Pediatric Heart Murmurs - My Illinois Statemy.ilstu.edu/~ddwilso2/nur471/Pediatric Heart Murmurs 2011.pdfclinical presentation of common ... pediatric heart murmurs Copyright © 2011

Pediatric Heart Murmurs

22 The Nurse Practitioner • Vol. 36, No. 3 www.tnpj.com

Evaluation and management in primary care

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

hen an NP performs a cardiac assessment on a pe-diatric patient, the parents are often relieved when the fi ndings are normal. If an atypical heart sound

is identifi ed, the ability of the NP to correctly discern the etiology as either physiologic or pathophysiologic is vital to both the care of the patient and the consolation of the family. Many cardiac murmurs are innocent with no harmful effects on the health of the child; the NP can provide reassurance to the family when an innocent murmur is found based on results of a confi dent and accurate assessment. Other car-diac murmurs are indicative of serious and potentially life-threatening problems; these may need referral to a specialist or immediate emergency treatment. Knowledge regarding clinical presentation of common pediatric heart murmurs, the impact of these murmurs on the health of the child, and the recommendations for diagnostic testing and referral are critical for evaluation and management in primary care.

■ Overview of pediatric heart murmursAccording to the National Heart Lung and Blood Institute, a heart murmur is defi ned as “an extra or unusual sound heard during a heartbeat.”1 In the pediatric population, in-nocent heart murmurs (those considered to be a variation of normal, not attributable to a problematic health condi-tion) account for the majority of cases. Innocent murmurs are most often caused by turbulent blood fl ow through the pulmonary arteries or a slightly patent ductus arteriosus

from delayed cardiac development in the neonate or pre-maturity.2,3 Conversely, pathologic heart murmurs are most commonly associated with a ventricular septal defect or a more severe patent ductus arteriosus, and may also result from congenital heart disease (see Ventricular septal defect and patent ductus arteriosus).2

■ Prevalence statisticsIn the newborn population, the prevalence of heart mur-murs is between 0.6% and 4.2%.4 Among infants and chil-dren, an estimated 90% will have a heart murmur at some point during their infancy or childhood.5 Approximately 50% to 70% of infants and children are reported to have a heart murmur identifi ed during a routine physical exam,6 but of all pediatric heart murmurs, less than 1% are caused by a congenital heart defect.7 About 70% of heart murmurs are asymptomatic in infants and children, and asymptomatic murmurs may be either innocent or pathologic.2

■ Assessing pediatric heart murmursWhen auscultation of the heart yields normal fi ndings, the fi rst heart sound (S

1) is heard as the atrioventricular valves

(mitral and tricuspid) close and ventricular systole begins, and the second heart sound (S

2) is heard as the semilunar

valves(aortic and pulmonic) close and ventricular dias-tole begins; no other heart sounds are heard and the heart rhythm is in a regular pattern.8 When a murmur exists, an

By Lauren Wierwille, RN, MS, FNP-C

2.5CONTACT HOURS

W

www.tnpj.com The Nurse Practitioner • March 2011 23

Abstract: The ability of the NP to discern pediatric heart murmurs is critical for accurate

assessment of etiology, appropriate diagnostic testing, and prudent referral when

indicated. This review includes an overview of cardiac assessment, distinguishing features

of innocent and pathologic murmurs, differential diagnosis of murmurs, and current

referral recommendations.

Key words: innocent murmur, pathologic murmur, pediatric heart murmurs



Pediatric heart murmurs: Evaluation and management in primary care

atypical heart sound is heard that may occur at various times throughout the course of the cardiac cycle depend-ing upon the type and cause of the murmur. There are three main factors responsible for the production of a heart murmur: (1) turbulent blood flow through vasculature or a normal or abnormal opening in the heart; (2) blood flow traveling forward through a narrowed valve into a dilated heart chamber or vessel; or (3) blood fl ow traveling backward or regurgitating into a previous heart chamber through an incompetent valve.9

■ The cardiac examThe three components of the cardiac exam are observa-tion, palpation, and auscultation, and the order of these components is fl exible in the pediatric population.6 Aus-cultating the heart of a pediatric patient before palpating the precordium is often recommended because the patient may be calmer early in the exam, making the heart easier to hear. When auscultating the heart, it is advised to fi rst listen for the normal heart sounds of S

1 and S

2 before trying

to detect the presence or absence of a murmur.8 This allows the NP to identify cardiac dysrhythmias and determine the presence or absence of the third and fourth heart sounds (S

3 and S

4). Murmurs are typically described as having a

harsh quality, a blowing sound, or a musical characteristic. The diaphragm of the stethoscope is most useful for hear-ing sounds with higher pitch, whereas the bell is best for sounds with lower pitch.8

Direct observation of the precordium is useful be-cause it can identify a heartbeat visibly moving the chest or abdomen.5 Although some of the information obtained

through observation does not directly assess the heart, such as breathing patterns and distension of the jugular veins in the neck, abnormalities can still indicate cardiac problems. Thrills can be identifi ed by palpation of the precordium, and the arterial pulses can be compared bilaterally by palpation to identify heart conditions such as coarctation of the aorta.5

■ Classifi cation and grading of murmursHeart murmurs are generally classifi ed according to timing (timing during the cardiac cycle), intensity (a grading scale that describes the intensity or volume of the murmur), quality (harsh, rumbling, vibratory, blowing, or musical), pitch (low, medium, or high), location (the anatomic loca-

tion wherein the murmur is heard best), and radiation (the site farthest from the location where the murmur can still be heard).

The timing of a murmur in the cardiac cycle is identifi ed as systolic, diastolic, or continuous. There are four types of systolic murmurs (holosystolic, mid-systolic, early systolic, and mid-to-late systolic) and three types of diastolic mur-murs (early diastolic, mid-diastolic, and late diastolic). A holosystolic or pansystolic murmur is heard throughout the duration of systole, whereas a mid-systolic also known as a systolic ejection murmur begins after S

1. Systolic ejec-

tion murmurs are characterized by a brief crescendo in volume followed by a decrescendo just before systole ends. An early systolic murmur begins simultaneously with or im-mediately after S

1 and ends midway through systole, while a

mid-to-late systolic murmur begins midway through systole and ends just before diastole.9 An early diastolic murmur is high-pitched and begins simultaneously with or imme-diately after S

2. A mid-diastolic murmur is heard shortly

after S2 and ends before the next cardiac cycle, while a late

diastolic murmur (also known as a presystolic murmur) occurs just before ventricular contraction when the atria have contracted and the ventricles are fi lling. Continuous murmurs are constantly heard behind the heart sounds.9

The intensity or volume of the murmur is assessed and documented by a system of grading, in which higher grades indicate a louder murmur. The most common grading sys-tem was developed by Levine in 1933, in which both systolic and diastolic murmurs are given a grade from 1 to 6.10 A grade 1 indicates that the murmur is barely audible through the stethoscope, whereas a grade 6 indicates that the mur-

mur is audible with the stethoscope lifted off the chest. Diastolic murmurs rarely reach grades of 5 to 6. In addi-tion to the Levine grading scale, there is another common grading scale for murmurs used that was developed by Wood and Leatham, two British car-

diologists.11 Their grading scale is similar in that louder murmurs receive higher grades, but Wood and Leatham use a smaller scale of grades 1 to 4, making the two grading systems incompatible because the range between grades is not identical for the two scales. Therefore, it is useful to document the grading system used concurrently with the grade assigned to a murmur (see The Levine grading scale for heart murmurs).11

■ History and further physical examThe NP can ask the patient and/or family about symptoms possibly indicating congenital or acquired heart disease such as chest pain, palpitations, syncope, activity intolerance,

An early diastolic murmur is high-pitched

and begins simultaneously with or

immediately after S2.




The Levine grading scale for heart murmurs19

Grade Explanation

1 Extremely faint murmur that is hardly audible when using the stethoscope

2 Murmur is quiet but audible when the stethoscope is placed on the chest

3 Easily audible murmur that is moderate in volume

4 Easily audible murmur that is moderate in volume and may have a palpable thrill

5 Very loud murmur, audible when stethoscope is light on chest, almost always has a palpable thrill

6 Murmur heard when stethoscope is not placed on chest, always has palpable thrill, often radiates

changes in skin color, or growth and development delays. For neonates and infants, the pertinent history includes information about length of gestation, birth history, normal habits of feeding, diffi culty breathing when feeding, and usual level of activity.6 For all pediatric patients with a heart murmur, it is especially important to obtain a thorough family history of congenital cardiac conditions (such as congenital heart defects and heart disease) because they are more likely to occur in patients with a fi rst-degree relative with a history of a congenital heart condition.7

A recent study assessed the value of cardiac signs and symptoms in predicting a pathologic heart murmur and concluded that these symptoms are signifi cantly helpful as a diagnostic aid, but the predictive values are variable depend-ing upon the age of the pediatric patient and corresponding ability or inability to assess certain signs and symptoms.12 Aside from the direct cardiac exam, other physical exam components that should be evaluated in an infant or child with a cardiac murmur include vital signs (such as tempera-ture [fever], pulse rate, respiratory rate, and BP), oxygen saturation, peripheral pulses, respiratory effort, cyanosis or pallor, carotid arteries for bruits, and jugular veins for abnormal pulsations.7 When assessing peripheral pulses, the brachial and femoral pulses are typically used for neonates and infants, whereas the radial and femoral pulses are used in children and young adults.13

■ Differentiating common pediatric heart murmursIn the pediatric population, there are four common innocent heart murmurs: Still murmur, pulmonary fl ow murmur, systolic fl ow murmur, and the venous hum. These murmurs are also known as functional murmurs, but the term “inno-cent” is preferable to use when educating families because it communicates more clearly to the parents that there is noth-ing abnormal or problematic about the murmur.7 Innocent

Ventricular septal defect and patent ductus arteriosus

Source: Pillitteri A. Maternal and Child Health Nursing. 6th Ed., Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. 2010; 1207, 1209

To rightlung

Aorta

To leftlung

Pulmonaryartery

Leftventricle

Rightventricle

Ventricular

septal defect

Venacava

Aorta

Pulmonary artery

Patent

ductus

arteriosus




Interventions for altering the intensity of

heart murmurs7,9

Interventiona Effect

Respiration Right-sided murmurs usually increase in volume with inspiration

Left-sided murmurs usually increase in volume with expiration

Supine position

Increases the intensity of Still murmur and pulmonary fl ow murmur

Venous hum usually cannot be heard

Standing position

Usually increases the intensity of the murmur associated with mitral valve prolapse

Softens the sound of the pulmonary fl ow murmur and venous hum

Squatting position

Usually decreases the intensity of the murmur associated with mitral valve prolapse

Transient arterial occlusionb

Augments the murmur associated with ventricular septal defect

Valsava maneuverc

Most murmurs decrease in length and intensity

Compression of jugular vein

Venous hum usually cannot be heard

aAll interventions can be performed in the outpatient setting, but some may not be possible for neonates and infants.bBilateral compression of extremities by infl ating cuff to 20 mm Hg greater than peak systolic BP.cCan be replicated by applying pressure to the abdomen of neonate or infant.

can be heard in early systole best between the apex and the left lower sternal border.15 This murmur has a vibratory quality that can be compared to the twanging of a stringed instrument or rubber band; it has been likened to the sound of a harp string being plucked or a buzzing sound.14

The pulmonary fl ow murmur is heard during systole and is most easily audible at the left upper sternal border.15 It typically has a high pitch with a harsh quality and origi-nates from the right ventricle outfl ow carried through the pulmonary arteries. For this reason, it may radiate bilaterally to the back and axilla.7 Pulmonary fl ow murmurs are more common in children and adolescents and less common in neonates and infants. When the cardiovascular system de-velops, only 10% of blood fl ows to the far branches of the pulmonary arteries, but later in life when the cardiovascular system becomes fully developed, the pulmonary arteries become larger and have greater blood fl ow.7

The systolic fl ow murmur is high-pitched, harsh sound-ing, and best heard in the superior chest and vessels of the head and neck.7 Its characteristic sound caused by normal blood fl ow through the carotid arteries helps differentiate the systolic flow murmur from a carotid bruit, which is caused by abnormal aortic outfl ow. Both pulmonary and systemic fl ow murmurs originate from a physiologic increase in blood fl ow, and can be classifi ed as hemic murmurs when blood fl ow naturally increases to compensate for such condi-tions as anemia or fever.7

The venous hum is a musical murmur that like Still murmur has a vibratory quality.15 It is best heard at both the upper right and left sternal borders and inferior neck region, and it is caused by blood fl ow returning to the heart through the venous system.7 The venous hum is the only innocent murmur heard during diastole.6 A few isolated case reports indicate that a venous hum may be audible to the child and may cause tinnitus, but this is not typical in the majority.16

■ Pathologic murmursA recent study identifi ed several physical exam fi ndings that were independently associated with the presence of a congeni-tal heart defect in neonates: harsh quality, location in either the aortic location (right upper sternal border), tricuspid location (left lower sternal border), or mitral location (apex), pansys-tolic timing, diastolic timing, and continuous murmurs.17 As a general rule, pathologic systolic murmurs are longer in duration and greater in intensity than innocent murmurs.6 If the murmur is heard during diastole (with the exception of the venous hum) or is holosystolic, the murmur is pathologic.6

A patent ductus arteriosus produces a continuous, holo-systolic murmur best heard at the upper left sternal border and left inferior neck region. In normal growth and develop-ment, the ductus arteriosus closes by the fourth day of life,

murmurs are more straightforwardly distinguished because they share the following characteristics: they occur in early systole (except venous hum), have a short duration, are typi-cally grades 1 or 2 on the Levine grading scale, and have a vibratory or musical quality.6 Because innocent murmurs are caused by normal blood fl ow, it is expected that the mur-murs should change in sound or intensity with positional changes that alter the normal blood fl ow. Several position changes and maneuvers can be performed to alter normal blood fl ow in order to help discern innocent from patho-logic murmurs and provide clues to the specifi c murmur etiology. (See Interventions for altering the intensity of heart murmurs).

■ Innocent murmursStill murmur was named for the surname of a physician who described a pediatric murmur with a musical quality in the year 1909.14 He followed his pediatric patients who presented with this murmur and after some time concluded that the murmur was not producing any abnormal signs and symp-toms and was, therefore, innocent in nature.13 Still murmur




Features of pediatric heart murmurs2, 6

Murmur type Physical exam fi ndings Other distinguishing characteristics

Innocent Murmurs:

Still murmur Systolic ejection, vibratory musical quality Accentuated by fever, exercise

Pulmonary fl ow murmur Systolic ejection, upper left sternal border Peak incidence in late childhood

Systolic fl ow murmur Superior to the clavicles, no ejection click Associated with thrill over carotids

Venous hum Diastolic components, vibratory quality Accentuated by learning forward

Pathologic Murmurs:

Patent ductus arteriosus Over superior chest, crescendo-decrescendo Diastolic murmur in older children

Atrial septal defect Wide and fi xed splitting of S2 Twice as common in females

Ventricular septal defect Discrete blowing sound with harsh quality Associated with palpable thrill

Aortic stenosis Radiates to neck, ejection click murmur Associated with palpable thrill

Pulmonary stenosis Ejection click murmur, radiates to back Asymptomatic if mild to moderate

Coarctation of the aorta Diminished volume, posterior scapular area Diminished femoral pulses

Mitral regurgitation Holosystolic, harsh blowing quality Associated diastolic murmur

Aortic regurgitation Diastolic murmur, decrescendo quality Associated with full, bounding pulses

Mitral stenosis Diastolic murmur, loudest over apex Diffi cult to distinguish, rumbling

Aortic stenosis Ejection click murmur, may radiate to neck Associated with palpable thrill

so this murmur is often found in premature newborns. The murmur of a patent ductus arteriosus is also associated with full and prominent pulses in children.2

An atrial septal defect causes a murmur best heard dur-ing systole that is loudest at the upper left sternal border. It is characterized by wide, fi xed splitting of S

2, and occasionally

an additional murmur is heard during diastole resulting from increased blood fl ow across the tricuspid valve.2 A ventricular septal defect produces a systolic murmur that may last the entire duration of systole. This murmur is characterized as a blowing sound with a harsh quality, and there is frequently a palpable thrill.2

The murmurs of both aortic and pulmonary stenosis are associated with ejection clicks.2 When auscultating the murmurs, a click will be heard as a sharp sound with a moderately loud intensity following S

1.6 Another pathologic

murmur can be caused by coarctation of the aorta. This murmur is systolic and heard best at the upper left sternal border and left posterior scapular area. It usually has a low volume but may be very intense and is associated with weak-ened femoral pulses and increased BP.2

The murmur of mitral regurgitation occurs from a dis-ruption in the normal functioning of the mitral valve in which the valve leafl ets are pushed back into the left atrium during left ventricular systole. Likewise, the murmur of

aortic regurgitation occurs from a disruption in the normal functioning of the aortic valve in which the valve leafl ets are pushed back into the left ventricle during left ventricular diastole. The murmur of mitral regurgitation is typically holosystolic while the murmur of aortic regurgitation is only heard throughout diastole.18

Mitral stenosis and aortic stenosis are caused by the calcifi cation or fi brosis of the mitral and aortic valves re-spectively. Aortic stenosis usually presents as a mid-systolic or systolic ejection murmur, while mitral stenosis is usually a very quiet rumble heard during diastole (see Features of pediatric heart murmurs).18

■ Diagnostic testing and indications for referralThe ECG and the chest X-ray have limited use in the diagno-sis of underlying pathology associated with pathologic heart murmurs, with low sensitivity and specifi city for identify-ing cardiac defects or anatomical abnormalities.13 A chest X-ray is not recommended in pediatric clients because it unnecessarily exposes the infant or child to ionizing radia-tion. The ECG has little benefi t for diagnosis of congenital heart defects because the majority of heart murmurs are found in asymptomatic patients.2 Nonetheless, the ECG should be considered as part of the routine physical exam for pediatric patients with a heart murmur because it is




noninvasive, easily conducted in the outpatient setting, useful to determine the need for further diagnostic testing through echocardiography, and has a high predictive value in ruling out cardiac dysrhythmias.13

■ EchocardiographyThe echocardiogram is the gold standard to defi nitively diagnose congenital cardiac malformations in pediatric patients.13 According to the American College of Cardiol-ogy/American Heart Association Task Force on Practice Guidelines, if a murmur is present and an abnormal chest X-ray or abnormal ECG is obtained, an echocardiography is indicated9 (see Evaluation of heart murmurs in the pediatric population). For pediatric patients with moderate left-sided congenital heart defects, it is recommended that a repeat

echocardiography be done if there is a change in cardiac status or every 2 to 5 years, whichever occurs fi rst.18 For patients with left-sided congenital heart defects that are severe, it is recommended to repeat echocardiography at least yearly.18

■ Cardiology referralIf there is any confusion about discerning an innocent from a pathologic murmur, or if additional reassurance regard-ing a suspected innocent murmur is desired by the parent, referral to a pediatric cardiologist is a prudent and recom-mended action on the part of the NP.7 Referral for specialty management of pediatric heart murmurs is indicated in the presence of symptomatic left-sided cardiac murmurs, aortic

murmurs with concomitant chest pain or syncope, and echocardiography yield-ing overload of the right ventricle with a murmur caused by mitral valve disease.18 Further research is needed to establish a general recommendation regarding spe-cialty referral of neonatal patients with asymptomatic heart murmurs.19

If a patient has a murmur associat-ed with mitral regurgitation and dem-onstrates heart failure symptoms, left ventricular dysfunction, atrial fi brilla-tion, or pulmonary hypertension, refer-ral to a cardiology specialist for surgery is indicated. Referral is also indicated

in the presence of suspected severe aortic regurgitation. With any severe left-sided valve lesions found on echocar-diography, or major left ventricular dilation, hypertrophy, or other dysfunction, referral to a cardiologist is indicated; if similar conditions are right-sided, cardiology referral is appropriate to consider.18

■ Patient and family educationThe NP is often the fi rst person to fi nd a heart murmur in a pediatric patient, and therefore is in a unique position to provide education regarding heart murmurs. Reassurance for the patient and the family regarding the benign nature of innocent murmurs is important. Although the murmur may never disappear and can persist into adulthood, the parents and child can be specifi cally educated that inno-

cent murmurs are additional sounds heard as a result of normal blood fl ow patterns, and therefore are completely harmlessness. Because these murmurs can be altered with positional changes and normal growth and development, parents should be educated that in-

nocent murmurs may seem to disappear and reappear throughout the course of the child’s life. The misconcep-tion that heart murmurs in adults are always pathologic can also be clarifi ed. Finally, the NP can allay fears about the likelihood of a murmur originating from a congenital heart defect with the statistic that less than 1% of pediatric murmurs actually have this etiology.7

■ ConclusionHeart murmurs are a frequent fi nding in the pediatric pop-ulation. The majority are innocent in nature, and the ability to correctly distinguish these physiologic from pathologic murmurs is a critical responsibility of the NP. Fortunately, the differential diagnosis of most common pediatric heart

Evaluation of heart murmurs in the pediatric population9

Systolic Murmurs

Midsystolic• Grade 2 or less – Asymptomatic and no associated signs or symptoms © No further workup – Symptomatic or other signs of cardiac disease © Echocardiogram• Grade 3 or more © EchocardiogramEarly systolic, late systolic, holosystolic © Echocardiogram

Diastolic and Continuous Murmurs

Echocardiogram

– Cardiac catheterization and angiogram may be indicated

Exceptions: Continuous venous hum © No further workup

*Murmurs are graded using the Levine grading scale.

The echocardiogram is the gold standard

to defi nitively diagnose congenital cardiac

malformations in pediatric patients.




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murmurs may be accomplished based solely on knowledge of clinical presentation and associated features of each mur-mur. When a murmur presents in accordance with patho-logic signs and symptoms, diagnostic testing by means of echocardiography is often indicated. Pathologic murmurs are almost always indications for referral and management by a pediatric cardiologist. The primary care NP is in a unique position to identify new onset cardiac murmurs and educate the patient and family regarding the specifi c cardiac fi ndings and implications on the health of the patient.

REFERENCES 1. National Heart Lung and Blood Institute. What is a Heart Murmur? http://

www.nhlbi.nih.gov/health/dci/Diseases/heartmurmur/hmurmur_what.html.

2. Manning D, Paweletz A, Robinson JL. Management of asymptomatic heart murmurs in infants and children. Paediatr Child Health. 2008;19(1):25-29.

3. Richmond S, Wren C. Early diagnosis of congenital heart disease. Semin Neonatol. 2001; 6: 27-35.

4. Mahle WT, Newburger JW, Matherne GP, et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientifi c statement from the American Heart Association and American Academy of Pediatrics. Circulation. 2009;120(5):447-458.

5. Mahnke CB, Mulreany MP, Inafuku J, Abbas M, Feingold B, Paolillo JA.. Utility of store-and-forward pediatric telecardiology evaluation in distinguishing normal from pathologic pediatric heart sounds. Clin Pediatr (Phila). 2008;47(9):919-925.

6. Menashe V Heart murmurs. Pediatr Rev. 2007;28(4):e19-e22.

7. Biancaniello T. Innocent murmurs. Circulation. 2005;111(3):e20-e22.

8. Schindler DM. Practical cardiac auscultation. Crit Care Nurs Q. 2007:30(2):166-180.

9. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2008; 118:e523-e661.

10. Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. Am J Cardiol. 2008;102(8):1107-1110.

11. Cheng TO. Grading heart murmurs must always indicate the grading system used. Int J Cardiol. 2009;135(2):143-145.

12. Koo S, Yung TC, Lun KS, Chau AK, Cheung YF. Cardiovascular symptoms and signs in evaluating cardiac murmurs in children. Pediatr Int. 2008;50(2):145-149.

13. Johnson R, Holzer R. Evaluation of asymptomatic heart murmurs. Curr Paediatr. 2005;15(7):532-538.

14. Guntheroth WG. Innocent murmurs: a suspect diagnosis in non-pregnant adults. Am J Cardiol. 2009;104(5):735-737.

15. Advani N, Menahem S, Wilkinson JL. The diagnosis of innocent murmurs in childhood. Cardiol Young. 2008;10(4):340-342.

16. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clin Pediatr (Phila). 2009;48(1):87-88.

17. Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ.. Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr. 2009;154(1):50-54.

18. Sonnenberg B. Murmurs on murmurs: When to ECHO, when to refer. Perspect Cardiol. 2008;25(4):29-34.

19. Niccolls C. Examination of the newborn: The innocent heart murmur. J Neonatal Nurs. 2009;15(2):38-46.

The author has disclosed that she has no fi nancial relationship related to this article.

Lauren Wierwille is a certifi ed family nurse practitioner at an independent primary care practice in Laurel, Md.

DOI-10.1097/01.NPR.0000393968.36683.f0


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Pediatric Heart Murmurs - My Illinois Statemy.ilstu.edu/~ddwilso2/nur471/Pediatric Heart Murmurs 2011.pdfclinical presentation of common ... pediatric heart murmurs Copyright © 2011