pediatric Murmur

Innocent Murmurs Innocent Murmurs in Childrenin Children

Georgeann Wang, MS3Georgeann Wang, MS3

Murmurs in ChildrenMurmurs in Children

Heart murmurs are one of the most Heart murmurs are one of the most common physical findings in any practice common physical findings in any practice that cares for childrenthat cares for children

50-60% of children have a heart murmur50-60% of children have a heart murmur Over 90% of heart murmurs are normal Over 90% of heart murmurs are normal

and require no further evaluation/referraland require no further evaluation/referral termed “innocent,” “functional,” “benign,” or termed “innocent,” “functional,” “benign,” or

“physiologic”“physiologic”

Evaluation of MurmurEvaluation of Murmur

Timing – where during cardiac cycle? – Timing – where during cardiac cycle? – systolic, diastolic, or continuoussystolic, diastolic, or continuous

Type – holosystolic, ejection/crescendo-Type – holosystolic, ejection/crescendo-decrescendo, early, latedecrescendo, early, late

Quality – harsh, blowing, vibratoryQuality – harsh, blowing, vibratory Intensity – grades I-VIIntensity – grades I-VI

Innocent MurmursInnocent Murmurs

NotNot solely solely diastolic!diastolic! (systolic or (systolic or continuous)continuous)

NotNot associated with a associated with a thrill!thrill! (grades I-III) (grades I-III) NotNot associated with a associated with a click!click!

Grading MurmursGrading Murmurs

GradeGrade DescriptionDescription

II Barely audibleBarely audible

IIII Easily audibleEasily audible

IIIIII Very audible without a thrillVery audible without a thrill

IVIV With thrill – stethoscope fully on chestWith thrill – stethoscope fully on chest

VV With thrill – stethoscope halfway off With thrill – stethoscope halfway off chestchest

VIVI With thrill – stethoscope off chestWith thrill – stethoscope off chest

Grading Murmurs – Grading Murmurs – A New ApproachA New Approach

GradeGrade DescriptionDescription

II Less in intensity to heart soundsLess in intensity to heart sounds

IIII Equal in intensity to heart soundsEqual in intensity to heart sounds

IIIIII Greater in intensity to heart sounds, Greater in intensity to heart sounds, without thrillwithout thrill

IVIV With thrill, stethoscope fully on chestWith thrill, stethoscope fully on chest

VV With thrill, stethoscope halfway offWith thrill, stethoscope halfway off

VIVI With thrill, stethoscope off chestWith thrill, stethoscope off chest

Logic-based PneumonicLogic-based Pneumonic

Innocent murmurs Innocent murmurs occur at sites with occur at sites with disproportionate-disproportionate-sized connectionssized connections

Smaller vessel Smaller vessel connecting to larger connecting to larger vesselvessel

Or larger vessel Or larger vessel branching into branching into smaller vessels smaller vessels

1. Venous Hum1. Venous Hum

Connection between Connection between jugular, subclavian, jugular, subclavian, and innominate veins and innominate veins to SVCto SVC

Venous HumVenous Hum

Most common Most common continuouscontinuous murmur in murmur in childrenchildren

Most often in ages 2-8 y/o (toddlers to Most often in ages 2-8 y/o (toddlers to school-age)school-age)

Low frequency, Low frequency, continuouscontinuous murmur often murmur often louder in diastolelouder in diastole

Best heard Best heard below the right claviclebelow the right clavicle

Venous HumVenous Hum

Increased: in sitting or standing positionIncreased: in sitting or standing position Decreased: in supine position, with Decreased: in supine position, with

compression of neck veins (directly or compression of neck veins (directly or with changes in head position) with changes in head position) Compressing neck veins or turning headCompressing neck veins or turning head to to

the right will diminish murmurthe right will diminish murmur Diminishes completely in supine positionDiminishes completely in supine position

Venous Hum – Venous Hum – differential differential diagnosisdiagnosis

PDAPDA – loud, continuous machinery – loud, continuous machinery murmur with murmur with systolicsystolic prominence prominence best heard on best heard on leftleft 2 2ndnd interspace and interspace and radiates radiates

to backto back not changednot changed with position or neck vein with position or neck vein

occlusionocclusion

AV fistulaAV fistula – – not changednot changed with position or with position or occlusion of neck veinsocclusion of neck veins

2. Pulmonary Flow 2. Pulmonary Flow MurmurMurmur

Connection of right Connection of right ventricle with main ventricle with main pulmonary arterypulmonary artery

Pulmonary Flow MurmurPulmonary Flow Murmur

May be heard in wide range from school-May be heard in wide range from school-age children to adolescents and young age children to adolescents and young adultsadults

Low intensity Low intensity systolic ejectionsystolic ejection murmur murmur Best heard at Best heard at LUSBLUSB (2 (2ndnd or 3 or 3rdrd interspace) interspace)


Increased: Increased: high output stateshigh output states (fever, (fever, illness, anemia, etc), with expirationillness, anemia, etc), with expiration

Decreased: standing position, with Decreased: standing position, with inspirationinspiration


Is exaggerated by any condition that Is exaggerated by any condition that brings the RVOT closer to the anterior brings the RVOT closer to the anterior chest wallchest wall eg. pectus excavatum, kyphoscoliosiseg. pectus excavatum, kyphoscoliosis

Pulmonary Flow Murmur Pulmonary Flow Murmur – – differential diagnosisdifferential diagnosis

ASDASD – “relative” pulmonic stenosis – “relative” pulmonic stenosis murmur (due to increased blood volume murmur (due to increased blood volume in right heart) in right heart) accompanied by a accompanied by a widely split S2, mid-widely split S2, mid-

diastolic flow murmur, right ventricular heavediastolic flow murmur, right ventricular heave Pulmonic stenosisPulmonic stenosis – – louder, harsherlouder, harsher

sounding murmursounding murmur can be associated with a can be associated with a thrill or ejection thrill or ejection

clickclick

3. Physiologic Peripheral 3. Physiologic Peripheral Pulmonary Stenosis (PPS)Pulmonary Stenosis (PPS)

Connection of main Connection of main pulmonary artery to pulmonary artery to right and left right and left pulmonary artery pulmonary artery branchesbranches

Physiologic PPSPhysiologic PPS

Most often in neonates and infants from birth to Most often in neonates and infants from birth to 6 mos of age6 mos of age

Soft, low-pitched Soft, low-pitched systolic ejectionsystolic ejection murmur (can murmur (can extend slightly past S2)extend slightly past S2)

““blowing” in quality, sounds blowing” in quality, sounds like breath soundslike breath sounds (can briefly occlude nares)(can briefly occlude nares)

Best heard at Best heard at left infraclavicularleft infraclavicular area with area with radiation to bilateral radiation to bilateral axillae and backaxillae and back

Physiologic PPSPhysiologic PPS

Increased in: high output states (fever, Increased in: high output states (fever, illness, anemia, etc), viral URI, RAD illness, anemia, etc), viral URI, RAD exacerbationsexacerbations

PPS – PPS – differential diagnosisdifferential diagnosis

Pulmonic stenosisPulmonic stenosis – – louder,louder, harsherharsher murmur, associated with ejection murmur, associated with ejection click or click or thrillthrill

VSDVSD – – no radiationno radiation to axillae to axillae PDAPDA – machinery like, – machinery like, lower pitchlower pitch Pathologic PPSPathologic PPS – – longerlonger duration, duration, higherhigher

pitch, pitch, olderolder children children

4. Still’s Murmur4. Still’s Murmur

Connection of left Connection of left ventricle with aortaventricle with aorta

Still’s MurmurStill’s Murmur

Most common innocent murmurMost common innocent murmur in in children children

Reported to be present in up to 75-85% Reported to be present in up to 75-85% of childrenof children

Most often in ages 2-6 y/o, but can be Most often in ages 2-6 y/o, but can be from birth to adolescencefrom birth to adolescence


Low-pitched II/VI early systolic ejection Low-pitched II/VI early systolic ejection murmurmurmur

Described as “vibratory,” “musical,” Described as “vibratory,” “musical,” “harmonic,” “twanging,” “groaning/moaning,” “harmonic,” “twanging,” “groaning/moaning,” “squeaky”“squeaky” Like the Like the soundsound of a of a guitar stringguitar string being plucked being plucked

Best heard at Best heard at LLSB/apexLLSB/apex


Increased: supine position, fever, anemiaIncreased: supine position, fever, anemia Decreased: sitting or standing, with Decreased: sitting or standing, with

valsalva valsalva

Still’s Murmur – Still’s Murmur – differential diagnosisdifferential diagnosis

VSDVSD – different quality, harsh – different quality, harsh not musicalnot musical LVOT obstructionLVOT obstruction – different quality – different quality HOCMHOCM – different quality – different quality

5. Supraclavicular 5. Supraclavicular Systemic BruitSystemic Bruit

Connection of Connection of brachiocephalic brachiocephalic vessels to aortic archvessels to aortic arch

Supraclavicular Systemic Supraclavicular Systemic BruitBruit

Heard in children and young adultsHeard in children and young adults Harsh, medium to high-pitched, brief Harsh, medium to high-pitched, brief

early early systolic ejectionsystolic ejection murmur murmur Best heard in the Best heard in the carotids bilaterallycarotids bilaterally with with

some radiation to infraclavicular areasome radiation to infraclavicular area

Supraclavicular Systemic Supraclavicular Systemic BruitBruit

Decreased: with shoulders pulled back Decreased: with shoulders pulled back (hyperextension)(hyperextension)

No change with positionNo change with position

Supraclavicular Systemic Supraclavicular Systemic Bruit – differential diagnosisBruit – differential diagnosis

Aortic stenosis/supraaortic stenosis Aortic stenosis/supraaortic stenosis – – louder in chestlouder in chest with radiation to carotids with radiation to carotids

ASDASD

Most common misdiagnosed heart Most common misdiagnosed heart murmur in childrenmurmur in children

More often than not there is no murmur More often than not there is no murmur heard with ASDheard with ASD

Auscultation of ASDAuscultation of ASD

3 auscultatory findings in ASD – 3 auscultatory findings in ASD – all due to L-all due to L-to-R shunting across defect to-R shunting across defect larger blood volume in larger blood volume in right heartright heart

1. 1. widely split S2widely split S2 – longer time to empty right – longer time to empty right side of heart vs. left sideside of heart vs. left side

2. 2. pulmonary “stenosis” flow murmurpulmonary “stenosis” flow murmur – large – large amount of blood exiting through RVOT amount of blood exiting through RVOT

3. 3. mid-diastolic flow murmurmid-diastolic flow murmur – large amount – large amount of flow across triscuspid valveof flow across triscuspid valve

Red Flags! – Caution!Red Flags! – Caution!

Holosystolic murmurHolosystolic murmur Presence of a thrill (grade >III/VI)Presence of a thrill (grade >III/VI) Harsh qualityHarsh quality Presence of early/mid systolic clickPresence of early/mid systolic click Abnormal S2Abnormal S2 Diastolic murmurDiastolic murmur Increase in intensity with standing upIncrease in intensity with standing up

Beware!Beware!

General appearanceGeneral appearance – dysmorphic features – dysmorphic features ConstitutionalConstitutional – poor weight gain, diaphoresis, – poor weight gain, diaphoresis,

cyanosis cyanosis Respiratory symptomsRespiratory symptoms – tachypnea, wheezing, – tachypnea, wheezing,

chronic cough, poor/difficulty feedingchronic cough, poor/difficulty feeding Cardiovascular symptomsCardiovascular symptoms – chest pain, – chest pain,

syncope/presyncope, tachycardiasyncope/presyncope, tachycardia Abnormal testsAbnormal tests – enlarged heart on CXR, – enlarged heart on CXR,

hypertrophy on EKGhypertrophy on EKG

Case 1Case 1

A 5 y/o Latin American boy presents for his A 5 y/o Latin American boy presents for his annual school physical. He has no significant annual school physical. He has no significant PMH and is very active. More recently he has PMH and is very active. More recently he has had fever and diarrhea. PE is normal with the had fever and diarrhea. PE is normal with the exception of this murmur heard at the LLSB exception of this murmur heard at the LLSB near the apex. near the apex.

You tell mom that he has a benign murmur. She You tell mom that he has a benign murmur. She asks you why no doctor has ever heard this asks you why no doctor has ever heard this murmur before today. You say?murmur before today. You say?

Case 1Case 1

He has a vibratory He has a vibratory Still’s murmurStill’s murmur that is just that is just now detected since he is sick with now detected since he is sick with fever fever (high output state increases intensity of (high output state increases intensity of the murmur). the murmur).

Case 2Case 2

You are a medical student and you are You are a medical student and you are examining a 6 y/o Caucasian girl here for examining a 6 y/o Caucasian girl here for routine check-up. She is previously healthy routine check-up. She is previously healthy and has no complaints. During PE, you listen and has no complaints. During PE, you listen to her heart as she lies on the exam table. You to her heart as she lies on the exam table. You present her CV exam as normal to your present her CV exam as normal to your attending. He examines her as she sits on the attending. He examines her as she sits on the table and he hears this murmur just below her table and he hears this murmur just below her right clavicle. right clavicle.

You are very embarrassed for missing this You are very embarrassed for missing this obvious murmur. What was your mistake?obvious murmur. What was your mistake?

Case 2Case 2

She has a She has a venous humvenous hum murmur that murmur that diminishes completely in the diminishes completely in the supinesupine position. It is important to perform the position. It is important to perform the CV exam in both supine and upright CV exam in both supine and upright positions. positions.

Your attending is not upset and tells you Your attending is not upset and tells you that you that you will not failwill not fail the cardiology the cardiology elective afterall. PHEW!elective afterall. PHEW!

Case 3Case 3

3 y/o AA girl is a new patient who has a 3 y/o AA girl is a new patient who has a history of a heart murmur per mom. history of a heart murmur per mom. Mom says her previous pediatrician told Mom says her previous pediatrician told her that the murmur was “harmless and her that the murmur was “harmless and normal.” You take a listen and hear this normal.” You take a listen and hear this murmur at the LUSB.murmur at the LUSB.

Do you refer her to a cardiologist? Why? Do you refer her to a cardiologist? Why? Why not? Why not?

Case 3Case 3

She has a LUSB SEM associated with a She has a LUSB SEM associated with a abnormally splitabnormally split second heart sound second heart sound which is indicative of an which is indicative of an ASDASD. .

ReferencesReferences

Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based Pneumonic. Pneumonic. PediatricsPediatrics 1997; 99(4):616-618 1997; 99(4):616-618

Biancaniello T. Innocent Murmurs. Biancaniello T. Innocent Murmurs. CirculationCirculation 2005; 111:e20-e22 2005; 111:e20-e22 Poddar B, Basu S. Approach to a Child with a Heart Murmur. Poddar B, Basu S. Approach to a Child with a Heart Murmur.

Indian J PediatrIndian J Pediatr 2004; 71(1):63-66 2004; 71(1):63-66 Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time

for a Cardiology Referral? for a Cardiology Referral? Contemporary Pediatrics Contemporary Pediatrics 2002; 2002; http://www.contemporarypediatrics.com/contpeds/article/articleDethttp://www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?idail.jsp?id=126596=126596

Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Grading Heart Murmur Intensity [abstract]. Grading Heart Murmur Intensity [abstract]. Arch Pediatr Adolesc Arch Pediatr Adolesc MedMed 2005; 159(4):329-34 2005; 159(4):329-34

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