Heart murmurs are common extra sounds heard in many infants and children. They are often physiological or innocent phenomena that require no further investigation or management, however it is important to be able to exclude a pathological underlying cause.
Murmurs are diagnosed clinically, being defined as any added sounds to the regular S1 and S2 heard in the normal cardiac cycle. Important considerations when assessing a murmur clinically include:
- age of the child
- if the child has an intercurrent illness
- position of loudest intensity
- timing (e.g. systolic), duration (e.g. ejection) and character (e.g. blowing) of murmur
- presence of radiation
- associated features (e.g. heaves, thrills, clicks/snaps, S3 +/or S4, cyanosis, peripheral pulse changes, blood pressure changes, syndromic features)
- Neonates
- Pulmonary flow or transitional murmur (1st few days of life, upper sternal edges, long systolic, radiating laterally)
- PDA (systolic to biphasic ‘machinery’ murmur, upper left sternal edge)
- PFO (systolic ejection, upper left sternal, radiated left lateral)
- Children
- Innocent or Still’s murmur (left sternal, ejection systolic, max. 2/6, differs from lying to sitting, no associated features)
- Flow murmur (predominantly left sternal, ejection systolic, only present during illness)
- VSD (lower left sternal, pansystolic, radiates to axilla, may have signs of overload, acyanotic)
- ASD (upper left sternal, early systolic, radiates to left upper chest)
- Murmurs are often physiological or innocent phenomena that require no further investigation or management, however it is important to be able to exclude a pathological underlying cause.
- persisting neonatal/infant murmurs of any type
- childhood murmurs that are persistent (i.e. not flow murmurs during illnesses) and have:
- abnormal positioning or
- 3/6 intensity (see innocent murmur description above).
- Children who show concerning cardiac signs should be sent for Emergency Department evaluation or discussed with paediatric services, and urgent CXR & ECG should be obtained. These incude those with:
- clinical central cyanosis (i.e. blue tongue or low SpO2 on oximetry)
- increased work of breathing not explained by an intercurrent illness (or shortness of breath and/or sweating during feeds for infants)
- signs of cardiac compromise
- poor perfusion
- absent/poor peripheral pulses
- hepatomegaly
- gross oedema
- altered conscious state)
- Paediatrician
- Referral to paediatric outpatient services is appropriate for any murmurs that are felt not to be innocent or transitional in nature. Innocent and transitional murmurs can be watched in the outpatient setting without further investigation.
- Cardiology
- Outpatient paediatric cardiology services and are available through Paediatrics Ballarat, however review by or discussion with general paediatric services is recommended prior to this given the large volumes of patients requiring cardiology review.
- Echocardiography
- Paediatric echocardiography is available through Ballarat Health Services Diagnostic Imaging (Ph: 53204201), with reporting undertaken by a paediatric cardiologist at RCH.
- Dedicated on site paediatric echocardiography is available through the paediatric cardiology services and are available through Paediatrics Ballarat.
- Further resources
- For those with diagnosed cardiac defects, further information can be obtained through the RCH Cardiology Department heart defects information pages.