Heart Murmur in a Child

Cardiac murmur is frequently recognized in healthy children, but it can also be the presenting feature in many forms of congenital heart disease, including regurgitation or stenosis of heart valves or left-to-right shunt lesions at the atrial, ventricular, or great arterial levels. Careful examination reveals innocent systolic murmurs in as many as 72% of all school-age children [1]. A high prevalence of innocent murmur also has been documented in infants and neonates [2]. Seven types of innocent heart murmurs are reported in children, including Still’s murmur [3–5], innocent pulmonary flow murmur [6–8], innocent pulmonary branch murmur of infancy [9], supraclavicular bruit [10], venous hum [11], mammary souffle [12], and cardiorespiratory murmur [13]. Generally, the clinical history and physical examination are diagnostic for these murmurs. Congenital heart disease is much less prevalent than innocent murmur, occurring in only about 0.8% of live births [14], but the natural history of many common congenital cardiac defects can be one of progressive limitation and premature death. The primary care physician, therefore, very frequently faces the challenge of distinguishing between the relatively rare but important pathologic murmur and the ubiquitous innocent murmur. Failure to diagnose heart disease is unacceptable because current treatments can dramatically improve outcomes. On the other hand, the costs of embarking nonselectively on an aggressive laboratory and/or subspecialty evaluation [15] for as much as 70% of the pediatric population would be staggering. This article discusses diagnostic strategies that allow for timely identification of important congenital cardiac defects while at the same time controlling costs.