I.

See Also

A. Pediatric Murmur
II. History

A. First described by Dr. George Still (1909)

II. Epidemiology

A. Common in children ages 2 to 8 years old

II. Signs

A. Low to medium frequency, mid-Systolic Murmur

B. Intensity: Grade II-III of VI (variable)
C. Location: near apex
D. Character
1. Vibratory, harmonic, musical, twanging, groaning
E. Provocative conditions and positions (increased murmur)
1. Supine position
2. Fever
3. Anemia
II. Differential Diagnosis

A. Ventricular Septal Defect

B. Left ventricular outflow obstruction
C. Hypertrophic Cardiomyopathy
II. Course

A. Innocent murmur

I. Epidemiology

A. Overall Murmur Prevelance: 50% of all children

B. Innocent murmurs more common than pathologic 10:1
C. Age of murmur onset related to pathology
1. Murmur onset at 24 hours of life: 8% pathologic
2. Murmur onset at 6 months of life: 14% pathologic
3. Murmur onset at 12 months of life: 2% pathologic
II. Etiologies: Innocent Murmurs

A. Still's Murmur (Aortic Vibratory Systolic)

1. Most common innocent murmur
B. Venous Hum of late infancy and early childhood
1. Second most common innocent murmur
 C. Septal hypertrophy due to myocardial fat deposition
1. Resolves over six months
D. Pulmonary Flow Murmur
E. Neonatal Pulmonary branch murmur
F. Physiologic PPS
G. Supraclavicular Murmur
II. Etiologies: Pathologic Murmurs

A. Ventricular Septal Defect (VSD) 38%

B. Atrial Septal Defect (ASD) 18%
C. Pulmonary Valve Stenosis 13%
D. Pulmonary Artery Stenosis 7%
E. Aortic Valve Stenosis 4%
F. Patent Ductus Arteriosus (PDA) 4%
G. Mitral Valve Prolapse 4%
H. Others 4%
II. Signs: Innocent Murmur accentuation maneuvers

A. Sitting forward
B. Exercise or increased Heart Rate
C. Fever
D. Anxiety, Restlessness, or crying
II. Signs: Pathologic Murmur

A. Evidence of Failure to Thrive

B. Lethargy
C. Cyanosis
D. Shortness of Breath
E. Parasternal heave or thrill
F. Murmur radiates to back or neck
G. Auscultation (6 Cardinal signs of pathology)
1. Harsh murmur
2. Pansystolic murmur
3. Murmur Grade III or more
4. Murmur at high Left sternal border
5. Early or Midsystolic click or murmur
6. Abnormal S2 Heart Sounds
II. Management: Pathologic murmur suspected

A. Newborn to eight weeks

1. See Congenital Heart Disease for evaluation
B. Pediatric Cardiology Referral
1. Do not create preconceived notions of evaluation
2. Not every Pediatric Murmur will need Echocardiogram
II. Management: Innocent Murmur suspected
 A. Trust skilled clinical evaluation
B. Study of clinical exam by pediatric cardiolgists
1. Exam is as accurate as Echocardiogram
2. Exam is more accurate than Electrocardiogram
3. Test Sensitivity: 96%
4. Test Specificity: 95%
5. Positive Predictive Value: 88%
6. Negative Predictive Value: 98%
C. Reference
1. McCrindle (1996) Arch Pediatr Adolesc Med

I. Characteristics

A. Identify beginning of systole and diastole

1. S1 Heart Sound
2. S2 Heart Sound
II. Timing

A. Determine timing of murmur

1. Systolic Murmur
2. Diastolic Murmur
B. Determine Early, Middle or late in interval
II. Severity

A. Grade 1/6: Barely audible

B. Grade 2/6: Just easily audible
C. Grade 3/6:
D. Grade 4/6:
E. Grade 5/6: Loudest requiring a stethoscope
F. Grade 6/6: Heard with stethoscope off chest
II. Location

A. Identify valve area involved

II. Pattern

A. Uniform: Constant
B. Crescendo: Increasing
C. Decrescendo (Diminuendo): Decreasing
D. Crescendo-Decrescendo: Diamond Shaped Murmur
II. Pitch
A. Low pitched
1. Best heard with bell chest-piece at light pressure
B. High pitched
1. Best heard with diaphragm at firm pressure
II. Dynamic Maneuvers

A. Position
1. Supine
2. Erect
3. Left lateral decubitus position
B. Exercise
II. Interpretation

A. Benign murmur findings

1. Murmur characteristics

1. Crescendo-decrescend character
2. Musical or vibratory murmur
3. Quiet murmur (Grade 2 or less)
4. Timing: Early systolic or mid Systolic Murmur
5. Location: Left sternal border or pulmonic area
b. Associated findings absent

1. Cardiopulmonary symptoms absent

2. Family History absent
3. Exam (BP, pulse, auscultation) otherwise
normal
4. Normal physiologic split S2 without gallup or
click
B. Pathologic murmur findings
a. Murmur characteristics

1. Timing: Diastolic, mid-late systolic, holosystolic

2. Loud murmur (Grade 3 or greater)
3. Murmur exacerbated by valsalva maneuver
4. Murmur radiates to carotid artery or axilla
b. Associated findings present

1. Arrhythmia present
2. Symptoms: Chest
Pain, Palpitation, Dyspnea, Syncope
3. Sudden Cardiac Death Family History
4. Jugular Venous Pulsation abnormal
5. Arterial pulsation abnormal

1. Wide Pulse Pressure
 2. Water-Hammer Pulse (rapidly rising,
bounding)
3. Weak, slow rising pulse
ii. Other abnormal precordial exam

1. Other heart sounds (e.g. Loud S1, fixed

split S2)
2. Left ventricular heave