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Discerning the pathology of a heart murmur.

SAN DIEGO -- Heart murmurs that seem to vary depending on a child's posture and respiration, that don't have any associated clicks or high-frequency "harsh" sounds, and that are not diastolic tend to be innocent rather than pathologic, Dr. William Lutin said at a meeting sponsored by the Los Angeles Pediatric Society.

But listening for the absence or presence of such sounds isn't the only thing pediatricians need to keep in mind when they try to make this distinction. It's also important for them to thoroughly examine children in a fully resting state--not after exercise--and while patients are standing, as well as lying on their back, said Dr. Lutin, director of the pediatric cardiac diagnostic laboratories at the Medical College of Georgia in Augusta.

Furthermore, a series of exams--rather than just one, especially if a child is feverish--will help distinguish innocent from pathologic murmurs, he said.

"If a murmur comes and goes" during multiple exams, said Dr. Lutin, "it's most likely to be innocent." A murmur also is probably benign if it is abolished or greatly reduced while the child is standing, he added.

"Physical exam and history are the most important parts of evaluation of a child with heart murmur," Dr. Lutin said.

Assessments in the cardiac portion of an exam should include inspection (visible cardiac impulses on the precordium are sometimes a bad sign), palpation, and auscultation, he said. During these steps, "we do everything we can to try to get the kid's heart rate as slow as possible--to have a relaxed comfortable patient in our office."

In palpation, he feels for left-ventricle and right-ventricle impulses as well as thrills at the lower-left, upper-left, and upper-right sternal borders and the suprasternal notch. In auscultation, he notes the location of the first and second heart sounds ($1 and $2), listens for $2 splitting, and assesses the pulmonic second heart sound (P2). He also listens for clicks. (See box.)

The patient's history is important because it may provide helpful clues, Dr. Lutin explained. (See box.) For example, proximal muscle development often is delayed in an infant with a significant cardiac problem, so the child might not walk, sit up, or roll over at the usual age.

A warning sign in older children is a self-imposed limitation on activity and exercise, which is their way of compensating. To find out if that's happening, "I always ask a parent this question: Does [your child] keep up with you at the mall?" he said.

Relying on sophisticated tests and equipment might seem like the best way to detect pathologic murmurs, but the stethoscope is still the most important piece of diagnostic equipment, Dr. Lutin said.

He performs ECG on only about 8% of patients newly diagnosed with a murmur, and doesn't use it as a substitute for a thorough physical exam.

"No imaging study, machinery, or diagnostic test replaces the eyes, hands, spirit, and brain of the clinician," he said.


Contributing Writer
History for Children With a Murmur

* Prenatal risk factors and teratogens,
including alcohol.

* Early growth and development
(motor milestones).

* Feeding pattern (for infants).

* Time and clinical setting when murmur
was first noted.

* Activity and exercise tolerance
(child may self-limit).

* Respiratory symptoms, especially
wheezing and recurrent problems.

* Orthopnea, dyspnea, diaphoresis,

* Family history of congenital heart
disease, syndromology, or sudden

Signs of Innocent vs. Pathologic Heart Murmurs

Murmur Characteristic   Innocent                     Pathologic

Quality                 Vibratory                    Harsh
Duration                Short                        Variable
Location                Variable                     Variable
Pitch                   Low- or midfre: uency        Variable
Radiation               Along left sternal border,   With flow
                        not to the back
Click, S3, or S4        No                           Variable
Timing                  Systolic                     Variable

Source: Dr. Lutin
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Title Annotation:Clinical Rounds
Author:Engstrom, Paul
Publication:Pediatric News
Geographic Code:1USA
Date:Feb 1, 2006
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