Parents may certainly worry if they're told that their child has a heart murmur. Not all heart murmurs are symptoms of heart disease. Sometimes, a murmur may be heard in a normal child who has a fever or who is anemic; these murmurs often go away when the underlying problem is treated.
Busy clinicians need an approach that allows them to appropriately identify and refer patients with pathologic murmurs to a pediatric cardiologist.
In this segment Georgeann Groh, MD., Washington University Pediatric Cardiologist at St. Louis Children's Hospital and the Director, of Outpatient Pediatric Cardiology, explains heart murmurs in children and when to refer to a pediatric cardiologist.
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Heart Murmurs in The Pediatric Population
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Learn more about Georgeann Groh, MD
Georgeann Groh, MD
Georgeann Groh, MD is a Washington University pediatric cardiologist at St. Louis Children's Hospital and the Director, of Outpatient Pediatric Cardiology.Learn more about Georgeann Groh, MD
Transcription:
Heart Murmurs in The Pediatric Population
Melanie Cole (Host): Parents may certainly worry if they’re told that their child has a heart murmur, but heart murmurs can be a very common. My guest today is Dr. Georgeann Groh. She’s a Washington University Pediatric Cardiologist at St. Louis Children’s Hospital, and the Director of Outpatient Pediatric Cardiology. Welcome to the show, Dr. Groh. First of all, what is a heart murmur?
Dr. Georgeann Groh (Guest): A heart murmur is a vague and non-descriptive term, to be honest. It’s simply a sound that we hear when we’re listening to a person’s heart. Normally when we listen to the heart, we hear those valve closure noises, and that’s what a lot of people argue hearing the Lub-Dub, or the Bum-Bum sound. Sometimes in-between those valve closure noises, we can hear an extra sound, that’s like a whooshing or a swishing sound. That extra sound we hear is called a heart murmur.
Melanie: Are most of them pathologic, or may it be a manifestation of a serious heart disease?
Dr. Groh: Well, there are two general classes of heart murmurs. Pathologic would be one of them. However, the overwhelming majority of children with heart murmurs have a kind of heart murmur classified as a functional murmur, or an innocent murmur, or a benign murmur. As you can guess, from the innocent or benign term, this means that their heart is, in fact, healthy and normal, and we just happen to be able to hear a whooshing sound as blood moves through their heart, but the heart itself is, in fact, healthy.
Melanie: What about significance in historical findings? What do you look for as far as family history and personal history?
Dr. Groh: Well, I would say if the child’s own medical history is pretty reassuring in that they’re a healthy child who has exhibited normal growth, normal development, has good energy, exercise tolerance, no complaints of any concerning symptoms such as chest pain, dizziness, fainting, not being able to keep up with their peers. In the absence of any of those sorts of findings or complaints, the heart murmur finding in and of itself is pretty benign. As far as family history, certainly there are a myriad of cardiac conditions that can be seen and passed on within family members. Questions I like to ask the parents would be, “Is there any family history of congenital heart disease?” and I like to specify what that is. Often parents don’t really understand what that means, so I go ahead and say, “Are there any children in the family, siblings, cousins, aunts, uncles, that were born with a heart condition that required treatment, either by surgery or a cardiac catheterization, or a pacemaker,” and so on. That would certainly be one question I would ask. I also always make sure to ask if there is any family history of heart muscle problems. Cardiomyopathy would be one term that often family members will have heard that term. I’d go on to say also, “is there any family history of any young person, either a child or a young adult who passed away suddenly and unexpectedly?” These are some mysterious, rare conditions that can cause that that may manifest in a child as a murmur initially.
Melanie: So Dr. Groh, in a busy office practice, time constraints may make it difficult to perform a complete cardiac physical examination on every patient for Pediatricians, so what symptoms would you like Pediatricians to know that suggest cardiac disease and would require referral to a Pediatric Cardiologist?
Dr. Groh: Sure. Symptomatology-wise, things I always ask are -- I pay attention to their growth, to make sure that through the years that you followed this child had they exhibited normal growth patterns, good weight gain, and so forth. If the child is an infant, important questions to ask would be – other than checking their weight gain – would also be to ask particularly their feeding patterns. Significant heart disease in infants, the primary symptoms you will see will be occurring with feeding, so some things you may see is the infant becoming short of breath when they feed, either from a bottle or the breast, having to pause frequently to catch their breath while they feed. I often like to say that they will do a burst of sucks on the breast or the bottle and then have to pause and catch their breath and then they’ll have to do another burst and then a pause, catch their breath. Any feeding issues, like frequent stopping, or really just taking a really long time to finish, what is considered a normal amount of formula, or breast milk for a child their age. Often parents will notice that they’ve had other children that didn't take this long to eat and so these are concerning symptoms in an infant. Another symptom that I look for in any age child that may be more prominent in younger children would be cyanosis, which is the medical term for a bluish discoloration and at times it’s not necessarily bluish, it can be a dark, dark red, or a purplish discoloration in the body. What we are more concerned about is something called central cyanosis, which is cyanosis of the mucous membranes, so it would be gums, tongue, those parts of the body, which is more concerning than something that is more common which is called acrocyanosis, which you see commonly. That’s when little kids come from the pool, they get cold, or they come out of the bathtub, they get cold – their hands and feet may turn blue, or they may get a little bluish discoloration of their lips or around their mouth. That’s much less concerning and typically not pointing to a heart cause, but if you look in the mucous membranes and you see any sort of cyanosis or bluish discoloration, then that is an indication that their oxygen levels may be low and in combination with a murmur and low oxygen saturation, that would be very concerning.
Melanie: While you’re speaking about oxygen saturation, what about iron deficiency anemia? Can that often be a causal effect to a murmur or vise verse?
Dr. Groh: Well, we can get murmurs caused by something called high-output cardiac status, which means for some underlying reason, the heart is working a bit harder than it needs to -- than is normal. Anemia, which is a low blood count, can be a cause of the heart needing to increase the force of which it contracts and also the heart rate, how often it contracts in order to circulate the proper amount of oxygen to the body. Anemia and iron deficiency being one type of anemia can certainly cause a high-output cardiac state, which can bring out a heart murmur, not because the heart itself is abnormal, but because the heart is working harder and squeezing harder and that produces a sound as the blood whooshes through the heart.
Melanie: So if a pediatrician refers to a pediatric cardiologist, tell us about the cardiac examination, how does that begin? And speak about the diagnostic methods.
Dr. Groh: We see children of all ages with heart murmurs on a routine basis in our clinic. The initial investigation starts, as always with a history. We ask important questions to rule out any concerning symptoms that the child may have been having. This is just sitting talking with the parents, talking to the child themselves. And then once we get the thorough history, often times the history alone will lead us down the path of whether this is an innocent or benign murmur, or in fact a pathologic murmur. Once we’re done with the history taking, then we proceed with the cardiac exam when really -- we do a thorough physical exam, but obviously focus on the cardiac exam, which always includes initially just looking at the patient as a whole, seeing if we notice any dysmorphism or dysmorphic facial features, or physical findings. Then we proceed with the cardiac exam, which I always like to start with just having the child take their shirt off and just looking at their chest, making sure the chest looks symmetric. Sometimes we can actually see a very active precordium, where the heart looks like it’s literally pounding out of the child’s chest. Then I palpate the chest, make sure we don’t feel anything abnormal, make sure the precordium is nice and quiet, that there’s no thrill, which is a buzzing sensation that we feel in the chest. That typically occurs when there’s a very loud murmur and the presence of a thrill always, always indicates a pathologic murmur. And we also feel if there’s any – sometimes you can feel if the heart is enlarged just by putting your hand on a child’s chest. We rule out something called the RV lift, or RV heave where you can really feel the heart pushing up against the chest wall because the heart itself is enlarged. Palpation is a very important thing that we do in the office. Then, of course, listening to the child and I always like to listen to the child both in the sitting upright position, as well as laying supine. Innocent murmurs can change in intensity based on the child’s position and often you’re able to bring that out in the office setting. The other thing that may be useful to do and often times primary pediatricians may not have all the time in the world be flipping the kid every which way, but if you’re able to, if you hear a murmur, and the child is otherwise healthy, and you think it may be an innocent murmur, you can do a series of tests to see if you can make the murmur change in intensity based on various maneuvers. The easiest of which is if you feel the murmur is louder when the child is laying down compared to sitting up, you can see if you can make the murmur go away by having the child perform a Valsalva maneuver, which is having the child essentially bear down. That impedes blood return to the heart, so it decreases the amount of blood in the heart and therefore, decreases the intensity of the murmur. If the child is an older child, they should be able to do what you ask them to. If they’re a younger child, maybe three to six or seven years of age, I like to push on their belly. I just tell them I’m going to push on their belly with my hand and then I ask them in response to pushing their belly out and push against my hand and don’t let me push down and you’re essentially having them bear down and that can be a very useful test that can be done in the office as well to differentiate an innocent from a pathologic murmur.
Melanie: Once you’ve made that differentiation, please explain, just a little bit in the last few minutes, about what you as a pediatric cardiologist would do treatment-wise and reassuring the parents, both as a pediatrician and the cardiologist and the process that’s involved.
Dr. Groh: Usually, I would say in the physical exam stage, in combination with the history, we’re able to determine if this child has a pathologic or an innocent murmur. If it’s an innocent murmur, I often just double check my ears and do a screening test called an EKG, or ECG, which is a bunch of stickers on the chest and printing out the heart beats for ten seconds. That’s a good screening to make sure there’s no chamber enlargement of the heart, and that will cement my diagnosis of an innocent murmur if that comes out being normal. Then I reassure the parents, I explain to them why you see your innocent murmurs. I explain to them and reassure them that this is something the child will outgrow. I also like to tell parents that the murmur can come and go based on the day and time and how active the child is, or if the child is ill or has a fever, it can be louder, just so they don’t worry in the future if a physician tells them that the murmur has changed in intensity. If it’s a pathologic murmur, or there’s any physical exam findings or history findings that’s concerning for a pathologic murmur, then we move to do more expensive testing, which is something called an echocardiogram, which is, as you all know, an ultrasound of the heart. That is really the definitive gold standard testing to delineate the cause of a murmur. Then, depending on what we find pathologically -- on the pathologic side -- then we would counsel the family of if there’s any interventions that need to be made or if this is something we feel that would affect the child down the road, or if this is something we feel that will heal up on its own and so forth, and of course there’s a wide variety of diagnoses that we can get into, but perhaps don’t have the time to today.
Melanie: So wrap it up for us, for other Pediatricians, when they should refer, what you would like them to know about heart murmurs.
Dr. Groh: Heart murmurs, by and large, especially in children, are not pathologic. The overwhelming majority of kids who have a heart murmur will have an innocent or benign murmur. If you’re not sure, if you’re not able to figure that out in your office, we’re happy to see them in our office to do further evaluation, but things that I would think should definitely prompt a referral would be any concerns about growth, or weight gain, any feeding concerns in an infant, or in an older child any coincidental complaints of chest pain, palpitations, not being able to keep up with their peers when they’re in PE class or playing sports, any issues with exercise stamina, shortness of breath, that sort of thing would be big markers. As far as the physical exam findings, any extra abnormalities in addition to the murmur that you may hear, like a click sound or a gallop rhythm or any other palpation of the chest with a thrill, or an active precordium, or a lift that you feel on that chest. Anything other than an otherwise completely normal physical exam, I think should also prompt a referral.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678- H-E-L-P, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks, so much, for listening.
Heart Murmurs in The Pediatric Population
Melanie Cole (Host): Parents may certainly worry if they’re told that their child has a heart murmur, but heart murmurs can be a very common. My guest today is Dr. Georgeann Groh. She’s a Washington University Pediatric Cardiologist at St. Louis Children’s Hospital, and the Director of Outpatient Pediatric Cardiology. Welcome to the show, Dr. Groh. First of all, what is a heart murmur?
Dr. Georgeann Groh (Guest): A heart murmur is a vague and non-descriptive term, to be honest. It’s simply a sound that we hear when we’re listening to a person’s heart. Normally when we listen to the heart, we hear those valve closure noises, and that’s what a lot of people argue hearing the Lub-Dub, or the Bum-Bum sound. Sometimes in-between those valve closure noises, we can hear an extra sound, that’s like a whooshing or a swishing sound. That extra sound we hear is called a heart murmur.
Melanie: Are most of them pathologic, or may it be a manifestation of a serious heart disease?
Dr. Groh: Well, there are two general classes of heart murmurs. Pathologic would be one of them. However, the overwhelming majority of children with heart murmurs have a kind of heart murmur classified as a functional murmur, or an innocent murmur, or a benign murmur. As you can guess, from the innocent or benign term, this means that their heart is, in fact, healthy and normal, and we just happen to be able to hear a whooshing sound as blood moves through their heart, but the heart itself is, in fact, healthy.
Melanie: What about significance in historical findings? What do you look for as far as family history and personal history?
Dr. Groh: Well, I would say if the child’s own medical history is pretty reassuring in that they’re a healthy child who has exhibited normal growth, normal development, has good energy, exercise tolerance, no complaints of any concerning symptoms such as chest pain, dizziness, fainting, not being able to keep up with their peers. In the absence of any of those sorts of findings or complaints, the heart murmur finding in and of itself is pretty benign. As far as family history, certainly there are a myriad of cardiac conditions that can be seen and passed on within family members. Questions I like to ask the parents would be, “Is there any family history of congenital heart disease?” and I like to specify what that is. Often parents don’t really understand what that means, so I go ahead and say, “Are there any children in the family, siblings, cousins, aunts, uncles, that were born with a heart condition that required treatment, either by surgery or a cardiac catheterization, or a pacemaker,” and so on. That would certainly be one question I would ask. I also always make sure to ask if there is any family history of heart muscle problems. Cardiomyopathy would be one term that often family members will have heard that term. I’d go on to say also, “is there any family history of any young person, either a child or a young adult who passed away suddenly and unexpectedly?” These are some mysterious, rare conditions that can cause that that may manifest in a child as a murmur initially.
Melanie: So Dr. Groh, in a busy office practice, time constraints may make it difficult to perform a complete cardiac physical examination on every patient for Pediatricians, so what symptoms would you like Pediatricians to know that suggest cardiac disease and would require referral to a Pediatric Cardiologist?
Dr. Groh: Sure. Symptomatology-wise, things I always ask are -- I pay attention to their growth, to make sure that through the years that you followed this child had they exhibited normal growth patterns, good weight gain, and so forth. If the child is an infant, important questions to ask would be – other than checking their weight gain – would also be to ask particularly their feeding patterns. Significant heart disease in infants, the primary symptoms you will see will be occurring with feeding, so some things you may see is the infant becoming short of breath when they feed, either from a bottle or the breast, having to pause frequently to catch their breath while they feed. I often like to say that they will do a burst of sucks on the breast or the bottle and then have to pause and catch their breath and then they’ll have to do another burst and then a pause, catch their breath. Any feeding issues, like frequent stopping, or really just taking a really long time to finish, what is considered a normal amount of formula, or breast milk for a child their age. Often parents will notice that they’ve had other children that didn't take this long to eat and so these are concerning symptoms in an infant. Another symptom that I look for in any age child that may be more prominent in younger children would be cyanosis, which is the medical term for a bluish discoloration and at times it’s not necessarily bluish, it can be a dark, dark red, or a purplish discoloration in the body. What we are more concerned about is something called central cyanosis, which is cyanosis of the mucous membranes, so it would be gums, tongue, those parts of the body, which is more concerning than something that is more common which is called acrocyanosis, which you see commonly. That’s when little kids come from the pool, they get cold, or they come out of the bathtub, they get cold – their hands and feet may turn blue, or they may get a little bluish discoloration of their lips or around their mouth. That’s much less concerning and typically not pointing to a heart cause, but if you look in the mucous membranes and you see any sort of cyanosis or bluish discoloration, then that is an indication that their oxygen levels may be low and in combination with a murmur and low oxygen saturation, that would be very concerning.
Melanie: While you’re speaking about oxygen saturation, what about iron deficiency anemia? Can that often be a causal effect to a murmur or vise verse?
Dr. Groh: Well, we can get murmurs caused by something called high-output cardiac status, which means for some underlying reason, the heart is working a bit harder than it needs to -- than is normal. Anemia, which is a low blood count, can be a cause of the heart needing to increase the force of which it contracts and also the heart rate, how often it contracts in order to circulate the proper amount of oxygen to the body. Anemia and iron deficiency being one type of anemia can certainly cause a high-output cardiac state, which can bring out a heart murmur, not because the heart itself is abnormal, but because the heart is working harder and squeezing harder and that produces a sound as the blood whooshes through the heart.
Melanie: So if a pediatrician refers to a pediatric cardiologist, tell us about the cardiac examination, how does that begin? And speak about the diagnostic methods.
Dr. Groh: We see children of all ages with heart murmurs on a routine basis in our clinic. The initial investigation starts, as always with a history. We ask important questions to rule out any concerning symptoms that the child may have been having. This is just sitting talking with the parents, talking to the child themselves. And then once we get the thorough history, often times the history alone will lead us down the path of whether this is an innocent or benign murmur, or in fact a pathologic murmur. Once we’re done with the history taking, then we proceed with the cardiac exam when really -- we do a thorough physical exam, but obviously focus on the cardiac exam, which always includes initially just looking at the patient as a whole, seeing if we notice any dysmorphism or dysmorphic facial features, or physical findings. Then we proceed with the cardiac exam, which I always like to start with just having the child take their shirt off and just looking at their chest, making sure the chest looks symmetric. Sometimes we can actually see a very active precordium, where the heart looks like it’s literally pounding out of the child’s chest. Then I palpate the chest, make sure we don’t feel anything abnormal, make sure the precordium is nice and quiet, that there’s no thrill, which is a buzzing sensation that we feel in the chest. That typically occurs when there’s a very loud murmur and the presence of a thrill always, always indicates a pathologic murmur. And we also feel if there’s any – sometimes you can feel if the heart is enlarged just by putting your hand on a child’s chest. We rule out something called the RV lift, or RV heave where you can really feel the heart pushing up against the chest wall because the heart itself is enlarged. Palpation is a very important thing that we do in the office. Then, of course, listening to the child and I always like to listen to the child both in the sitting upright position, as well as laying supine. Innocent murmurs can change in intensity based on the child’s position and often you’re able to bring that out in the office setting. The other thing that may be useful to do and often times primary pediatricians may not have all the time in the world be flipping the kid every which way, but if you’re able to, if you hear a murmur, and the child is otherwise healthy, and you think it may be an innocent murmur, you can do a series of tests to see if you can make the murmur change in intensity based on various maneuvers. The easiest of which is if you feel the murmur is louder when the child is laying down compared to sitting up, you can see if you can make the murmur go away by having the child perform a Valsalva maneuver, which is having the child essentially bear down. That impedes blood return to the heart, so it decreases the amount of blood in the heart and therefore, decreases the intensity of the murmur. If the child is an older child, they should be able to do what you ask them to. If they’re a younger child, maybe three to six or seven years of age, I like to push on their belly. I just tell them I’m going to push on their belly with my hand and then I ask them in response to pushing their belly out and push against my hand and don’t let me push down and you’re essentially having them bear down and that can be a very useful test that can be done in the office as well to differentiate an innocent from a pathologic murmur.
Melanie: Once you’ve made that differentiation, please explain, just a little bit in the last few minutes, about what you as a pediatric cardiologist would do treatment-wise and reassuring the parents, both as a pediatrician and the cardiologist and the process that’s involved.
Dr. Groh: Usually, I would say in the physical exam stage, in combination with the history, we’re able to determine if this child has a pathologic or an innocent murmur. If it’s an innocent murmur, I often just double check my ears and do a screening test called an EKG, or ECG, which is a bunch of stickers on the chest and printing out the heart beats for ten seconds. That’s a good screening to make sure there’s no chamber enlargement of the heart, and that will cement my diagnosis of an innocent murmur if that comes out being normal. Then I reassure the parents, I explain to them why you see your innocent murmurs. I explain to them and reassure them that this is something the child will outgrow. I also like to tell parents that the murmur can come and go based on the day and time and how active the child is, or if the child is ill or has a fever, it can be louder, just so they don’t worry in the future if a physician tells them that the murmur has changed in intensity. If it’s a pathologic murmur, or there’s any physical exam findings or history findings that’s concerning for a pathologic murmur, then we move to do more expensive testing, which is something called an echocardiogram, which is, as you all know, an ultrasound of the heart. That is really the definitive gold standard testing to delineate the cause of a murmur. Then, depending on what we find pathologically -- on the pathologic side -- then we would counsel the family of if there’s any interventions that need to be made or if this is something we feel that would affect the child down the road, or if this is something we feel that will heal up on its own and so forth, and of course there’s a wide variety of diagnoses that we can get into, but perhaps don’t have the time to today.
Melanie: So wrap it up for us, for other Pediatricians, when they should refer, what you would like them to know about heart murmurs.
Dr. Groh: Heart murmurs, by and large, especially in children, are not pathologic. The overwhelming majority of kids who have a heart murmur will have an innocent or benign murmur. If you’re not sure, if you’re not able to figure that out in your office, we’re happy to see them in our office to do further evaluation, but things that I would think should definitely prompt a referral would be any concerns about growth, or weight gain, any feeding concerns in an infant, or in an older child any coincidental complaints of chest pain, palpitations, not being able to keep up with their peers when they’re in PE class or playing sports, any issues with exercise stamina, shortness of breath, that sort of thing would be big markers. As far as the physical exam findings, any extra abnormalities in addition to the murmur that you may hear, like a click sound or a gallop rhythm or any other palpation of the chest with a thrill, or an active precordium, or a lift that you feel on that chest. Anything other than an otherwise completely normal physical exam, I think should also prompt a referral.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678- H-E-L-P, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks, so much, for listening.