Northampton General Hospital Department of Paediatrics
Protocol for managing the newborn with a murmur
The newborn baby with a murmur
This presentation may be a normal physiological finding or a manifestation of
cardiac disease. In the first week of life as many as 50% of term infants may
have an innocent systolic murmur.1 In contrast, a neonate with serious lifethreatening congenital heart disease may not have an audible murmur.
The four commonest innocent murmurs in newborns are:
1.
Pulmonary flow murmur
A soft ( 2/6 intensity) systolic murmur best heard at the upper left sternal edge (ULSE)
radiating to both axillae and the back. Usually persists for weeks and then disappears by 6
months of age.
2.
Transient systolic murmur of PDA
A soft ( 2/6 intensity) systolic murmur, audible at the ULSE and beneath the left clavicle on
day 1 of life.
3.
Transient systolic murmur of tricuspid regurgitation
Maximally audible at the lower left sternal edge (LLSE) and may mimic a VSD. Reflects
naturally high pulmonary vascular resistance (PVR) and usually disappears within the first 2448 hours of life as PVR falls.
4.
Vibratory innocent murmur
Best audible at the LLSE, is typically ejection systolic and has a low-frequency vibratory
quality.
Clinical approach
History:
1.
Was nuchal scanning (if done) abnormal, and was karyotyping
undertaken?
2.
Was the anomaly scan normal?
3.
Are there any maternal conditions that increase the fetal risk of
congenital heart disease (CHD)?
Examples: diabetes, collagen vascular disease, teratogen exposure (rubella,
anticonvulsants, lithium, alcohol)
4.
Is there a history of congenital heart disease in parents or siblings?
4.
Is the baby otherwise ‘well’?
5.
Is there any history of breathlessness, poor colour (looking grey, blue
or mottled) or poor feeding?
Examination
1.
Plot weight and head circumference on a growth chart and confirm that
within normal range.
Northampton General Hospital Department of Paediatrics
Protocol for managing the newborn with a murmur
2.
Does the baby look dysmorphic?
3.
Confirm that both brachial and both femoral pulses are palpable.
Confirm that there is no difference in strength of pulse when comparing
right brachial pulse with the other three pulses, or when comparing the
brachial pulses with femoral pulses.
4.
Record blood pressure in both arms and 1 leg. Normal systolic blood
pressure in a settled term baby is between 60-80mmHg.There should
not be a difference of more than 20mmHg between the arms and the
selected leg, or when comparing the blood pressure in each arm.
5.
Look clinically for cyanosis and measure pulse oximetry in both arms
and one leg. Normal oxygen saturations are at least 95% in all limbs.
6.
Record heart rate and respiratory rate with baby awake and settled.
Normal heart rate
100-140*
Normal respiratory rate
1st 48 hours
After 48 hours
40-60
40
*Resting heart rate in a normal sleeping term neonate may
fall to as low as 85. Of no concern provided otherwise
completely well, examination normal and ECG demonstrates
sinus rhythm.
7.
Precordial and suprasternal palpation
a. Confirm that the apex beat is left-sided and situated around the
5th intercostal space in the mid-clavicular line.
b. Ensure that there is no thrill palpable anywhere over the
precordium. If present, document where best felt.
8.
For the murmur, record the following:
a. Whether heard in systole, diastole or in both phases of the
cardiac cycle. If you are uncertain, listen whilst palpating
brachial pulse (murmur with pulse is systolic, after pulse is
diastolic).
b. Intensity (Grade 1-4)
Grade 1
Grade 2
Grade 3
Grade 4
Barely audible
Soft, but easily audible
Moderately loud but not associated with a thrill
Louder and associated with a thrill
c. Where heard loudest and where it radiates to
Northampton General Hospital Department of Paediatrics
Protocol for managing the newborn with a murmur
Assess the ‘work of breathing’ with the baby settled. Ensure that it
looks ‘comfortable’ and that none of the following are present:
9.
Grunting
Tracheal tug
Subcostal or intercostal recession
10.
Listen to the lung fields and ensure that the breath sounds are
vesicular.
11.
Palpate the abdomen and ensure that you can palpate no more than
just the leading edge of the liver 1cm beneath the right costal margin.
Initial investigations
Note: In an unwell baby with a murmur investigation should be deferred until a
senior clinician (StR grade or consultant) has reviewed the baby and
confirmed that no immediate medical intervention is required.
1.
ECG should be done in all. If the infant is otherwise perfectly well,
(in particular, has normal pulses and is not breathless or cyanosed)
he/she can go to the department of cardiology for the ECG
technician on duty would prefer such.
2.
Indications for chest x-ray:
Tachypnoea/elevated work of breathing
Oxygen saturations <95%
Clinical suggestion of dextrocardia
Northampton General Hospital Department of Paediatrics
Protocol for managing the newborn with a murmur
Murmur
‘Well’ baby
Unwell baby
Senior opinion immediately
Resuscitate
Admit to Gosset ward
Inform Gosset ward consultant
Consider cardiology opinion
Consider need for echocardiogram
Pre-discharge echocardiogram not indicated provided:
Pre-discharge echocardiogram mandatory if:
History unremarkable (see questions)
Murmur intensity  2/6
No difference in upper and lower limb pulses
No significant difference in upper/lower limb blood pressure
Otherwise normal physical examination
Oxygen saturations all limbs  95%
Normal ECG
Murmur intensity 2/6
Difference in limb pulses
Significant difference in limb blood pressures
Oxygen saturation < 95% in any limb
Dextrocardia or elevated work of breathing
Abnormal ECG
StR or Consultant concurs with assessment
Prompt review by StR
Consider pre-discharge echocardiogram if:
Murmur + otherwise normal cardiorespiratory
examination, but:
Abnormal karyotype or anomaly scan
Maternal condition associated with CHD
CHD in a first-degree relative
Dysmorphic baby e.g. Down Syndrome
Discuss case with attending consultant
Discharge
Follow-up options: (confirm with consultant*)
1. Sign and send standard proforma letter
to GP, copy of GP letter into set of baby
notes, give parents information leaflet
and copy of GP letter
2. OPA with attending consultant
Discuss with attending Consultant*
Arrange in-patient echocardiogram
* For infants admitted to Gosset ward, attending consultant is Gosset consultant of the week; for infants
never admitted to Gosset ward attending consultant is general paediatric consultant of the week
Northampton General Hospital Department of Paediatrics
Protocol for managing the newborn with a murmur
References
1.
2.
3.
4.
5.
Park MK 2002 Manifestations of Cardiac Problems in Newborns. In: Pediatric Cardiology, 4 th edition, Mosby, St Louis.
Ainsworth SB, Wyllie JP, Wren C. Prevalence and clinical significance of cardiac murmurs in neonates. Arch Dis Child Fetal
Neonatal Ed 1999; 80:F43-F45.
Arlettaz R, Archer N, Wilkinson A. Natural history of innocent heart murmurs in newborn babies: controlled echocardiographic study
Arch. Dis. Child. Fetal Neonatal Ed., May 1998; 78: F166 - F170.
Farrer KFM, Rennie JM. Neonatal murmurs: are senior house officers good enough? Arch. Dis. Child. Fetal Neonatal Ed., Mar
2003; 88: F147 - F151.
C Patton and E Hey. How effectively can clinical examination pick up congenital heart disease at birth?
Arch. Dis. Child. Fetal Neonatal Ed., Jul 2006; 91: F263 - F267.
Written by
Date
For review
Dr Nick Barnes, Consultant Paediatrician
May 2008
May 2011