Heart murmurs in pediatric practice

Pediatric heart murmurs are common and may be innocent or associated with cardiac pathology and risk of sudden cardiac arrest. The aim of this article is to review the common pediatric heart murmurs including evaluation, indications for pediatric cardiology referral, and patient and family education. The first step in the evaluation of a heart murmur is to take a thorough and systematic history, including history of present illness, symptoms and signs of cardiovascular disease, and prenatal, past medical, family, and social history. The systematic cardiovascular examination includes vital signs, inspection, palpation, and auscultation. The seven characteristics of a heart murmur include timing, shape, location, radiation, intensity, pitch, and quality. The normal first heart sound S 1 occurs from mitral and tricuspid valve closure. The normal second heart sound S 2 occurs from aortic and pulmonary valve closure. Innocent murmurs such as the Still, pulmonary flow, supraclavicular murmurs, and venous hum do not require treatment. Pathologic murmurs are caused by structural heart disease and necessitate referral to a pediatric cardiologist. Systolic ejection murmurs may be caused by aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy, or coarctation of the aorta. Holosystolic murmurs may be caused by ventricular septal defect, mitral regurgitation, mitral valve prolapse, or tricuspid regurgitation. Diastolic murmurs are pathologic and include murmurs caused by aortic regurgitation, pulmonary regurgitation, mitral stenosis, or tricuspid stenosis. The most common pathologic continuous murmur is caused by patent ductus arteriosus. Referral of a patient with a murmur to pediatric cardiology is indicated by age, murmur characteristics, associated symptoms and findings consistent with possible cardiovascular disease, and family and genetic history. Parental anxiety about the upcoming cardiology visit may be decreased through discussion with the clinician. • Heart murmurs are produced by turbulent blood flow. • Pediatric heart murmurs are common and may be innocent or associated with pathology. • Murmurs are evaluated with history and physical examination including auscultation. • Murmurs vary with timing, shape, location, radiation, intensity, pitch, and quality. • Pathologic murmurs may be systolic ejection, holosystolic, diastolic, or continuous.