Innocent pediatric murmurs: Difference between revisions
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==Background==
==Background==
*72% of all school-age children have innocent murmurs
*72% of all school-age children have innocent murmurs
*Congenital heart disease 0.8% of live births
*[[Congenital heart disease]]- 0.8% of live births
*Check height and weight- left-to-right can cause decrease in weight, but are usually symptomatic.
*Color- so, so but cyanosis of hands, feet, periorally on exertion.
*Feeding- fatigue or short feeding times for infants- perspiring, grunting, coughing, tachycardia while feeding. Severe CHF may show at rest deep breathing with dyspnea with distress.
*Enlarged heart (ie ASD) can cause bulging of chest
*Older kids- activity causing dyspnea/cyanosis- keeping up with peers, grunting, coughing, tired from stairs. Syncopal/presyncopal, fatigue, palpitations/angina can occur with [[hypertrophic cardiomyopathy]]
*Yet older- Aortic valve with rheumatic fever,myocarditis (h/o URI), endocarditis (IV drug use)
*Preg Hx- Diabetes M (ASD, coarctation of aorta, cardiomyopathies), CMV, Coxsackie B5, warfarin, antiseizure, EtOH (ASD,VSD), prematurity (PDA)
*Worry when- family history of HCOM/sudden death and prominent apical thrust (indicates LVH)


==Clinical Features==
==Clinical Features==
*Goal to distinguish innocent (benign) murmurs from clinically significant pathology
*Red flag features that may point to pathology, ''not'' innocent murmurs:
**[[Failure to thrive (peds)|Poor weight gain]]: check height and weight- left-to-right can cause decrease in weight, but are usually symptomatic
**Color - cyanosis of hands, feet, perioral on exertion
**Feeding - fatigue or short feeding times for infants- perspiring, grunting, coughing, [[tachycardia]] while feeding. Severe [[CHF]] may show at rest deep breathing with [[dyspnea]] with distress
**Enlarged heart (ie [[ASD]]) can cause bulging of chest
**Older kids - activity causing [[dyspnea]]/cyanosis- keeping up with peers, grunting, coughing, tired from stairs. [[Syncope (peds)|syncope]]/presyncope, fatigue, [[palpitations]]/[[chest pain (peds)|angina]] can occur with [[hypertrophic cardiomyopathy]]
**Yet older - Aortic valve with [[rheumatic fever]], [[myocarditis]] (history of [[URI]]), [[endocarditis]] (IV drug use)
**Pregnancy history - Maternal diabetes ([[ASD]], [[coarctation of the aorta]], cardiomyopathies), [[CMV]], [[Coxsackie]] B5, [[warfarin]], [[AEDs]] use, EtOH (ASD,[[VSD]]), prematurity ([[PDA]])
**Worry when - family history of [[[[HCM]]]]/sudden death and prominent apical thrust (indicates [[LVH]])


==Differential Diagnosis==
==Differential Diagnosis==
{{Valvular emergencies DDX}}
{{Valvular emergencies DDX}}


==Diagnosis==
==Evaluation==
*most innocent murmurs are
*Most innocent murmurs are
**not holo or diastolic
**'''Not''' holo or diastolic
**not >grade III
**'''Not''' >grade III
**hockey stick dist
**Hockey stick dist
**normal S1 & S2
**Normal S1 & S2


===Types===
===Types===
*Still's
====Still's====
**Mid-Systolic, best at left lower sternal border, likely from harmonic vibrations of LV outflow tract (chordae tindinae). All ages, particularly young school age. Low pitch, musical. Decr. with inspiration, sitting, standing. Not a VSD- not regurgitant or with thrill. VSD - HSM
*Mid-Systolic, best at left lower sternal border, likely from harmonic vibrations of LV outflow tract (chordae tindinae)
*Innocent Pulmonary Flow Murmur
*All ages, particularly young school age
**Systolic best at left upper sternal border, minor turbulence in RV outflow tract and main pulmonary artery.
*Low pitch, musical
**Often infants and preschool age. Higher pitched than still's, less musical.
*Decreased with inspiration, sitting, standing. Not a VSD- not regurgitant or with thrill
**Not PS- no ejection click, no incr. RV impulse. no wide s2 split  
====Innocent Pulmonary Flow Murmur====
**Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no increased RV impulse.
*Systolic best at left upper sternal border, minor turbulence in RV outflow tract and main pulmonary artery
**Decreased on inspiration/sitting/standing.
*Often infants and preschool age. Higher pitched than still's, less musical
*Innocent Pulmonary Branch Murmur of Infancy
*Not PS- no ejection click, no increased RV impulse. no wide s2 split  
**Systolic ejection murmur from turbulence in pulmonary artery branches (one or both). Medium pitch.
*Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no increased RV impulse
**Physiologic in neonates, becoming audible at L,R,B USB between 0-2wks
*Decreased on inspiration/sitting/standing
**transmits well to back and axilla. common in premature; disappears early in infancy.
====Innocent Pulmonary Branch Murmur of Infancy====
**Not PS- no ejection click, no increase in RV impulse.
*Systolic ejection murmur from turbulence in pulmonary artery branches (one or both)
*Supraclavicular Bruit
*Medium pitch
**Systolic ejection murmur of med pitch from physiologic turbulence of carotid/subclavian and heard at base of neck.
*Physiologic in neonates, becoming audible at L,R,B USB between 0-2wks
**Can be palpable. Disappears on hyperextension of shoulders.
*Transmits well to back and axilla. common in premature; disappears early in infancy
**Not AS which is loudest at URSB with systolic thrill, sometimes with click.
*Not PS- no ejection click, no increase in RV impulse
*Venous Hum
====Supraclavicular Bruit====
**Continuous murmur from turbulent flow in SVC heard at L,R,or B infraclavicular position while sitting/standing
*Systolic ejection murmur of medium pitch from physiologic turbulence of carotid/subclavian and heard at base of neck
**Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation. Disappears in recumbent position, rotation of head, by pressure at jugular.
*Can be palpable. Disappears on hyperextension of shoulders
*Mammary Souffle
*Not AS which is loudest at URSB with systolic thrill, sometimes with click
**Blood flow in A and V to engorged breast. - systolic or continuous, disappears with stethoscope pressure.
====Venous Hum====
*Cardiorespiratory murmur
*Continuous murmur from turbulent flow in SVC heard at L,R,or B infraclavicular position while sitting/standing
**High pitched cooing, anywhere, but especially apex.
*Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation
**Breath sound so not timed to heart, disappear when holding breath.
*Disappears in recumbent position, rotation of head, by pressure at jugular
====Mammary Souffle====
*Blood flow in A and V to engorged breast
*Systolic or continuous, disappears with stethoscope pressure
====Cardiorespiratory murmur====
*High pitched cooing, anywhere, but especially apex
*Breath sound so not timed to heart, disappear when holding breath


==Management==
==Management==

Latest revision as of 23:19, 28 November 2019

Background

Clinical Features

  • Goal to distinguish innocent (benign) murmurs from clinically significant pathology
  • Red flag features that may point to pathology, not innocent murmurs:

Differential Diagnosis

Valvular Emergencies

Evaluation

  • Most innocent murmurs are
    • Not holo or diastolic
    • Not >grade III
    • Hockey stick dist
    • Normal S1 & S2

Types

Still's

  • Mid-Systolic, best at left lower sternal border, likely from harmonic vibrations of LV outflow tract (chordae tindinae)
  • All ages, particularly young school age
  • Low pitch, musical
  • Decreased with inspiration, sitting, standing. Not a VSD- not regurgitant or with thrill

Innocent Pulmonary Flow Murmur

  • Systolic best at left upper sternal border, minor turbulence in RV outflow tract and main pulmonary artery
  • Often infants and preschool age. Higher pitched than still's, less musical
  • Not PS- no ejection click, no increased RV impulse. no wide s2 split
  • Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no increased RV impulse
  • Decreased on inspiration/sitting/standing

Innocent Pulmonary Branch Murmur of Infancy

  • Systolic ejection murmur from turbulence in pulmonary artery branches (one or both)
  • Medium pitch
  • Physiologic in neonates, becoming audible at L,R,B USB between 0-2wks
  • Transmits well to back and axilla. common in premature; disappears early in infancy
  • Not PS- no ejection click, no increase in RV impulse

Supraclavicular Bruit

  • Systolic ejection murmur of medium pitch from physiologic turbulence of carotid/subclavian and heard at base of neck
  • Can be palpable. Disappears on hyperextension of shoulders
  • Not AS which is loudest at URSB with systolic thrill, sometimes with click

Venous Hum

  • Continuous murmur from turbulent flow in SVC heard at L,R,or B infraclavicular position while sitting/standing
  • Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation
  • Disappears in recumbent position, rotation of head, by pressure at jugular

Mammary Souffle

  • Blood flow in A and V to engorged breast
  • Systolic or continuous, disappears with stethoscope pressure

Cardiorespiratory murmur

  • High pitched cooing, anywhere, but especially apex
  • Breath sound so not timed to heart, disappear when holding breath

Management

See Also

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