Innocent Murmurs in Children

Georgeann Wang, MS3

Murmurs in Children

   Heart murmurs are one of the most common physical findings in any practice that cares for children 50-60% of children have a heart murmur Over 90% of heart murmurs are normal and require no further evaluation/referral  termed “innocent,” “functional,” “benign,” or “physiologic”

Evaluation of Murmur

    Timing – where during cardiac cycle? – systolic, diastolic, or continuous Type – holosystolic, ejection/crescendo decrescendo, early, late Quality – harsh, blowing, vibratory Intensity – grades I-VI

Innocent Murmurs

   Not solely diastolic!

(systolic or continuous) Not associated with a Not associated with a thrill!

click!

(grades I-III)

Grading Murmurs

I Grade II III IV V VI Description Barely audible Easily audible Very audible without a thrill With thrill – stethoscope fully on chest With thrill – stethoscope halfway off chest With thrill – stethoscope off chest

I Grade II III IV V VI

Grading Murmurs – A New Approach

Description Less in intensity to heart sounds Equal in intensity to heart sounds Greater in intensity to heart sounds, without thrill With thrill, stethoscope fully on chest With thrill, stethoscope halfway off With thrill, stethoscope off chest

Logic-based Pneumonic

   Innocent murmurs occur at sites with disproportionate sized connections Smaller vessel connecting to larger vessel Or larger vessel branching into smaller vessels

1. Venous Hum

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

Venous Hum

 Most common

continuous

murmur in children  Most often in ages 2-8 y/o (toddlers to school-age)  Low frequency, continuous murmur often louder in diastole  Best heard below the right clavicle

Venous Hum

  Increased: in sitting or standing position Decreased: in supine position, with compression of neck veins (directly or with changes in head position)  Compressing neck veins or turning head to the right will diminish murmur  Diminishes completely in supine position

Venous Hum – differential diagnosis

  PDA – loud, continuous machinery murmur with

systolic

prominence  best heard on

left

2 nd

radiates to back

interspace and  not changed occlusion with position or neck vein AV fistula – not changed occlusion of neck veins with position or

2. Pulmonary Flow Murmur

 Connection of right ventricle with main pulmonary artery

Pulmonary Flow Murmur

   May be heard in wide range from school age children to adolescents and young adults Low intensity Best heard at interspace) systolic ejection LUSB (2 nd or 3 rd murmur

Pulmonary Flow Murmur

 Increased: high output states (fever, illness, anemia, etc), with expiration  Decreased: standing position, with inspiration

Pulmonary Flow Murmur

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

Pulmonary Flow Murmur – differential diagnosis

  ASD – “relative” pulmonic stenosis murmur (due to increased blood volume in right heart)  accompanied by a

widely split S2, mid diastolic flow murmur, right ventricular heave

Pulmonic stenosis sounding murmur  – louder, harsher can be associated with a

thrill or ejection click

3. Physiologic Peripheral Pulmonary Stenosis (PPS)

 Connection of main pulmonary artery to right and left pulmonary artery branches

Physiologic PPS

 Most often in neonates and infants from birth to 6 mos of age   Soft, low-pitched systolic ejection murmur (can extend slightly past S2) “blowing” in quality, sounds like breath sounds (can briefly occlude nares)  Best heard at left infraclavicular area with radiation to bilateral axillae and back

Physiologic PPS

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

PPS – differential diagnosis

    Pulmonic stenosis – louder, harsher murmur, associated with ejection

click or thrill

VSD – no radiation to axillae PDA – machinery like, lower pitch Pathologic PPS – longer duration, higher pitch, older children

4. Still’s Murmur

 Connection of left ventricle with aorta

Still’s Murmur

 Most common innocent murmur children in  Reported to be present in up to 75-85% of children  Most often in ages 2-6 y/o, but can be from birth to adolescence

Still’s Murmur

  Low-pitched II/VI early systolic ejection murmur Described as “vibratory,” “musical,” “harmonic,” “twanging,” “groaning/moaning,” “squeaky”  Like the sound of a guitar string being plucked  Best heard at LLSB/apex

Still’s Murmur

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

Still’s Murmur – differential diagnosis

   VSD – different quality, harsh not musical LVOT obstruction – different quality HOCM – different quality

5. Supraclavicular Systemic Bruit

 Connection of brachiocephalic vessels to aortic arch

Supraclavicular Systemic Bruit

  Heard in children and young adults Harsh, medium to high-pitched, brief early systolic ejection murmur  Best heard in the carotids bilaterally with some radiation to infraclavicular area

Supraclavicular Systemic Bruit

 Decreased: with shoulders pulled back (hyperextension)  No change with position

Supraclavicular Systemic Bruit – differential diagnosis

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

ASD

 Most common misdiagnosed heart murmur in children  More often than not there is no murmur heard with ASD

Auscultation of ASD

 3 auscultatory findings in ASD – to-R shunting across defect  all due to L larger blood volume in right heart    1. widely split S2 – longer time to empty right side of heart vs. left side 2. pulmonary “stenosis” flow murmur – large amount of blood exiting through RVOT 3. mid-diastolic flow murmur – large amount of flow across triscuspid valve

Red Flags! – Caution!

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

Beware!

     General appearance – dysmorphic features Constitutional cyanosis – poor weight gain, diaphoresis, Respiratory symptoms – tachypnea, wheezing, chronic cough, poor/difficulty feeding Cardiovascular symptoms – chest pain, syncope/presyncope, tachycardia Abnormal tests – enlarged heart on CXR, hypertrophy on EKG

Case 1

A 5 y/o Latin American boy presents for his annual school physical. He has no significant PMH and is very active. More recently he has had fever and diarrhea. PE is normal with the exception of this murmur heard at the LLSB near the apex. You tell mom that he has a benign murmur. She asks you why no doctor has ever heard this murmur before today. You say?

Case 1

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

Case 2

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

Case 2

 She has a venous hum murmur that diminishes completely in the supine position. It is important to perform the CV exam in both supine and upright positions.  Your attending is not upset and tells you that you will not fail the cardiology elective afterall. PHEW!

Case 3

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

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

Case 3

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

References

      Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based Pneumonic.

Pediatrics

1997; 99(4):616-618 Biancaniello T. Innocent Murmurs.

Circulation

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

Indian J Pediatr

2004; 71(1):63-66 Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time for a Cardiology Referral? ail.jsp?id=126596

Contemporary Pediatrics

2002; http://www.contemporarypediatrics.com/contpeds/article/articleDet Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Grading Heart Murmur Intensity [abstract].

Arch Pediatr Adolesc Med

2005; 159(4):329-34 Moses S. http://www.fpnotebook.com/