This document discusses the approach to murmurs in pediatrics. It defines a murmur as a heart sound produced by turbulent blood flow across a heart valve or defect. Murmurs can be innocent, pathological, or symptomatic. Innocent murmurs are harmless and common in children. Pathological murmurs indicate an underlying structural issue. Symptomatic murmurs cause issues like shortness of breath. The document outlines characteristics of different types of murmurs and provides guidance on evaluating a child presenting with a murmur through history, physical exam, and potential further workup.

1. Approach to murmur in
Paediatrics
By:- Jwan Ali Ahmed AlSofi

2. Murmur
•Murmurs are heart sounds that are produced as a result of turbulent
blood flow across a defect or heart valve (either it has a defect like
stenosis or regurgitation or there is overflow) that is sufficient to
produce audible noise that can only be heard with the assistance of
a stethoscope or “auscultation”.
•Can be present at birth (congenital) or develop later in life.
•A murmur can be appreciated in:-
1. two thirds of all normal children
2. three quarters of normal newborns.
•Murmurs are a clinical finding, not a disease, but they may indicate
an underlying heart problem.
•Most heart murmurs are harmless (innocent) and don't need
treatment.
•Murmurs are the most common presentation of (CHD).

3. Murmur
Pathological
Symptomatic
Non-
symptomatic
Non-pathological
Innocent
Functional flow
murmur
• SOB, Feeding difficulty
• Cyanosis
• Systolic murmur that is
loud, long, and harsh
• Diastolic murmur
• Abnormal heart sound
• Click
• Abnormal pulse
• Abnormal investigation
• Not affected by position
change
• ASD, mild form
• AS, PS, MVP
• HOCM
• Symptom free
• Short systolic
murmur that is soft,
musical, and
localized (no
radiation)
• Normal investigations
• Disappears (on
movement and later
on in life)
• Anemia
• Thyrotoxicosis
• Fever

4. Clinical Features of murmurs:-
1. Timing
2. Duration
3. Character and pitch
4. Intensity
5. Location
6. Radiation

5. Innocent Murmurs
(benign, vibratory functional)

6. •Occurs in the absence of any pathological or
structural changes of heart,
•Does not indicate organic disease of the
heart,
•During a febrile illness or anaemia, innocent
or flow murmurs are often heard because of
increased cardiac output.
•Usually disappears later.
•They usually disappears by 6 years of age but
may persist up to 12-14 years of age.

7. Criteria of innocent murmur:-
1.Systolic murmur only, not diastolic
2.the quality of the sound - Soft blowing
3.a lack of significant radiation,
4. Left Sternal edge
5.a significant alteration in the intensity of the murmur with
positional changes
6.the cardiovascular history and examination are otherwise
normal.

10. Pulmonary flow murmur of newborn
(or Peripheral pulmonary stenosis or
Pulmonary branch murmur)
(newborn-6months).
- Consequence of flow turbulence made by normal blood flowing from (RV) to (PA)
- Mechanisms:-
1.the pulmonary arteries that had limited blood flow in the uterus, and are therefore
small.
2.increasing cardiac output associated with declining haemoglobin level after birth.
- Features of the murmur of peripheral pulmonary stenosis:-
- heard best in the pulmonary area,
- radiates along the pulmonary arteries (so the murmur can be heard along the axillae and
back- posterior lung fields). What this means is that because the pulmonary arteries go
to each lung, the murmur is often heard in the right and left lateral chest.

12. - A soft systolic at the upper left sternal border
may be because of
1.normal flow across small pulmonary arteries (the
peripheral pulmonary flow murmur)
2.increased blood flow across normal pulmonary
arteries.- e,g, as in ASD.
3.Pulmonic stenosis

13. Still's murmur or Vibratory
murmur (3 - 6 years):-
- is the most common one.
- Due to vibrations in either the right or left ventricle, or ‘‘tendons’’ often
seen in the left ventricle.
- Best heard at the left middle-lower sternal border
- Are loudest when the patient is supine
- Get softer when the patient stands.
(the murmur in HCM, behaves just the opposite of a Still’s murmur- When
any patient stands, gravity takes blood to the lower extremities, and
therefore less blood is in the heart. With less blood filling the ventricle, the
walls of the ventricles get closer together, and in the case of hypertrophic
cardiomyopathy, the obstruction within the cavity of the left ventricle
worsens)

14. Venous hum (3 – 6 years ).
- Is caused by blood flow returning from the child’s head and flowing
from the superior vena cava to the right atrium.
- It is a blowing, continuous murmur, sounding like a soft hum during
both systole and diastole.
- heard at the base of the heart just below the clavicles, mainly on the
right side,
- Best heard while standing
- Disappears while the chest is flat.
- Changes with:-
- Moving the child’s head to either side
- child is lying down
- Light pressure to the right side of the neck, which temporarily stops blood flow through
the right jugular venous system.

17. Carotid bruit (any age).
- Occurs due to normal passing of blood from the
aorta to the carotid, heard best above the clavicle
- Hyperextend the shoulders  murmur disappears

19. The Aortic Outflow Murmur
• Heard in adolescents and young adults
• The murmur is usually grade one or two in intensity
• It is different from valvar aortic stenosis in that the
patients do not have an ejection click.
• The murmur is often heard in athletes, who typically
have a low resting heart rate and therefore a large
stroke volume of blood flowing in the left ventricular
outflow tract in systole.
• Standing a patient with hypertrophic cardiomyopathy
should increase the murmur, whereas standing the
patient with the aortic outflow murmur should result in
either a decrease in the murmur, or no significant
change.

24. Pathological Murmurs
•Are sounds produced by turbulent flow due to abnormal intra cardiac
or intravascular obstructions or connections.
•When one or more of the following are present, the murmur is more
likely pathologic and requires cardiac consultation:
1.Abnormal heart sounds S12
2.A systolic murmur that is loud ( grade 3/6 or with a thrill ) long in duration and
transmits well to other parts of the body, of harsh quality
3.holosystolic,
4.late systolic,
5.Diastolic,
6.continuous (except for the venous hum) murmurs
7.presence of a thrill are not normal.
8.Active precordium
9.Abnormal cardiac size or silhouette or abnormal pulmonary vascularity on
chest radiography
10.Abnormal ECG
11.The presence of symptoms, including failure to thrive or dysmorphic features,
12.Associated Cyanosis

26. Innocent Pathological
Symptom free Symptomatic
Short systolic Pansystolic or diastolic
Short, soft, and musical Harsh quality and intensity >grade 3
Localized with no radiation Radiation and posterior propagation
Disappears with changing position Does not disappear
No thrill May be associated with thrill
Normal Investigations Often abnormal

27. Typically – no change with standing/positional changes
ATRIAL SEPTAL DEFECT:
• systolic ejection murmur radiating to axilla &
back
• fixed split second heart sound (S2)
AORTIC VALVE/ PULMONARY VALVE STENOSIS:
•harsh, higher pitched, systolic ejection murmur
•systolic “click”
•AS – radiation RUSB carotids, suprasternal notch thrill
•PS – radiation to axilla and back
Am I missing…

28. VENTRICULAR SEPTAL DEFECT:
• holosystolic murmur
• systolic regurgitant murmur (TR)
• harsh, higher pitched
• large VSDs may not have a loud murmur
PATENT DUCTUS ARTERIOSUS:
• continuous murmur
• left upper sternal border, left infraclavicular area
• murmur does not decrease with head position
changes
Am I missing…

29. HYPERTROPHIC CARDIOMYOPATHY:
• systolic ejection murmur at left sternal border
• does NOT decrease in intensity with standing
(innocent murmur should decrease with
standing)
• may increase in intensity with standing
• may decrease in intensity with squatting
Am I missing …

30. ………………..……………………………………………………………………………………………………………………………………..
Diastolic Murmur
• Pathologic, if present
• Timing with pulse
• Causes:
- Aortic Valve regurgitation
- Pulmonary valve regurgitation
Am I missing…

31. History:
• Pregnancy and birth history
• Intermittent nature
• Normal growth and development
• Negative family history
Physical Examination:
• Characteristic qualities of innocent murmur - practice
• Second heart sound:
o “physiologic splitting” inspiration- splits… expiration- single
o no increased intensity, pounding or loud
• No click, no thrill (grade IV/VI murmur)
• No suprasternal notch thrill
• Positional changes - supine and standing
Innocent Murmurs
What You Can Do

32. • Greater than grade III/VI (thrill)
• Holosystolic
• Diastolic
• Harsh
• Click
• Pulse abnormality
• Failure to thrive
• Significant family history
Murmurs -
When to be concerned?

33. EVALUATION of a child
with murmur

34. 1. History:
• Feeding history, exercise intolerance. [HF. In <1-year exercise level
is obtained during feeding (an infant with HF can only take small
volumes of milk, develops SOB on sucking, and often perspires)]
• Heavy sweating with minimal or no exertion.
• Poor appetite and failure to grow normally (in infants). [indicates
heart failure (HF)]
• Chronic cough. [indicates lung congestion]
• Swelling or sudden weight gain. [Edema]
• Cyanosis or cyanotic spells ± squatting posture (indicates cyanotic
CHD, classically seen in tetralogy of Fallot).
• Chest pain, prolonged fever. [Endocarditis]
• Dizziness, fainting episodes.

35. • Feeding difficulty:
• When the mother complains that the baby is not able to take
feeds properly (either breast feed or bottle feed), becomes
breathless and has excessive sweating during feeding, the
physician should think of congestive heart failure (CHF) of any
cause.
• If the parents complain that the baby starts crying each time while
taking feeds and if the feed is stopped, feels comfortable, one
should think of a rare possibility of vascular ring malformation.
• Repeated respiratory infection:
• History of repeated cold and cough requiring admission to the
hospital should be noted.
• If the infant is having repeated attacks of breathlessness, rapid
breathing, cough, grunting sounds and restlessness (indicating
repeated lower respiratory tract infection) more than six times
per year, indicates high pulmonary flow due to significant left to
right shunt.

36. • History of blue discoloration of lips, nails especially on crying
indicates the possibility of cyanotic heart disease with decreased
pulmonary blood flow and right to left shunt.
• When the cyanotic infant lies calm and listless having less
physical activity it indicates cyanotic spell or low output state.
• History of squatting after exertion in a cyanosed child indicates:-
1. tetralogy of Fallot (TOF)
2. TOF like physiology and tricuspid atresia (TA).
• History of frequent palpitations in a cyanotic child, one should
think of Ebstein anomaly.
• History of syncope on mild to moderate exertion in an acyanotic
child indicates:-
1. severe aortic stenosis (AS),
2. hypertrophic cardiomyopathy,
3. severe pulmonary hypertension
4. congenitally corrected transposition of great arteries producing
significant bradycardia.

37. • Birth History.
• Was the baby term or preterm (structural abnormalities)?
• Was there asphyxia? (caused by a type of C.M., low O2 to the
heart),
• ask for prolonged labor, history of convulsion, and SGA
• Maternal complications:
• DM leads to HOCM.
• HTN leads to TGA.
• SLE lead to COMPLETE HEART BLOCK.
• TORCH: rubella leads to PDA.
• Drug history:
• Isotretinoin is teratogenic.
• Anti-convulsants.
• Aspirin.
• Is there a family history of congenital heart disease? [There
is a higher risk of heart defects in siblings of children with
congenital heart disease.]

38. 2. Examination
• Appearance
• Posture.
• Color.
• Dysmorphic features.
• Respiratory distress.
• Nutritional assessment.
• Edema.
• Clubbing.
• Vital signs:
• Tachycardia is a sign of cardiac failure.
• The character of the pulse can also give a clue to cardiac pathology.
• Palpate the femoral pulses, as in coarctation of the aorta they are absent or weak
and delayed compared with the radial pulse.
• Take the blood pressure, and if you suspect coarctation you need to do this in
both arms and legs. Normally it is 10-20mmHg higher in the legs.

39. • Other signs of heart failure:
- Tachypnoea, hepatomegaly, and crepitations in the
lungs are the major clinical manifestations of cardiac
failure in childhood.
- Peripheral oedema is rare.
- Cyanosis if present suggests reversal of shunt, urgent
investigation is required.
• Raised JVP.
• Growth parameters: Failure to thrive and poor
growth are important signs of cardiac failure in
childhood and are also important in monitoring
medical management.

40. 3. Precordium examination
• Precordial bulge : cardiomegaly
• Substernal thrust, parasternal heave : right ventricular
(RV) enlargement
• Hyper dynamic precordium : volume overload ( large
LR shunt / severe valvular regurgitation)
• Apex beat position quality :
• Thrill.
• Auscultation: S1. S2, added sounds, murmur.

43. 4. Investigations
• Chest X-ray:
• size: is not reliable at all in <1-year-olds, so send for echo. Because of thymus
shadow and the heart is initially horizontal then moves down. Cardiothoracic ratio
of up to 55% is normal in infants.
• shape:
• Boot shape: TOF
Truncus arteriosus
• Egg shape: TGA
• Snowman silhouette (double contour of the heart): TAPVR
• vascularity: vascular markings should not exceed 1/3 of the thoracic diameter
normally:
• Increased: plethoric
• Decreased: oligemic
• lung, thoracic abnormalities: rib notching → COA
TAPVR= Total anomalous pulmonary
venous return. Oxygen-rich blood from the
lungs goes to the right atrium instead of the
left atrium.

44. Oligemic
Plethoric

45. Rib notching

46. Boot-shaped heart

47. Snowman sign Egg-shaped

48. 1. ECG: Rate, Rhythm, axis, (P, QRS, T). gives further
information about ventricular and atrial hypertrophy.
2. Echo is important in evaluating cardiac structure and
performance, gradients across stenotic valves and the
direction of flow across a shunt:
• M-mode
• 2-dimensional
• Doppler
• transesophageal
3. Cardiac Catheterization: is now rarely required for
diagnosis.
4. Angiography (Angiocadiography).
5. MRI.
6. CT.

50. MCQS

51. • Which one of the followings is not characteristic
of innocent murmur:
A. Symptom free
B. The murmur is soft in character
C. There is cardiomegaly on chest X-ray film
D. The murmur is a grade I systolic murmur
E. The murmur is heard at the left sternal edge
C.
There
is
cardiomegaly
on
chest
X-ray
film

52. • Alan, a 4-month-old boy, sees his general
practitioner for an ear infection. On listening to his
chest a heart murmur is heard. Which one of the
following features most suggests that it requires
further investigation? Select one answer only.
A. A thrill
B. Disappearance of murmur on lying flat
C. Murmur maximal at the left sternal edge
D. Sinus arrhythmia
E. Systolic murmur
A. A thrill

53. • Nada, a 5 month old female infant has a fever and
runny nose for 2 days. On examination she has a
fever of 38.3° C and a runny nose. Her tongue is
pink. Her breathing is normal. Pulse is 160
beats/min. Her heart sounds are normal but she
has a soft systolic murmur at the left sternal edge.
Pulses are normal. Diagnosis???
Innocent murmur

54. Thanks