Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

Heart Murmurs: When to Refer

Introduction: It is frequently difficult to decide when to get a consultation from a pediatric cardiologist.  Depending on the confidence of the physician, some practicing pediatricians refer all murmurs while others refer only a few children.  In residency it is important to become proficient in evaluating murmurs so that you can be fairly confident of what to do.

Clearcut Indications for Referral to the Pediatric Cardiologist:

1. Any child with signs of heart failure, cyanosis, tachypnea, significant murmurs, questionable PEs in the nursery.
2. All children with Down syndrome, chromosomal abnormalities, multiple anomalies.
3. Any child in whom you diagnose an arrhythmia, Kawasaki, collagen vascular disease (r/o myocarditis or pericarditis).
4. Any child with a persistent murmur that sounds organic.

Not-as-Clearcut Situations

Four Case Histories: All children in cases were products of normal deliveries and grew well.  None were symptomatic and all had normal oxygen saturations.

Case 1: 4 week old with normal physical examination except for a Grade III/VI murmur heard to both the left and right of the sternum.  Pulses are full, blood pressures are normal in all four extremities.  There is no cardiac heave, no tachypnea, no tachycardia.  You are not sure about the second heart sound, but it seems to split normally.

Case 2: Same history, but murmur is G IV/VI; Rest of exam the same as in Case 1.

Case 3: Same history, but murmur is harder to localize: G III/VI murmur is heard loudest in he 2nd-3rd left intercostal area, and is heard in the back.

Case 4: 3 year old with GII/III murmur heard best in 2nd Left intercostal space that does not radiate to the back.  Child is febrile, and when child returns later, murmur sounds the same, but is definitely a GII at this time.

Evaluation: What course of action do you take in each of the four cases?  Do you order EKG, X-Ray in each case.  If you do and they are normal, which, if any, case do you refer?

“Normal” murmurs (i.e., benign, physiologic, innocent, flow).  It is always difficult to decide whether to tell parents about normal heart murmurs. 

Reasons to tell parents:            

• If goes to ER, ER physicians often will tell parents
• You may be in practice with someone that tells parents
• Parents get upset if they find out from someone else

Reasons not to tell parents:

• If it is normal, why tell parents
• “Vulnerable Child Syndrome” can result: once you mention the       words “heart murmur” the parent will never forget.

This is a decision that many practicing pediatricians struggle with.  What will you do?

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004