-1
..cAdI co
10 .1os
130
RATE 1 ..In r$: 170 InnE 190
.7n 18o Iq) 200

HEART RAXTE 0.06

V-.
50
-
60
-
70
-
80
-
90
-
100
-
110 120
- -
140 150
130 - --
160
-
I170
-
180
-
190 200
- -11

FIG. 1. Influence of heart rate is shown on the HEART RATE

average P-R for the entire series without specifically FIG. 3. Average PI-R values are shown at different
considering the effect of age. heart rates for the various age groups (see text).
 ALIMURUNG AND MASSELL 259
TABLE 1-Heart Rate
Below 71 71-90 91-110
Age Groups
Cases Av. SD | Range Cases Av. SD Range Cases Av. SD Range

I (a) Below 1 month (new- 6 .103 .005 .10-.11

boirii)
(b) 1-9 months 1 .130 2 .120 .11-.14
10 months-2 years 26 .121 .014 .10-.15
III 3-5 years 34 .129 .012 .11-.16 60 .128 .012 .09- .16
IV 6-13 years 24 .142 .014 l.11-18 88 .136 .014 .11-.18 71 .131 .013 .10-16
111-130 131-150 Above 150
Cases Av. SD Range Cases Av. SD Range Cases Av. SD Range

I (a) Below 1 month (new- 7 .10( 3 .005 .10-.11 7 .10( 6 .005 .10-.11 6 .098 .007 .09-.A
born)
(b) 1-9 months 14 .114i .007 .10-13 33 .1077 .008 .09_ -.12 13 .104 .0(5 .10-.11
Downloaded from http://circ.ahajournals.org/ by guest on May 30, 2017

II 10 moinths-2 years 40 .1177 .012 .10-.14 25 .1141 .011 .10- -.14 7 .100 0 .10-.10
III 3_5 years 21 .1283 .014 .10-.16 7 6 .010 .10- -.13
IV 6-13 years 13 .1391 .013 .12-.16 1 .13C
Average values as well as the range (minimum and maximum limits) of the P-R interval are given for the
different age groups and for different heart rates. The number of observations is also given for each age group
with heart rates within the heart rate range indicated.

hand and heart rate and age on the other.
Such a relationship is substantiated by the
curves just presented. In the second part of
this study, therefore, an analysis was made of
the combined effects of age and heart rate on
the P-R interval. In order to accomplish this
purpose, it was necessary to divide the cases
into certain age groups. Since any age sub-
divisions would necessarily have to be arbi-
trary, it was decided to follow the same
age groupings that we had used in previous
reports' 3 on other data of the normal child's
electrocardiogram. These age groups are as
follows: Group I, from birth to 9 months;
group II, from 10 months to 2 years; group
III, from 3 to 5 years and group IV, from 6 to
13 years. The newborn (under 1 month of
age) were further separated into another sub-
group within group I because of the compara-
tively shorter P-R intervals noted in the first
month of life.
Figure 3 shows the relation of the average
P-R interval to heart rate for each age group.
It is evident that the P-R interval is longer in
the older ages for any given heart rate. Thus,
for instance, at a heart rate of 120 per minute
the average P-R interval is 0.106 second for the
newborn, 0.114 second for children between
1 month and 9 months, 0.117 second for those
between 10 months and 2 years, 0.128 second
for ages 3 to 5 years, and 0. 134 second for 6
to 13 years of age.
Finally in table 1, the same data depicted
in figure 3 are shown together with the range
of the P-R interval and the standard deviation
for those groups in which a sufficient number of
cases allowed for its calculation. In this table
it is shown that, on the whole, at any given
heart rate the maximum as well as the average
values for P-R were longer for the older ages.
Not shown in table 1 is that only one child
had a P-R of 0.18 second at rates below 71
and only one child each had P-R intervals of
0.18 and 0.17 second in the heart rate range
between 71 and 90 per minute. In contrast to
the average and maximum values the mini-
mum limits do not vary appreciably with age
and with heart rate. It should be noted that
the number of observations, as shown in the
table, was small for some of the groups of
cases.
DIscUSSION
The influence of age on the P-R interval is
well accepted. The fact that the heart of a
child is many times smaller than that of an
 260 NORMAL P-R INTERVAL IN INFANTS AND CHILDREN
adult explains why the P-R is significantly
shorter in a child than in an adult. Studies on
adults further indicate that the P-R increases
with age even at constant heart rates, espe-
cially "in the second and the fifth to sixth
decades." This observation28 was recently sub-
stantiated by Packard, Graettinger and Gray-
biel29 in their follow-up study in 1950 on healthy
aviators, whom they had previously examined
in 1940. These authors noticed an increase of
the mean P-R from 0.154 to 0.159 second in
spite of an increase of average heart rate from
64 to 75 per minute. At any given heart rate
the 1950 mean P-R was consistently longer
than the 1940 value. Careful study of their
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data led these authors to the conclusion that
the difference noted was not due to chance or to
change in either blood pressure or body weight
but was most likely due to "some factor asso-
ciated with aging."
That the P-R interval is likewise influenced
by heart rate is also generally supposed. In
fact some workers have proposed formulae to
express the relationship between heart rate
and P-R.30 Obviously such formulas cannot
express completely the standards for the P-R
interval unless the role of age is simultaneously
represented. Other authors", 32 doubt that
there is an important influence of heart rate
on the P-R interval.
As far as our own findings are concerned,
there seems to be sufficient indication that,
at least in infants and children, both age and
heart rate exert a definite influence on the P-R
interval. What factor has a greater influence
cannot be determined from our study. Never-
theless, it is evident from our data that ob-
servations relating the P-R interval to either
age or heart rate alone are unsatisfactory es-
pecially if such data are to be applied clini-
cally.
The lower limit of the normal P-R interval
has not been studied as much as the upper
limit. Thus Kossman33 has recently stated that
''a precise definition of the lower limit must
await more precise statistical study." In our
study, therefore, the data for the lower limit
of the P-R interval were also collected.
An attempt was made to compare our re-
sults with those of other reports in the medical
literature. This comparison could be done only
to a very limited degree because of two main
reasons. First, in some reports the P-R inter-
val was studied in relation to either heart
rate or age alone but not to both. Second, when
consideration was given to both age and heart
rate, the age grouping followed was different
from that used in our study.
Such a limited comparison could be made
with the data furnished by Ashman and
Hull.34 Their table, a widely used reference for
the normal values of the P-R interval, provides
data on the upper limits of the normal P-R for
various age groups, including children and
adults, and for various heart rates. As far as
the comparison was feasible, it can be noted
that our data are very similar to those of
Ashman and Hull. Thus, for instance, for
children between 7 and 13 years of age, Ash-
man and Hull give for upper limits of P-R
0.18 second for rates below 70 per minute,
0.17 second for rates between 71 and 90, 0.16
second for rates between 91 and 110, and 0.15
second for rates between 111 and 130. Our
data for the comparable age group, 6 to 13
years, show upper limits for P-R of 0.18 sec-
ond, 0.18 second, 0.16 second, and 0.16 second
for corresponding heart rates. The other age
groupings for younger children, new born to
112 years and 112 to 6 years, followed by
Ashman and Hull are different from our age
grouping in this age span; hence, no compar-
ison could be made in these age periods. Fur-
thermore, our data suggest that more age
subdivisions are needed in the younger ages.
Finally, Ashman and Hull do not furnish the
average and minimum values of the P-R in
their table.
SUMMARY
Because of the value of the P-R interval
in evaluating the treatment of rheumatic
carditis, a disease occurring predominantly
in the younger age groups, the normal P-R
for infants and children was re-examined. This
study was based on the electrocardiograms of
506 normal infants and children, ranging from
birth to 13 years of age.
Both age and heart rate were found to exert
a significant influence on the P-R interval.
 ALIMURUNG AND MASSPIJ2,6
Normal values must therefore be related to
both factors.
The average normal P-R interval and the
mininmum and maximum limits of normal for
various age groups and for different heart
rates are given.
ACKNOWLEDGMENT
The authors are indebted to Dr. Lester G. Joseph
of New Haven, Conn., who took the electrocardio-
grams used in this study at the Children's Medical
Center, Boston, (1947 and 1948); to D)r. .Jane Worces-
ter, Assistant Professor of Biostatistics, Harvard
School of Public Health, for her valuable advice on
the statistical aspects of this study; to _Miss Rita
Nickerson for the statistical calculations; and to
Dr. Fred _M. Snell for devising the special reflecto-
Downloaded from http://circ.ahajournals.org/ by guest on May 30, 2017
scope useol in this study.
SUMIXJAI I N INTERLINGUA-
A can.sa del signification del initervallo P-R
ill evalutar le tractamento de carditis rheu-
matic Unl morbo que occurre predominante-
inente al etates plus juvene-le norma de P-R
pro infamites e juveniles essex-a re-examiinate.
Nostre studio es basate super le electrocardio-
grammas de 506 infantes e juveniles normal,
de etates ab infra mense usque a 1:3 annos.
un
I1 essexa constatate que le etate e le fre-
quentia cardiac exerce influentia signiificativ'e
un
super le inteirallo P-l. Valores normal debe
consequenitemnente esser relationate a anlbe iste
factores.
Nos lista le valor median del normal inter-
vallo P-l1 e le limites minimal e maximal del
norma pro vanie etates e varie frequentias
cardiac.
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 The Normal P-R Interval in Infants and Children
MARIANO M. ALIMURUNG and BENEDICT F. MASSELL

Circulation. 1956;13:257-262
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doi: 10.1161/01.CIR.13.2.257
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