Palpitations are not an uncommon complaint in the paediatric emergency department, causing significant anxiety for families concerned about serious heart disease. However, most cases are benign, often stemming from normal physiological responses like fever or anxiety. Primary cardiac arrhythmias are rare in this clinical setting.

The main challenge is identifying the few children with dangerous arrhythmias among the many benign cases. Fear of missing a life-threatening condition often leads to extensive, costly, and stressful investigations, even in low-risk patients, without significantly improving detection rates.

This review aims to create a structured, risk-based framework for evaluating paediatric palpitations in the emergency department. The goal is to help clinicians efficiently distinguish benign from potentially life-threatening causes, thereby optimising resource use and reducing family anxiety.

A thorough clinical history, physical exam, and a standard 12-lead electrocardiogram are the most effective evaluation tools. “Red-flag” features—such as palpitations with fainting (syncope), onset during exercise, or a family history of sudden cardiac death—successfully identify nearly all children with significant arrhythmias. Barring certain risk factors and any abnormalities on a 12 lead electrocardiogram, a dangerous cardiac condition is highly unlikely.

A stratified approach is recommended. Low-risk children (no red-flag features, normal electrocardiogram) can be safely discharged with reassurance. High-risk patients require immediate, aggressive evaluation, including cardiology consultation and potential hospital admission. This strategy improves accuracy, is cost-effective, and enhances patient safety.