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Innocent Murmurs in Children. Georgeann Wang, MS3. 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

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Innocent murmurs in children

Innocent Murmurs in Children

Georgeann Wang, MS3

Murmurs in children
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”

Evaluation of murmur
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

Innocent murmurs
Innocent Murmurs

  • Not solely diastolic! (systolic or continuous)

  • Not associated with a thrill! (grades I-III)

  • Not associated with a click!

Grading murmurs a new approach
Grading Murmurs – A New Approach

Logic based pneumonic
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

1 venous hum
1. Venous Hum

  • Connection between jugular, subclavian, and innominate veins to SVC

Venous hum
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

Venous hum1
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

Venous hum differential diagnosis
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

2 pulmonary flow murmur
2. Pulmonary Flow Murmur

  • Connection of right ventricle with main pulmonary artery

Pulmonary flow murmur
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)

Pulmonary flow murmur1
Pulmonary Flow Murmur

  • Increased: high output states (fever, illness, anemia, etc), with expiration

  • Decreased: standing position, with inspiration

Pulmonary flow murmur2
Pulmonary Flow Murmur

  • Is exaggerated by any condition that brings the RVOT closer to the anterior chest wall

    • eg. pectus excavatum, kyphoscoliosis

Pulmonary flow murmur differential diagnosis
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

3 physiologic peripheral pulmonary stenosis pps
3. Physiologic Peripheral Pulmonary Stenosis (PPS)

  • Connection of main pulmonary artery to right and left pulmonary artery branches

Physiologic pps
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

Physiologic pps1
Physiologic PPS

  • Increased in: high output states (fever, illness, anemia, etc), viral URI, RAD exacerbations

Pps differential diagnosis
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

4 still s murmur
4. Still’s Murmur

  • Connection of left ventricle with aorta

Still s murmur
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

Still s murmur1
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

Still s murmur2
Still’s Murmur

  • Increased: supine position, fever, anemia

  • Decreased: sitting or standing, with valsalva

Still s murmur differential diagnosis
Still’s Murmur – differential diagnosis

  • VSD – different quality, harsh not musical

  • LVOT obstruction – different quality

  • HOCM – different quality

5 supraclavicular systemic bruit
5. Supraclavicular Systemic Bruit

  • Connection of brachiocephalic vessels to aortic arch

Supraclavicular systemic bruit
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

Supraclavicular systemic bruit1
Supraclavicular Systemic Bruit

  • Decreased: with shoulders pulled back (hyperextension)

  • No change with position

Supraclavicular systemic bruit differential diagnosis
Supraclavicular Systemic Bruit – differential diagnosis

  • Aortic stenosis/supraaortic stenosis – louder in chest with radiation to carotids

Innocent murmurs in children

  • Most common misdiagnosed heart murmur in children

  • More often than not there is no murmur heard with ASD

Auscultation of asd
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

Red flags caution
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


  • 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

Case 1
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?

Case 11
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).

Case 2
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?

Case 21
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!

Case 3
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?

Case 31
Case 3

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


  • Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based Pneumonic. Pediatrics 1997; 99(4):616-618

  • 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.