a clinical approach to Pediatric heart murmurs when evaluating a heart murmur the most important thing to determine is whether the murmur is innocent or pathologic the majority of cardiac murmur in children are innocent with no underlying heart defect however it is important to identify pathologic murmur that are manifestation of cardiac abnormalities in this lecture we will go through how to take a focus history and a thorough physical exam to identify the likely cause of the murmur and determine whether further investigations or cardiologist referrals are necessary we will discuss the common causes of heart murmur and the investigations and management required the history and physical exam should focus on searching for symptoms and signs suggestive of congenital heart disease innocent murmur by definition have no clinical significance thus children with Innocent murmur are always asymptomatic in contrast all symptomatic murmur are pathologic although some pathologic murmur may be asymptomatic innocent murmur are typically early ejection systolic Soft short at the sternal Edge and without added sounds all diastolic murmur except the Venus hum are pathologic s are all pens systolic murmur obscuring S1 other features suggestive of pathology include loud murmur more than grade 3 over 6 continuous murmur and murmur with other Associated cardiac abnom ities such as Thrills edit sounds and abnormal pulses congenital heart diseases that cause murmurs are often asymtomatic though they may rarely present with cyanosis Syncopy cardiac failure or a sudden state of cardiogenic shock cardiovascular collapse occurs when the doctor's atosis closes in Duck dependent lesions such as an equation of the aorta and hypoplastic left heart syndrome when taking a history it is important to ask about symptoms of cardiac failure in an infant this would manifest as poor feeding due to fatigue resulting in smaller feeds breathlessness on sucking perspiration on feeding and a resulting failure to thrive the infant may also have respiratory symptoms such as wheezing and teyia or more rarely cyanosis in older children features of concern include exercise intolerance exertional disia exertional chest pain and Syncopy congenital heart diseases that present early in infancy with congestive heart failure include large ventricular sepal defects a large Paton ductus arteriosis and critical atic or pulmonary stenosis it is also important to ask for a family history of sudden death especially in young relatives suggestive of hypertrophic cardiomyopathy or a history of siblings with congenital heart disease it is also useful to have an idea of the birth and developmental history of the child including complications during pregnancy and maternal chronic diseases and medications maternal diabetes melus SLE certain infections anti-convulsant medications and maternal substance abuse are associated with a higher rate of congenital heart defects also ask when the murmur was first detected as obstructive lesions such as eotic and pulmonary stenosis are generally heard at Birth or shortly after birth whereas lesions in which shunts and flows depend on a delayed fall in pulmonary resistance such as an atpal defect or ventricular septal defects are more typically Hur days or weeks after birth on examination observe the child for sinosis and respiratory distress at rest and when crying or feeding look for characteristic features of syndromes associated with cardiac disease such as Down syndrome and morphan syndrome about 50% of patients with Down Syndrome have congenital heart defects the most common of which are arterial ventricular sepal defects also known as endocardial C iion defects and ventricular septal defects 69% of all patients with atrial ventricular septal defects have Down syndrome this is heard as a hollow systolic murmur at the left lower stle border and Apex with an accentuated S2 and S3 also observe for respiratory distress and wheezing which may be a manifestation of cardiac failure and assess for the presence of clubbing and decreased peripheral profusion pulses should be easily palpable and equal in their intensity throughout the body generalize weak pulses suggest poor cardiac output either due to severe heart failure or severe aortic stenosis pulses that are stronger in the upper extremities as compared to the lower extremities suggest coact of the aota bounding pulses are felt in patients with a low diastolic pressure due to aoic regurgitation or presence of a systemic to pulmonary arterial connection such as Pon ductus atosis the precordium should normally be quiet hyp dnamic circulation due to increased pulmonary blood flow right ventricular hypertrophy or left ventricular hypertrophy will cause prominence of the right ventricular or left ventricular impulses pable Thrills are felt with murmur grade four or higher prominent cardiac impulses or thrill indicate pathology homeg May reflect a high right atrial pressure associated with congestive cardiac failure on OS scalation evaluate the heart sounds assess for any edit sounds and clicks and describe the various characteristics of the murmur such as the timing character length quality frequency loudness location best heard and any radiation listen for each component of the cardiac cycle heart sounds and innocent heart murmurs are normal S1 and S2 should be distinctly audible S2 should split in inspiration and become single in expiration a one widely fixed split S2 can be heard in atrial sepal defects a loud P2 indicates pulmonary hypertension additional sounds such as presystolic S4 are pathological while early diastolic S3s may be normal for the timing of the murmur listen for the absence of silence in a diastolic murmur innocent heart murmurs could be systolic and diastolic such as in Venus hum but never purely diastolic for character a typical innocent heart murmur is vibratory or musical in quality harsh murmur indicate pathology for intensity innocent heart murmur are typically 1 to 2 upon 6 in intensity rarely they are 3 upon six but never louder this slide shows some common pediatric murmurs where they are best heard and their classic characteristics if the history and physical exam findings are suspicious for pathological murmur initial investigations to order include a chest x-ray and ECG in addition to a four limb blood pressure in the case of a murmur that is suspected to be pathologic a Cardiology referral is appropriate further investigations include 2D echocardiography and cardiac catheterization if necessary management depends on the cause of the murmur and may involve medical or surgical therapy or both treatment should also address the symptoms complications and the overall health of the child including adequate growth in conclusion cardiac murmur in children may be innocent or pathological first determine if the child is symptomatic or not then assess the murmur for its timing character quality frequency loudness location and radiation the definitive investigation for murmur is a 2d Echo cardiography management includes correcting the structural abnormality but also addressing the comp complications quiz time you are examining a 5-year-old child with no prior medical history she has normal developmental milestones and has a weight within the 50th percentile she is currently saturating well on oxygen and her lung sounds are clear on osculation of her heart you hear S1 and S2 heart sounds you also detect a continuous Machinery murmur over the upper left stal Edge which radiates to the left clavicle the MMA does not vary with position which of the following is this m most likely to reflect the answer is patent ductus arteriosis next question which of the following is a cause of cyanotic congenital heart disease the answer is transposition of great vessels next question you are examining a 3-day old neonate with low set ears flattened nasal bridge and a single Palmer crease suggested of a genetic condition which is the most common congenital heart defect associated with this syndrome the answer is atrio ventricular septal defect note the patent doctor's arteriosis in an extremely pre-m baby does not present very classically as a Machinery murmur in fact it may even sound systolic what would be more telling is therefore a hyperdynamic precordium plus diastolic drift however do note that this scenario is more for neonatal specialists