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GG&C Paediatric Guidelines  Heart murmurs in the neonate: an approach to the neonate with a heart murmur
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GG&C Guidelines
Audience


Anaesthetics This guideline is applicable to medical and nursing sta caring for neonates in the West of Scotland.

Biochemistry
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Burns

Introduction 

Cardiovascular Diseases
A heart murmur heard in the neonatal period may be associated with congenital heart disease.

Child Protection However, it must be remembered that not all infants with congenital heart disease have a heart murmur in
the neonatal period.
A neonate with any of the following ndings needs urgent assessment including echocardiogram even if a
Dentistry
murmur is not present:
present signs of heart failure or shock (see below), lower limb saturations <96% in the absence
of respiratory disease, >3% di erence between pre and post ductal saturations, absent/weak femoral pulses.
Dermatology

Diabetes

The investigation of the neonate with a heart murmur 

Emergency Medicine

Investigation will vary depending upon local resources and expertise. The following recommendations represent the
Endocrinology
minimum requirements to ensure the safe management of neonates with heart murmurs and the timely
identi cation of congenital heart disease.
ENT
All infants with a heart murmur on neonatal examination should be reviewed by a senior paediatrician

Gastroenterology (middle grade or consultant).

All infants with a heart murmur should remain in hospital until >24 hours old (unless de nitive diagnosis is
reached before this).
Genetics
All infant with a heart murmur should have a detailed cardiovascular clinical examination which must include
measurement of pre and post ductal saturations.
Haematology/Oncology
If a baby with a heart murmur is discharged before a de nitive diagnosis is reached, the parents should be
given a written information lea et describing warning signs and advising them of what to do in the event that
Imaging, Radiology, X-Ray
their baby became unwell.

Infectious Disease
Clinical examination:

Intensive and critical care Dysmorphic features

Signs of heart failure (tachypnoea, increased respiratory e ort, hepatomegaly, shock)
Palpation of brachial and femoral pulses
Kidney Diseases
Presence of cyanosis (as measured by lower limb saturations – a reading < 96% or >3% di erence between
pre and post ductal saturations should prompt further investigation 1)
Maxillofacial and oral
Heart sounds
surgery
Presence of a heave
Murmur – intensity, character, location and radiation
Microbiology

Electrocardiogram
Musculoskeletal diseases
ECG has been shown to be a sensitive and speci c tool for diagnosing atrioventicular septal defect2 (more
common in infants with Trisomy 21) but has not been shown to aid signi cantly in the diagnosis of other
Neonatology 
structural congenital heart disease 3.  It is not necessary to perform an ECG as part of the routine assessment
of a baby with a heart murmur.
Admission criteria:
If performed, a normal neonatal ECG shows right axis deviation because of the right ventricular dominance of
Neonatal Unit &
the newborn heart. Left axis deviation in a newborn is a signi cant abnormal nding and should prompt
Transitional Care
further investigation.
Whilst an abnormal ECG should prompt further investigation, a normal ECG should not be considered
Antibiotic guidelines
reassuring if there are abnormal clinical ndings or lower limb saturations <96%.
for the neonatal unit

CXR and 4 limb blood pressure

Congenital
hypothyroidism in There is no evidence to support the use of CXR or 4 limb blood pressure measurements in the assessment of
Scotland, guidelines neonates with heart murmurs 3,4,5,6.
for the management
Echocardiography
of

This is the gold standard investigation for di erentiating between innocent and pathological murmurs. Some
Cord clamping units will undertake an echocardiogram in all neonates with heart murmurs. For many units this is not
guidelines currently practical.
In units where it is not feasible to perform echocardiogram for all infants with heart murmurs, information

Cranial ultrasound: a gathered from examination ndings and oxygen saturations can be used to determine the need for and

guideline for the timing of echocardiography and follow up:

performance of
routine cranial USS 1. Likely signi cant congenital heart disease –urgent echocardiogram and review (same day)

for preterm infants

Infants with a heart murmur and any of the following warning signs: lower limb saturations < 96%; >3%  pre / post
ductal di erence; absent/weak femoral pulses; signs of heart failure or shock. These infants require admission to a
Criteria for
neonatal unit for consideration of prostaglandin and urgent discussion  +/- transfer to a cardiac centre. If
attendance at
appropriately skilled local PEC or visiting cardiologist is available to perform echocardiogram while retrieval is
delivery by neonatal
awaited then this can be linked by telemedicine link / used to update surgical centre. This should not be allowed to
sta
delay transfer.

Early onset sepsis in 2. Asymptomatic but clinically pathological murmur – soon echocardiogram (pre-discharge or as soon as possible

the neonate: within 1 week)

prevention and
Infants without any of the above warning signs but with any of the following abnormal clinical ndings:
treatment
dysmorphism; heave; abnormal heart sounds; loud murmur (>2/6); pansystolic, diastolic, continuous murmur;
murmur location other than left sternal edge/radiation.
Enteral feeding of
preterm infants 3. Low risk of congenital heart disease - routine review neonatal OPC 2-6 weeks

Well infants with no signs of heart failure, normal pulses, lower limb saturations >96%, soft (1-2/6) systolic murmur
Expressed breast at the left sternal edge with no radiation.
milk (maternal and
donor)

Flowchart 
Eye infections in the
neonate: Ophthalmia
Neonatorum and the
management of
systemic Gonococcal
and Chlamydial
infections

Heart murmurs in
the neonate: an
approach to the
neonate with a
heart murmur

Hyperglycemia in the
neonate

Immunisation
guideline for
neonates

Intubation and
premedication for Information for parents 
neonates

Click here to download parent information lea et (Word)

Jaundice : neonatal
guideline

Jaundice References 
management on the
postnatal wards
Editorial Information 

Less Invasive
Surfactant
Administration (LISA),
neonatal guideline

Management of
infants born to HIV
positive mothers

Management of the
di cult airway,
neonates

Neonatal abstinence
syndrome (NAS)

Neonatal pain
guideline

Neonatal transfusion
guideline

Oesophageal atresia
and tracheo-
oesophageal stula

Oral sucrose for

procedural pain

Palliative care
resource folder
(Neonatal &
Children's Services)
[Sta net]

Patent ductus
arteriosus (PDA) :
medical treatment
and indications for
surgical closure

Peripheral arterial
lines: insertion and
care

Peripherally inserted
central catheters
(PICC Lines) -
Neonatology
guideline

Renal anomalies
detected or
suspected antenatally

Respiratory
management of
preterm infants:
primary respiratory
therapy with CPAP or
intubation and
surfactant

Resuscitation at the
threshold of viability

Seizures in the
neonate

Seldinger chest drain

insertion and
management

Transcutaneous
bilirubinometry in the
Community

Umbilical catheters

Enoxaparin use in
neonatal and
paediatric critical
care

Virological
assessment of
fetuses and neonates

Humidi ed High Flow

Nasal Cannulae
(HHFNC)

Epidermolysis Bullosa
(EB) Care of Neonates

Evaluation of the
oppy infant

Trisomy 21 - Care
Pathway

Cytomegalovirus
(CMV) - congenital
infection

Napkin care
guidelines, neonates

Capilliary blood
sampling

Cardiac genetics
pathway for infants
with congenital heart
disease and the
appropriate
utilisation of
irradiated blood
products

Anti-Ro & Anti-La

antibodies : Guideline
for the management
of babies born to
mothers with
systemic lupus
erythematosus (SLE)
and other
autoimmune
disorders

Passage of a
nasogastric or
orogastric feeding
tube (neonatal
guideline)

Con rming the

position of a naso-
gastric / oro-gastric
tube in neonates

Vitamin K prophylaxis
for neonates

WoSPGHAN enteral
tube feeding
information pack for
healthcare
professionals

Extravasation
injuries: prevention
and management
(neonatal guideline)

Neurology

Neurosurgery

Ophthalmology

Orthopaedics

Paediatrics

Pain

Pharmacy

Plastic Surgery

Psychiatry

Public Health

Respiratory

Rheumatology

Surgery

Urology

Author Guidance

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West of Scotland Critical

Care Guidelines

Other Guidelines

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