1. Innocent Murmurs in Children
Georgeann Wang, MS3

2. Murmurs in Children
Heart murmurs are one of the most common physical findings in any practice that cares for children
50-60% of children have a heart murmur
Over 90% of heart murmurs are normal and require no further evaluation/referral
termed “innocent,” “functional,” “benign,” or “physiologic”

3. Evaluation of Murmur
Timing – where during cardiac cycle? – systolic, diastolic, or continuous
Type – holosystolic, ejection/crescendo-decrescendo, early, late
Quality – harsh, blowing, vibratory
Intensity – grades I-VI

4. Innocent Murmurs Not solely diastolic! (systolic or continuous)
Not associated with a thrill! (grades I-III)
Not associated with a click!

5. Grading Murmurs Grade Description I Barely audible II Easily audible
III
Very audible without a thrill IV
With thrill – stethoscope fully on chest V
With thrill – stethoscope halfway off chest VI
With thrill – stethoscope off chest

6. Grading Murmurs – A New Approach
Grade
Description I
Less in intensity to heart sounds II
Equal in intensity to heart sounds
III
Greater in intensity to heart sounds, without thrill IV
With thrill, stethoscope fully on chest V
With thrill, stethoscope halfway off VI
With thrill, stethoscope off chest

7. Logic-based Pneumonic
Innocent murmurs occur at sites with disproportionate-sized connections
Smaller vessel connecting to larger vessel
Or larger vessel branching into smaller vessels

8. 1. Venous Hum
Connection between jugular, subclavian, and innominate veins to SVC

9. Venous Hum Most common continuous murmur in children
Most often in ages 2-8 y/o (toddlers to school-age)
Low frequency, continuous murmur often louder in diastole
Best heard below the right clavicle

10. Venous Hum Increased: in sitting or standing position
Decreased: in supine position, with compression of neck veins (directly or with changes in head position)
Compressing neck veins or turning head to the right will diminish murmur
Diminishes completely in supine position

11. Venous Hum – differential diagnosis
PDA – loud, continuous machinery murmur with systolic prominence
best heard on left 2nd interspace and radiates to back
not changed with position or neck vein occlusion
AV fistula – not changed with position or occlusion of neck veins

12. 2. Pulmonary Flow Murmur
Connection of right ventricle with main pulmonary artery

13. Pulmonary Flow Murmur
May be heard in wide range from school-age children to adolescents and young adults
Low intensity systolic ejection murmur
Best heard at LUSB (2nd or 3rd interspace)

14. Pulmonary Flow Murmur
Increased: high output states (fever, illness, anemia, etc), with expiration
Decreased: standing position, with inspiration

15. Pulmonary Flow Murmur
Is exaggerated by any condition that brings the RVOT closer to the anterior chest wall
eg. pectus excavatum, kyphoscoliosis

16. Pulmonary Flow Murmur – differential diagnosis
ASD – “relative” pulmonic stenosis murmur (due to increased blood volume in right heart)
accompanied by a widely split S2, mid-diastolic flow murmur, right ventricular heave
Pulmonic stenosis – louder, harsher sounding murmur
can be associated with a thrill or ejection click

17. 3. Physiologic Peripheral Pulmonary Stenosis (PPS)
Connection of main pulmonary artery to right and left pulmonary artery branches

18. Physiologic PPS
Most often in neonates and infants from birth to 6 mos of age
Soft, low-pitched systolic ejection murmur (can extend slightly past S2)
“blowing” in quality, sounds like breath sounds (can briefly occlude nares)
Best heard at left infraclavicular area with radiation to bilateral axillae and back

19. Physiologic PPS
Increased in: high output states (fever, illness, anemia, etc), viral URI, RAD exacerbations

20. PPS – differential diagnosis
Pulmonic stenosis – louder, harsher murmur, associated with ejection click or thrill
VSD – no radiation to axillae
PDA – machinery like, lower pitch
Pathologic PPS – longer duration, higher pitch, older children

21. 4. Still’s Murmur
Connection of left ventricle with aorta

22. Still’s Murmur Most common innocent murmur in children
Reported to be present in up to 75-85% of children
Most often in ages 2-6 y/o, but can be from birth to adolescence

23. Still’s Murmur Low-pitched II/VI early systolic ejection murmur
Described as “vibratory,” “musical,” “harmonic,” “twanging,” “groaning/moaning,” “squeaky”
Like the sound of a guitar string being plucked
Best heard at LLSB/apex

24. Still’s Murmur Increased: supine position, fever, anemia
Decreased: sitting or standing, with valsalva

25. Still’s Murmur – differential diagnosis
VSD – different quality, harsh not musical
LVOT obstruction – different quality
HOCM – different quality

26. 5. Supraclavicular Systemic Bruit
Connection of brachiocephalic vessels to aortic arch

27. Supraclavicular Systemic Bruit
Heard in children and young adults
Harsh, medium to high-pitched, brief early systolic ejection murmur
Best heard in the carotids bilaterally with some radiation to infraclavicular area

28. Supraclavicular Systemic Bruit
Decreased: with shoulders pulled back (hyperextension)
No change with position

29. Supraclavicular Systemic Bruit – differential diagnosis
Aortic stenosis/supraaortic stenosis – louder in chest with radiation to carotids

30. ASD Most common misdiagnosed heart murmur in children
More often than not there is no murmur heard with ASD

31. Auscultation of ASD
3 auscultatory findings in ASD – all due to L-to-R shunting across defect  larger blood volume in right heart
1. widely split S2 – longer time to empty right side of heart vs. left side
2. pulmonary “stenosis” flow murmur – large amount of blood exiting through RVOT
3. mid-diastolic flow murmur – large amount of flow across triscuspid valve

32. Red Flags! – Caution! Holosystolic murmur
Presence of a thrill (grade >III/VI)
Harsh quality
Presence of early/mid systolic click
Abnormal S2
Diastolic murmur
Increase in intensity with standing up

33. Beware! General appearance – dysmorphic features
Constitutional – poor weight gain, diaphoresis, cyanosis
Respiratory symptoms – tachypnea, wheezing, chronic cough, poor/difficulty feeding
Cardiovascular symptoms – chest pain, syncope/presyncope, tachycardia
Abnormal tests – enlarged heart on CXR, hypertrophy on EKG

34. Case 1
A 5 y/o Latin American boy presents for his annual school physical. He has no significant PMH and is very active. More recently he has had fever and diarrhea. PE is normal with the exception of this murmur heard at the LLSB near the apex.
You tell mom that he has a benign murmur. She asks you why no doctor has ever heard this murmur before today. You say?

35. Case 1
He has a vibratory Still’s murmur that is just now detected since he is sick with fever (high output state increases intensity of the murmur).

36. Case 2
You are a medical student and you are examining a 6 y/o Caucasian girl here for routine check-up. She is previously healthy and has no complaints. During PE, you listen to her heart as she lies on the exam table. You present her CV exam as normal to your attending. He examines her as she sits on the table and he hears this murmur just below her right clavicle.
You are very embarrassed for missing this obvious murmur. What was your mistake?

37. Case 2
She has a venous hum murmur that diminishes completely in the supine position. It is important to perform the CV exam in both supine and upright positions.
Your attending is not upset and tells you that you will not fail the cardiology elective afterall. PHEW!

38. Case 3
3 y/o AA girl is a new patient who has a history of a heart murmur per mom. Mom says her previous pediatrician told her that the murmur was “harmless and normal.” You take a listen and hear this murmur at the LUSB.
Do you refer her to a cardiologist? Why? Why not?

39. Case 3
She has a LUSB SEM associated with a abnormally split second heart sound which is indicative of an ASD.

40. References
Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based Pneumonic. Pediatrics 1997; 99(4):
Biancaniello T. Innocent Murmurs. Circulation 2005; 111:e20-e22
Poddar B, Basu S. Approach to a Child with a Heart Murmur. Indian J Pediatr 2004; 71(1):63-66
Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time for a Cardiology Referral? Contemporary Pediatrics 2002;
Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Grading Heart Murmur Intensity [abstract]. Arch Pediatr Adolesc Med 2005; 159(4):329-34
Moses S.