Pediatric Murmurs. Zager. Katelyn Rogers. 03.24.10.
Pathologic and problem murmurs
Cases
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 courseand unremarkable exams
Exam= normal except for a grade 3/6 holosystolic murmur
What is the likely cause for this murmur? VSD- easiest murmur to
diagnose.
Why did you miss it in the newborn period? It wasn’t there. Over
days P in R heart drops for pulm flow P, so the hole in the
interventricular septum is now a open pathway for blood to flow
through.
What comes next?
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.
What is the likely cause of the murmur? Stills murmur.
How would you advise the parents? This is innocent!
What further investigations would you order? None.
MAJORITY OF MURMURS IN PEDS ARE INNOCENT!
Ex: loud blowing regurg mitral murmur. Kids looked fine, but had a sore throat.
Had Rheumatic Fever.
Innocent Murmurs: KNOW!
Steps in Evaluation of Pediatric Heart Murmurs
1. Ask … history, concerns, activity (may have a tough time feeding, don’t play
as much as other kids)
2. Observe… skin color (cyanosis can be hard to notice), growth, syndromes,
vitals
3. Palpation… pulses (can be tachycardic), “thrills” (simply by palpation, can
also see more chest heave), organomegaly (sometimes only sign is
hepatomegaly to suggest HF)
4. Auscultate… heart sounds, physiologic splitting of S2, murmurs, extra
sounds
Pediatric Auscultation Steps
1. Quick Survey: cardiac dynamics
2. Listen to heart sounds in “cardinal” areas (aortic, pulmonic, etc.) S3? S4?
3. Listen to dynamics of S2
4. Systolic phase assessment for murmur:
a. Grade
b. Location and radiation
c. Quality (harsh- never normal, vibratory)
d. Duration
e. Does it go beyond systole?
5. Is there a “click”?
a. location
b. timing
c. variation
Stills murmur is louder supine, position can enhance the murmurs.
6. Diastolic assessment
7. Rub?
8. Repeat above – upright vs. supine
9. Put it all together
It’s impt to do in steps when listening to heart sounds: start w/ listening for
rhythm, then clicks, then murmurs… etc.
Table 1:
1. Stills murmur under the age of 2 he will refer just for reassurance.
Common in age 2 to 8.
2. Often innocent.
3. Blowing, flowing character. If can hear in pulmonic area and on
both sides of chest then it is reassuring that it is innocent.
4. Won’t see on board exam.
5. Heard near clavicle, goes away with compression of the jugular. He
will tell the parents they are hearing a murmur bc with a fever the
sound will increase, so it wont scare them if they have to go to the
ER.
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Characteristics of “Abnormal Murmur (Pathologic or Px Mumurs)”
1. Grade 3 or louder- if goes away when lay down then it is a venous hum.
2. Diastolic
3. “Harsh” in quality
4. Associated with click or abnormal heart sounds
5. Presence of a “thrill”
6. Associated with unusual precordial activity
7. “Big picture” suggests a medical diagnosis commonly associated with
congenital heart disease – good to do an exam, but will probably need to refer.
Syndromes-Cardiac Lesions
Down Synd –VSD, endocardial cushion defect (50% will have defect)
Fetal Alcohol Syndrome- VSD
Marfan- aortic root dissection, mitral valve prolaps
Noonan- pulmonic stenosis, ASD
Turner- coarctation of aorta, bicuspid valve
Congenital Rubella- PDA
DiGeorge- aortic arch abnormality, Tetralogy of Fallot (favorite on BOARDS)
May run into w/ a PDA.
The “Problem” Heart Murmur- What to do?
1. Noncardiac studies- chromosomes, CBC, ABG (In genl doesn’t help a lot,
but can be used to eval for polycythemia & hypoxia), etc. (If child has no clear
medical issues & looks fine, he thinks you should refer, if sick then can do the
following.)
2. CXR- might give useful pulmonary info
3. ECG- cardiac dynamics, rhythm (Follow even with resp, can show
conduction abnltis w/ defects too)
4. ECHOcardiogram- expensive, much variability in quality by tech (not best)
5. Referral to Pediatric Cardiologist (often most “cost-effective”)
Look at area of chamber contraction which are responsible for the defects and
ECG patterns.
Holosystolic will often obscure S1 & S2
Early systolic may obscure the S1
Isolated VSD is the most common! VSD (50% will close by 9 mos), by age of 3
(another 50% of those remaining). Not many need surgery. VSD can be
assocted with other defects too, but they are have a great prognosis
themselves. Antibiotic prophylaxis is not supported much by research to help
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heal VSD and prevent bactl endocarditis. They can get bactl endo even w/ the
antibiotics.
PDA: Machinery style murmur – whistley in first 12 hours, systolic murmur, a
few days later goes away.
It really helps to visual in head when reading through these! It will help retain
the info.
1st Congenital heart procedure. Things have improved even more so.
More through the pulmonic artery than systemic flow. Short-circuiting/recycling
that BF. Richer blood is even going to the lungs, which is not efficient! They
won’t repair a VSD unless phys risk for child.
Case
A 15-year-old male (6 ft 2in, 200lbs) 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? Coarctation of the aorta!
Can usually detect in newborn (check their pulses), it is a very txable cause of
HTN. IF don’t txirreversible myocardial damage.
Mixing and overriding aorta that cause dec systemic oxygen content.
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Questions:
1. What is the most common and easiest to diagnose in pediatric
mumurs?
2. Which murmur/condition is described here: a early-med systolic
murmur that is medium pitch, audible from near apex to left sternal
border, with a buzzing, cooing or “twangy string” quality.
a. Still’s
b. Pulmonic
c. Peripheral pulmonic
d. Supraclavicular
e. Cervical venous hum
3. Which murmur/condition is described here: A short midsystolic,
vibratory, somewhat rough, left upper sternal border.
a. Still’s
b. Pulmonic
c. Peripheral pulmonic
d. Supraclavicular
e. Cervical venous hum
4. Which murmur/condition is described here: Blowing, louder in
diastole, best heard w/ patient sitting often disappears w/ jugular
compression or in supine position.
a. Still’s
b. Pulmonic
c. Peripheral pulmonic
d. Supraclavicular
e. Cervical venous hum
5. Which of the following is not associated with abnormal murmurs?
a. Grade III
b. Thrill
c. Click
d. Systolic
e. Grade IV
6. In what congenital syndrome are aortic arch abnormalities and
tetralogy of fallot?
7. In what condition are kids monitored rather than sent to surgery
and the condition demonstrate more BF (L) through the pulmonary
artery than the aorta?
Answers:
1.
2.
3.
4.
5.
6.
7.
VSD
A
C
E
D- Systolic is usually not associated with pathologic murmurs, rather
diastolic!
DiiGeorge
VSD
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