Heart murmurs in children

Clare O’Donnell

Paediatric/Adult Congenital Cardiologist

Greenlane Paediatric and Congenital Cardiac Service

Murmurs in childhood are:

Common

Usually innocent

Innocent heart murmurs

Prevalence ? 40-60% after infancy

Findings– normal heart sounds

– soft

– systolic (except venous hum)

– usually brief

– localised

– change intensity with position

– otherwise WELL - normal exam and history

When to worry/refer

• Failure to thrive/poor feeding

• Breathlessness/Fatigue

• Cyanosis

• Not soft/systolic

• Family History

Increased risk

• Sibling or parent with CHD

• Associated chromosomal condition

• Associated congenital abnormality

– eg diaphragmatic hernia

• Diabetic Mother

Congenital Heart Disease

Approximately 1/100 children

Neonates

– Blue

– Breathless

– Poorly perfused

Duct important for either pulmonary supply or aortic supply

Post neonatal presentation

• Murmur

• Blue Spells

• Poor growth

• Chest infections

• Fast heart rate

• (stridor, wheeze, choking)

Common stuff

• VSD 35 % (remember small hole – BIG noise)• ASD 10%• PDA 7%• Pulmonary stenosis 7%• Aortic stenosis 4%• Coarctation 4%• Tetralogy 4%

All cyanotic 14%

Percent of total CHD in liveborn infants

Tips on exam

• Failure to thrive

• Breathlessness

• Murmur – listen broadly and on back

• Femoral pulses!

Coarctation – a good problem to find

Murmur – front of chest but particularly posteriorly

• Diminished or absent femoral pulses

• Hypertension Right arm

Cyanosis – difficult clinical sign

Detectable clinically ? 80-85%

– Oximeter

• Remember acrocyanosis - blue peripheries

Pulse oximetry screening

Rheumatic heart disease

Most commonly Mitral regurgitation and Aortic regurgitation

NZ guidelines

The classical innocent murmurs in children

Vibratory murmur

Still’s murmur

“a twanging sound, very like that made by twanging a piece of

tense string” George F Still 1909

Aortic leaflet vibration

almost disappears with sitting

Venous hum

continuous murmuraccentuated in diastole

varies with posture, head movement

A few thoughts re tests

If you can’t examine the child tests may be difficult….

ECGs in children

Echocardiogram

Congenital heart disease assessment ‘structural’ vs adult ’functional’ assessment

What about antenatal scans in children?

What do they miss?

• Limitations to views

• Varying degrees of experience

• Assessment may be based on four chamber view

Our standard approach to triage

To finish

• Murmurs are common

• Significant Congenital Heart disease is not

• Watch for ‘clues’ – failure to thrive, frequent chest infections

• Check femoral pulses

• Watch for rheumatic heart disease in susceptible populations

Thank you