Evaluation and Management of Heart Murmurs in Children

• Published in: American family physician Vol. 84; no. 7; pp. 793 - 800
• Main Authors: Frank, Jennifer E., MD, Jacobe, Kathryn M., MD
• Format: Journal Article
• Language: English
• Published: United States American Academy of Family Physicians 01.10.2011
• Subjects: Adolescent; Age; Asthma; Asymptomatic; Births; Blood pressure; Cardiology; Cardiomyopathy; Cardiovascular disease; Child; Child, Preschool; Children & youth; Childrens health; Congenital diseases; Coronary vessels; Dyspnea; Failure to thrive; Families & family life; Family medical history; Genetic disorders; Heart Auscultation; Heart failure; Heart Murmurs - diagnosis; Heart Murmurs - epidemiology; Heart Murmurs - etiology; Heart Murmurs - therapy; Humans; Hypoxia; Infant; Infant, Newborn; Infections; Internal Medicine; Marfan syndrome; Mitral valve prolapse; Newborn babies; Pain; Pathology; Pediatrics; Physical Examination; Physical examinations; Physical fitness; Prevalence; Referral and Consultation; Ultrasonic imaging; Vital signs
• ISSN: 0002-838X; 1532-0650

Heart murmurs are common in healthy infants, children, and adolescents. Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease. Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. Physical examination should focus on vital signs; age-appropriate exercise capacity; respiratory or gastrointestinal manifestations of congestive heart failure; and a thorough cardiovascular examination, including features of the murmur, assessment of peripheral perfusion, and auscultation over the heart valves. Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2 , maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Electrocardiography and chest radiography rarely assist in the diagnosis. Referral to a pediatric cardiologist is recommended for patients with any other abnormal physical examination findings, a history of conditions that increase the likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified by the family physician. Echocardiography provides a definitive diagnosis and is recommended for evaluation of any potentially pathologic murmur, and for evaluation of neonatal heart murmurs because these are more likely to be manifestations of structural heart disease.