Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Bob Underwood. And with us today are Dr. Pezad Doctor, a board-certified pediatric cardiologist and advanced cardiac imaging specialist from Children's Mercy, along with Dr. Mahmoud Jaara, pediatric cardiology fellow.

And today, we are talking about heart murmurs. We're going to have a panel discussion and talk about what's innocent, what's not, and how primary care providers can confidently evaluate murmurs and counsel families on them. So, Doctors, welcome to Pediatrics in Practice.

Dr. Mahmoud Jaara: Thank you.

Host: It's really great to have you on. I mean, we all learn about murmurs when we're in our training. And unless you listen to them and are very familiar with them, it's hard to distinguish sometimes what are the important murmurs and which ones are clinically relevant and which ones aren't.

So, Dr. Jaara, let's start with you and talk about what features help distinguish an innocent murmur from one that might need more evaluation?

Dr. Mahmoud Jaara: Sure. Thank you so much again for hosting us. Hopefully, we'll be able to provide some helpful information. When it comes to innocent murmurs, they're usually soft, systolic and short duration and position dependent murmurs, and they're often louder when the patient is in supine position and softer when standing.

Some of the concerning features that could be suggestive of not innocent murmur is if the murmur itself is diastolic and it's harsh or loud murmur, and if it's a holosystolic murmur in duration or with abnormal S2 and any other additional sounds like a click or a thrill or radiation to the back or the neck. So, the child's overall clinical picture is really important, not only the murmur itself. So, I would look into many other pieces on the physical exam.

Host: Yeah. So, there's definitely a clinical context component. I'm seeing this in the patient and there is a murmur, and those things come together to really drive what does this evaluation need to be in a next step? So Dr. Pezad, what red flags really start to prompt referral to pediatric cardiology?

Dr. Pezad Doctor: Yeah. So, as Dr. Jaara said, definitely the physical examination is key. But also, in addition to that, I feel understanding the patient overall, how the patient is doing clinically in terms of the symptoms. And it depends on how old the child is at presentation. So, let's say if it's a baby and the pediatrician heard a heart murmur, then the things that I would be looking for is how the kid is feeding, how the kid is gaining weight, is there any like sweating while the child is feeding or is breathing faster. So, any clinical concerns that the child is working hard while doing the regular activities.

And as you get older, in older kids, the incidence of congenital heart disease undiagnosed gets less and less as they grow older. So, other symptoms like not able to keep up with their friends while playing or having severe chest pain or other clinical symptoms would warrant further investigation.

Host: And I think that's really important for us to be able to keep that in context when we see these kids. So, we talked about context, infancy, adolescence, prenatal findings. What about family history? Have you any kind of lower or higher thresholds for further evaluation of the murmur based on those contextual things, Dr. Jaara?

Dr. Mahmoud Jaara: Yeah. Sure thing. I think to echo what Dr. Pezad just said, you know, that we have always lower threshold in a newborns and young infants, because we didn't want to miss significant congenital heart disease that may have a subtle findings. And also, the presence of risk factors about the family history or prenatal cardiac abnormalities. If mom had a scan and we are already aware of certain cardiac diagnosis, then this is an automatic scan and automatic referrals to the cardiology. A presence of any genetic syndromes or on the testing, on the physical exam, if there's any abnormal pulse oximetry screening, this is very important.

Some of the important aspects of the family history, we really need to clarify always with the family is cardiomyopathy or history of arrhythmia or sudden unexplained death of, different generations in the family. This is definitely a lower threshold for scan and referring the patient to the pediatric cardiology clinic.

In otherwise healthy older children or adolescent, if it's a classic innocent murmurs with the correct resting that we have discussed, I would have much higher threshold to refer to cardiology. It's completely reasonable to watch it and maybe examine the patient on two different days and see how the patient is doing.

Host: Again, looking at context as being really, really important for those patients and how they're presenting. So, Dr. Pezad, what misconceptions about heart murmurs do you see most often? And we all have our predetermined concepts of what we think about them. What are a couple of misconceptions that are out there?

Dr. Pezad Doctor: So, when parents come to me in the clinic and they have been referred by their pediatrician or other physician who heard a heart murmur, they're quite nervous and anxious as you could imagine. You know, anything with the heart can sound scary initially.

But most of the times that I've heard is parents tell me, "Is my child going to be normal? Will he be able to play? Will he be able to do grow and do other things normally?" I feel that's one of the most common concerns that parents have. And then, I have to reassure them multiple times that this heart murmur is an innocent heart murmur. Sometimes it's as funny as I make this sound of what I hear on the stethoscope when I listen to the kid and kind of reassure them that your child is going to do well and if it's an innocent heart murmur. And of course, if there are other findings associated with, we'll definitely investigate further.

Host: Sure. Absolutely. And so, Dr. Jaara, so say a patient has been appropriately referred to cardiology, how do you approach that workup after that referral has been done? And when is echocardiography or other advanced imaging needed?

Dr. Mahmoud Jaara: Yeah. I think, once we get the patient to clinic, we really circle back to the most important tools in murmur patients is the history and the physical exam. And we focus if the patient has any symptoms, if the patient has normal growth or not, and then any family history, like I mentioned.

And then, some of the vital signs that we look at always, the oxygen saturation, pulses, and blood pressures, and detailed auscultation. If the heart murmur sound is innocent, that's it really. It's not every patient would need an ECG and an echocardiogram. ECG could be helpful in certain selected cases. But the echo specifically, we do it if we see certain finding on the EKG of left ventricle hypertrophy or right ventricle hypertrophy or any other finding that could be suggestive of structural heart disease. So, echo specifically, if we really suspect heart disease and symptoms and risk factors are present already, and the diagnosis remains uncertain after all that evaluation.

So, these are the most important things on the workup. Advanced imaging or advanced more tools in cardiology is less likely to be done for the murmur itself, except if we see a certain finding on the echocardiogram

Host: Yeah, I think those things are really, really important to keep in mind. Again, we're coming back a lot to the clinical context in terms of what's going to be important to be able to look at more thoroughly. So, thank you for that great explanation. And Dr. Pezad, you already kind of mentioned this in terms of talking to families about murmurs. So, how should a pediatrician counsel a family when a murmur is first detected?

Dr. Pezad Doctor: I would like to emphasize that a heart murmur is, again, an exam finding rather than a diagnosis itself. And I feel it's important that the pediatrician explain that, most of the times, a heart murmur can be an innocent finding in a healthy child and then, of course, can give a broader explanation of what to expect when you see a cardiologist.

As Dr. Jaara said, we will examine the child, again, take a detailed history, and then depending on what we find, can do further imaging or EKG and diagnostic testing in the clinic.

Host: I think that that's incredibly important. I think that family members often will jump to the worst-case scenario, and sometimes it's just really important to say, "Hey, a murmur's kind of normal in a lot of circumstances and doesn't necessarily mean that there's something bad that's going on."

So as we conclude, this is really to both of you, is there anything else that you'd like to add, especially for pediatricians who are evaluating, managing children that might have heart murmurs?

Dr. Mahmoud Jaara: I would emphasize on really three things when it comes to the murmurs. The first one is look at the child and not just the murmur. As I said, like it's an exam finding, it's a sound, it's not a diagnosis. Check femoral pulses and oxygen saturations. And the most important one is trust your clinical judgment.

If you have something on the history and the physical exam that does not fit an innocent murmur, that's completely fine to refer and ask for more resources and more help from the pediatric cardiology teams. But if you don't see anything that's really concerning and does not concern you about the patient himself or herself, I would trust the clinical judgment and just assume this is an innocent murmur.

Dr. Pezad Doctor: Similarly, I would like to echo saying that usually a murmur is something where parents are anxious, pediatricians are anxious, rightfully, you know, as it's a scary thing. But again, overall looking at the child and acknowledging that we are there if needed, that a cardiologist input would be necessary if there are other things associated with the heart murmur.

Host: Yes, absolutely. And thank you. And thank you for being there to help some of us who aren't ultra-specialists like you to kind of be able to determine, what may be a normal transitional physiology versus what might be something that might be more serious. So, thank you for being with us and helping explain these things to us today. Really, really great stuff.

Dr. Pezad Doctor: Thank you so much for your time.

Host: Yeah, absolutely. And as a reminder to our audience, claim your CME credits after listening to this informative episode today. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm your host, Dr. Bob Underwood, and this has been Pediatrics in Practice, a CME podcast.