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Ninety percent of children will have an audible heart murmur at some point in time. Normal murmurs include vibratory and pulmonary flow murmurs, venous hums, carotid bruits, and the murmur of physiologic branch pulmonary artery stenosis. Less than 5% of heart murmurs in children are caused by
Clinical Evaluation of Heart Murmurs
Cyanosis, exercise intolerance, feeding difficulties, dyspnea, or syncope signify potential cardiac dysfunction. Failure to thrive, diffuse diaphoresis, unexplained persistent irritability or lethargy, and atypical chest pain also suggest the possibility of
The majority of children who have heart murmurs Heart Murmurs Heart Murmurs are asymptomatic. In early infancy, however, cardiac malformations that are critical may Heart Murmurs Heart Murmurs manifest as persistent peaceful tachypnea (a respiratory rate greater than 60 Heart Murmurs Heart Murmurs breaths/min).
| Syndromes Heart Murmurs Heart Murmurs and Associated Cardiac Malformations | ||
Syndrome |
Incidence of Cardiac Malformations (%) |
Cardiac Malformations |
| Down Syndrome | 50 | AVSD, heart murmurs, heart murmur VSD, ASD, PDA, TOF |
| Trisomy 18 | 99 | VSD, heart murmurs, heart murmur PDA, DORV, BPV |
| Trisomy 13 | 90 | VSD, ASD, PDA |
| Turner Syndrome | 40 | Aortic coarctation, AVS, HLH |
| Noonan Syndrome | 50 | PVS, heart murmurs, heart murmur HCM |
| William Syndrome | 90 | SVAS, SVPS, RAS |
| Marfan Syndrome | 60-80 | MVP, AoRD, AI |
| DiGeorge Syndrome | 90 | IAA (B), TA |
| VACTERL | 80 | VSD, ASD, PDA, TOF |
| AVSD = atrioventricular septal or canal defect, VSD = ventricular heart murmurs, heart murmur septal defect, ASD = atrial septal defect, PDA = patent ductus arteriosus, TOF = tetralogy of Fallot, DORV = double outlet right ventricle, BPV = bicuspid pulmonary valve, AVS = heart murmurs, heart murmur aortic valve stenosis, HLH = hypoplastic left heart, PVS = pulmonary valve stenosis, HCM = heart murmurs, heart murmur hypertrophic cardiomyopathy, SVAS = supravalvular aortic stenosis, SVPS = supravalvular pulmonary stenosis, RAS = renal artery stenosis, MVP = mitral valve prolapse, AoRD = aortic root dilatation, AI = aortic insufficiency, IAA (B) = interrupted | ||
Family history of a congenital cardiovascular malformation increases the risk of a cardiac defect, such as with DiGeorge syndrome (type B interrupted aortic arch, truncus arteriosus).
Gestational course should be reviewed for exposure to teratogens or maternal illnesses. Fetal exposure to lithium may cause Ebstein anomaly of the tricuspid valve. Ventricular and atrial septal defects occur with fetal alcohol syndrome. Transient hypertrophic cardiomyopathy and tetralogy ofFallot are associated with infants of diabetic mothers. Maternal collagen vascular disease may lead to the development of
Physical Examination
Noncardiac malformations. Twenty five percent of children who have heart disease have extracardiac anomalies.
Major gastrointestinal malformations (diaphragmatic hernia, tracheoesophageal fistula and esophageal atresia, omphalocele, imperforate anus) are associated with congenital cardiac defects in 15-25% of infants. The most common cardiac malformations are ventricular septal defect and tetralogy of Fallot.
Cyanotic infants or children should be immediately referred to a cardiologist. Abnormal rate or pattern of breathing, a persistently hyperdynamic precordium, precordial bulging, or asymmetric pulses should also be referred.
Signs of congestive heart failure (inappropriate tachycardia, tachypnea, hepatomegaly, abnormal pulse volume) also should prompt a referral to a cardiologist.
Evaluation and Treatment