Zager – Pediatric Murmurs
Case 1:
 You are evaluating a 2 week old infant for a routine well child check. The child is healthy and feeding/
gaining weight well.
 Past hx = unremarkable pregnancy, NSVD, unremarkable neonatal course- and unremarkable exams
 Exam= normal except for a grade 3/6 holosystolic murmur
o What is the likely cause for this murmur?
 Ventricular Septal Defect (MC congenital heart lesion)
o Why did you miss it in the newborn period?
 B/C Cardiac dynamics change to dramatically in newborn period
o What comes next?
 Explain to parents, eval by peds cardiologist
Case 2:
 You are examining a 5 year old male for a routine pre- Kindergarten exam. He has been healthy in all
respects except for some viral induced asthma that has been inactive for 2 years.
 On exam you notice a grade 2/6 vibratory systolic murmur. First and second heart sounds are normal.
o What is the likely cause of the murmur?
 Stills murmur (innocent heart murmur) – Lower left sternal border. Hear best when they
are laying down
o How would you advise the parents?
 Let them know it’s not a concern
o What further investigations would you order?
 None
Evaluation of Pediatric Heart Murmurs
 Ask … history, concerns, activity. Ex: if kid has difficulty eating, pale, sweaty…
 Observe… skin color, growth, syndromes, vitals
 Palpation… pulses, “thrills”, organomegaly
 Auscultate… heart sounds, physiologic splitting of S2, murmurs, extra sounds
Pediatric Auscultation
 Quick Survey: cardiac dynamics
 Listen to heart sounds in “cardinal” areas (aortic, pulmonic, etc.) S3? S4?
 Listen to dynamics of S2
 Systolic phase assessment for murmur:
o Grade
o Duration
o Location and radiation
o Does it go beyond systole?
o Quality (harsh, vibratory)
 Is there a “click”? – Hard to hear but good diagnostic sign.
o location / timing / variation
 Diastolic assessment
 Rub?
 Repeat above – upright vs. supine
Innocent Murmurs:
 Systolic
o Still’s murmur: medium pitch, audible from near apex to left sterna boarder. Buzzing, cooing or
‘twangy string’ quality. Early-mid systole
o Pulmonic murmur: Vibratory, somewhat rough, L upper sterna border. Short midsystolic
o Peripheral pulmonic: vibratory, radiates well to back and axillae, midsystolic. <6mo
o Supraclavicular: rough, vibratory, best heard above clavicles and base of neck. Midsystolic
 Continuous
o blowing, louder in diastole, best heard w/ pt sitting. Goes away if compress jugular
Characteristics of “Abnormal Murmur”
 Grade 3 or louder
 Diastolic
 “Harsh” in quality
 Associated with click or abnormal heart sounds
 Presence of a “thrill”
 Associated with unusual precordial activity
 “Big picture” suggests a medical diagnosis commonly associated with congenital heart disease
Syndromes- Cardiac Lesions
 Down – ventricular septal defect, endocardial cushion defect
 Fetal Alcohol Syndrome- VSD
 Marfan- aortic root dissection, MVP
 Noonan- pulmonic stenosis, ASD
 Turner- coarctation of aorta, bicuspid valve
 Congenital Rubella- PDA
 DiGeorge- aortic arch abnormality, Tetralogy of Fallot
 CATCH 22: Cardiac, Abnl facies, absent Thymus, Cleft Palate, Hypoglycemia
The “Problem” Heart Murmur- What to do?
 Noncardiac studies- chromosomes, CBC, ABG, etc.
 CXR- might give useful pulmonary info
 ECG- cardiac dynamics, rhythm
 ECHOcardiogram- expensive, much variability in quality by technique
 Referral to Pediatric Cardiologist (often most “cost-effective”)
Case 3:
 A 15 year old male comes as new patient seeking a refill of antihypertensive medications. He was
diagnosed with essential hypertension 3 years ago by a pediatrician in another community after extensive
studies, including renal imaging, urine catecholamines, and an abdominal CT are negative.
 Past history is otherwise unremarkable. On exam you find a BP of 158/102. After completing a detailed
cardiovascular exam you are able to give the father a definitive diagnosis of his hypertension.
 He has no heart murmur- what is his diagnosis?
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