CLINICIAN UPDATE
Innocent Murmurs
Thomas Biancaniello, MD
A
7-year-old boy visited his pri-
mary care physician for his
annual school physical. The
child had been in perfect health. He
reported no cardiovascular symptoms.
The boy’s physical examination was
normal except for a 2 to 3/6 systolic
ejection murmur not previously heard
at the lower left sternal border. How
should a clinician distinguish between
innocent murmurs and pathological
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murmurs, and what factors should be
evaluated? If the primary care physi-
cian is unsure whether the murmur is
innocent, then referral to a pediatric
cardiologist is the next step.
Murmurs are common findings in
infants and children. Most murmurs in
infants and children originate through
normal flow patterns with no structural
or anatomic abnormalities of the heart
or vessels and are referred to as “inno-
cent,” “physiological,” or “normal”
murmurs. “Innocent” is the preferred
term because it strongly conveys that
nothing is abnormal, as opposed to the
older term “functional,” which is not
always understood clearly by parents
and patients as being “normal.” Al-
though murmurs may be heard in vir-
tually anyone, they are most com-
monly heard in children. Virtually all
children will have a murmur sometime
while they are growing up. Con-
From the Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, State University of New York-Stony Brook, Stony Brook,
New York.
Correspondence to Thomas Biancaniello, MD, Department of Pediatrics, Division of Pediatric Cardiology, SUNY-Stony Brook School of Medicine,
Stony Brook, NY 11794-8111. E-mail tbiancan@notes.cc.sunysb.edu
(Circulation. 2005;111:e20-e22.)
© 2005 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
versely, murmurs may be created by
abnormal flow patterns in the heart and
vessels resulting from congenital heart
abnormalities, valve disease, or other
acquired conditions. In evaluating the
infant or child with a murmur, the
clinician must make a complete assess-
ment of the cardiovascular system—
not just listen to the murmurs— be-
cause there are some serious
cardiovascular abnormalities that may
have no murmurs.
Looking for clues of heart disease,
the clinician must obtain a focused
history from the patient’s parents. For
infants, this history will include birth
history, feeding patterns, breathing dif-
ficulties, color changes, growth pat-
tern, and activity levels. Changes in
feeding patterns, particularly a pro-
gressively longer time to complete the
feeding, may be an early sign of con-
gestive heart failure. For children, par-
ents should be asked about activity
capacity: Can the child keep up with
peers while playing vigorously? Have
there been complaints of shortness of
breath, palpitations, or chest pain?
Chest pain is a common complaint, but
a cardiac cause is found in less than
1% of children complaining of chest
pain.1 Syncope occurs in about 15% of
children before they reach 21 years of
age,2 and it is most often not the result
e20
of primary heart problems; however,
the practitioner will want to know
whether syncope has occurred and un-
der what circumstances so cardiac
causes can be excluded. Although not
commonly associated with cardiac dis-
ease in childhood, syncope and chest
pain may be manifestations of serious
cardiac conditions such as aortic ste-
nosis or hypertrophic cardiomyopathy,
which are common causes of sudden
unexpected death in childhood.3 If
these symptoms are present, particu-
larly if they are related to exercise or
there is a positive family history of
hypertrophic cardiomyopathy, then
they should be evaluated carefully.
Obtaining a thorough family medi-
cal history is extremely important in
assessing a child because congenital
heart defects occur more commonly in
families in which a first-degree rela-
tive has been born with a heart defect.4
In addition, hypertrophic cardiomyop-
athy, a primary muscle disorder of the
heart, is an inherited autosomal domi-
nant condition that may result in sud-
den unexpected death, especially dur-
ing or after vigorous exercise, in young
people.5 Obtaining a history of this
condition or of sudden unexplained
death in young people with first-
degree relatives who have a heart de-
fect entails a search for hypertrophic
cardiomyopathy, which may be silent.
DOI: 10.1161/01.CIR.0000153388.41229.CB

Physical examination of a child in-
cludes an assessment of general ap-
pearance, color, respiratory effort, and
vital signs, including heart rate, respi-
ratory rate, and blood pressure. The
vital signs should be evaluated by
comparing them with age-established
norms. The neck should be evaluated
for prominence of vessels and abnor-
mal pulsation and listened to for bruits.
The chest should be auscultated for
abnormal breath sounds. The pulses in
the arms and legs should be checked. If
the pulses are not equal, then coarcta-
tion of the aorta may be present and 4
extremity blood pressures should be
obtained.
Examination of the heart begins
with observation and palpation of the
chest for abnormal impulses and
thrills. Auscultation begins with listen-
ing for the normal sounds of the valves
closing and for S1 and S2. It is impor-
tant not to focus on murmurs initially.
Atrial septal defect accounts for about
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one third of the congenital defects first
detected in adulthood.6 This is because
the characteristic murmur, a pulmo-
nary flow murmur, also is one of the
most common childhood innocent
murmurs. The key to diagnosis is ap-
preciating the wide fixedly split-
second heart sound resulting from
right volume overload. This will not be
easily appreciated if the clinician fo-
cuses on murmurs before defining the
heart sounds. Gallop sounds also may
be present, signaling difficulty in keep-
ing up with the demands placed on the
heart. Conversely, isolated S3 gallop
sounds may be heard in healthy
adolescents.
When murmurs are heard, they
should be defined by the following
characteristics:
1. Timing—when during the cardiac
cycle they occur
2. Location—where in the heart they
may originate, keeping in mind that
vibrations are transmitted in both
directions along a column of blood
3. Quality or pitch— how they sound,
which is important in differentiating
normal flow murmurs from abnormal
Biancaniello
4. Intensity or loudness—not necessar-
ily defining the severity, but changes
in intensity may help determine the
type of murmur being heard
5. Ejection or nonejection clicks—
presence or absence
Innocent murmurs are murmurs pro-
duced by normal flow. Changing the
flow should therefore change the in-
tensity of the murmur. Characteristi-
cally, maneuvers that decrease the
flow of blood returning to the heart
through the venous system will de-
crease the intensity of flow murmurs,
suggesting that the murmur is flow
related or innocent. Changing the
child’s position from supine to sitting,
then to standing, and finally to squat-
ting during the examination will
change the flow and is useful in help-
ing to define innocent murmurs. The
child may be asked to push out the
abdomen or bear down to perform a
Valsalva maneuver, which reduces ve-
nous blood flow to the heart and the
intensity of innocent murmurs. An ex-
aminer can coax even a young toddler
into doing this by placing a hand on
the child’s abdomen and asking the
child to push it out.
The following are the classic types
of innocent or flow murmurs:
1. Still’s murmurs.7 These murmurs
are low-pitched sounds heard at the
lower left sternal area. They are mu-
sical or have a relatively pure tone in
quality or may be squeaky. These
most commonly occur between age 3
and adolescence. Because they are
low pitched, they are heard best with
the bell of the stethoscope. They are
related to flow, and they can change
with position alteration and then can
decrease or disappear with the Val-
salva maneuver. No clicks are present.
2. Pulmonary flow murmurs. These
are high-pitched, harsher murmurs
heard at the upper left sternal bor-
der. Because they are high pitched,
they are heard best with the dia-
phragm of the stethoscope. They
are flow dependent and also will
change with position alteration and
decrease or disappear with the Val-
salva maneuver. These murmurs
originate from the right ventricular
Innocent Murmurs e21
outflow tract and radiate along the
pulmonary arteries and thus may be
well heard in the back and axilla
bilaterally. They are differentiated
from pulmonic stenosis by their
quality and from valvar pulmonic
stenosis by the absence of an ejec-
tion click. Pulmonary flow mur-
murs can occur at any age, but they
are common particularly in adoles-
cents or in children with pectus
excavatum. They are prominent in
high-flow situations, such as when
a child has a fever or is anemic,
because flow increases in these sit-
uations. In infants, these sounds
may be most prominent in the back
or axilla because turbulence occurs
when the blood flows from the
larger main pulmonary artery to the
smaller, less well-developed distal
pulmonary arteries. In fetal life, the
main pulmonary artery transports
about 90% of the blood to the
ductus arteriosus and only about
10% to the distal pulmonary arter-
ies. The main pulmonary artery is
thus large, whereas the distal pul-
monary arteries are relatively
smaller and come off at more acute
angles than they do later as the
child’s chest grows. An analogy
from nature would be the noise that
is created as a large stream narrows
into smaller streams. This innocent
murmur has been termed “benign
peripheral pulmonary stenosis of
the newborn” to differentiate it
from true anatomic obstructions to
distal pulmonary arteries that occur
in pathological conditions such as
congenital rubella syndrome.
3. Systemic flow murmurs (supracla-
vicular systemic bruits). These are
harsh high-pitched murmurs caused
by normal blood flow into the aorta
and into the head and neck vessels
and are heard best high up in the
chest and above the clavicles. They
are also heard best with the dia-
phragm of the stethoscope. No ejec-
tion click is associated with these
murmurs. They are transmitted to
the arch vessels and are heard when
listening over the carotid arteries of
the neck. It has been said that be-
cause of these sounds “all children
have carotid bruits”; however, the
sounds differ in quality from true
 e22 Circulation January 25, 2005
carotid bruits and are not associated
with aortic outflow pathology.
4. Venous hums. These are low-
pitched continuous murmurs made
by blood returning from the great
veins to the heart. They are heard
best with the bell of the stetho-
scope. By changing the position of
the patient’s head or by pressing in
the area of the major neck veins, the
flow may be changed and these
murmurs will change or disappear.
Having the child look down or to
the side while listening will often
make these murmurs or sounds dis-
appear. They are differentiated
from the murmurs of patent ductus
arteriosus in that they are louder in
diastole, when maximal flow oc-
curs in the venous system, and are
often heard bilaterally. Venous
hums are sensitive to posture and
head and neck position, whereas the
murmur of patent ductus is not.
Although an ECG is usually part of
the evaluation and may be helpful,
further testing is not needed in the
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overwhelming majority of infants and
children to distinguish between normal
or pathological hearts. It has been
shown that a competent pediatric car-
diologist can determine with a high
degree of certainty whether there is
heart disease.8 Because of the charac-
teristics of the sounds and the maneuvers
that can be used to facilitate identifying
them as flow-related phenomenon, these
murmurs can be correctly identified
without further testing.
After concluding that the murmur or
murmurs (a child may have more than
one kind) are innocent, the practitioner
should explain the findings to the par-
ents and child. The practitioner should
emphasize during the discussion that
murmurs simply mean sounds or
noises and that in and of themselves
they are not synonymous with abnor-
malities of the heart. The clinician
should stress that although a large
percentage of infants and children
have murmurs, less than 1% are born
with the congenital heart defects that
are the most common cause of heart
disease in children. Parents should not
be promised that their children will
outgrow these murmurs because this is
not necessarily true; adults can have
innocent murmurs as well. Assurances
should be given that because the heart
is normal, whether or not the murmur
disappears or changes is of no conse-
quence. In addition, because flow
changes the murmur, with growth and
the changing configuration of chest
and heart dynamics, murmurs may
change, disappear, and reappear at var-
ious times—further evidence that the
murmurs are indeed flow related and
innocent.
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JI, Neill CA, Perry LW, Hepner SI, Downing
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