Paeds · cardiology
Cardiovascular examination and murmur assessment
Also known as Paediatric cardiac auscultation · Heart murmur evaluation in children · Innocent vs pathological murmur · Paediatric precordial examination · Newborn cardiovascular assessment · Four-limb blood pressure and pulse oximetry screening
A fellowship approach to the paediatric cardiovascular examination and the heart murmur: perform a systematic inspection-palpation-auscultation sequence with four-limb blood pressure and pulse oximetry, recognise the benign fingerprint of an innocent murmur, identify the departures that mark a murmur as pathological, and resuscitate the duct-dependent neonate or the hypercyanotic spell before the echocardiogram confirms the lesion.
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Target exams
Red flags
- A neonate who is cyanotic, tachypnoeic and not improving on oxygen may have a duct-dependent critical congenital heart lesion — start a prostaglandin E1 infusion before the echo confirms the anatomy
- Weak or absent femoral pulses with an arm-to-leg systolic blood pressure gap above 20 mmHg is coarctation of the aorta or an interrupted arch until proven otherwise
- Differential cyanosis — pink hands and blue feet — signals a right-to-left ductal shunt; reverse differential cyanosis signals transposition with pulmonary hypertension
- A child who suddenly squats, turns deeply cyanosed and becomes inconsolable is having a hypercyanotic (tet) spell — knee-to-chest position, oxygen and the tet-spell bundle
- Any diastolic, continuous or pansystolic murmur, any thrill, or any murmur of grade 3 or louder is pathological until proven otherwise
- Heart failure in an infant hides behind sweating with feeds, tachypnoea, hepatomegaly and failure to thrive — a murmur may be absent in the sickest duct-dependent lesions
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- Performing a systematic paediatric cardiovascular examination including four-limb blood pressure and pulse oximetry
- Recognising the benign fingerprint of an innocent murmur and the features that mark a murmur as pathological
- Identifying the duct-dependent neonate and starting prostaglandin E1
- Correlating murmur timing, location and character with the underlying structural lesion
- The hypercyanotic spell bundle and the resuscitation of critical congenital heart disease
- Distinguishing acyanotic shunt lesions from obstructive and cyanotic lesions at the bedside
- The duct-dependent neonate presenting with cyanosis or shock
- Differentiating an innocent from a pathological murmur in clinic
- Communicating murmur findings, safety-netting and the referral plan to a family
- Short case demonstrating the precordial examination and a systolic murmur
- Long case of an infant with a duct-dependent lesion discussing resuscitation and transfer
- Cardiovascular examination across the age range including the newborn
- Evaluation of the heart murmur and recognition of critical congenital heart disease
- Multidisciplinary referral and follow-up of congenital heart disease
- Cardiac cycle physiology and the generation of heart sounds and murmurs
- Anatomical and haemodynamic basis of congenital heart lesions
- Principles of prostaglandin therapy and the hypercyanotic spell
- Cardiovascular examination and murmur characterisation in a short case
- Communicating safety-netting and the urgent referral plan to a family
- The systematic cardiac examination and the innocent-versus-pathological murmur
- Newborn screening for critical congenital heart disease with pulse oximetry
- Initial stabilisation of the cyanotic infant with prostaglandin E1
- Cardiovascular examination and murmur assessment in infants and children
- Recognition and resuscitation of critical congenital heart disease
- Referral pathways and echocardiographic confirmation
- The paediatric cardiac examination and four-limb blood pressure
- Distinguishing innocent from pathological murmurs
- Stabilisation of the duct-dependent neonate and the hypercyanotic spell
The mark goes to the candidate who treats the murmur as a question, not an answer. Most murmurs in children are innocent — found on a routine check in a thriving child, soft and short, and resolving with reassurance. The skill is not in naming every innocent murmur but in not missing the one that matters. The critical congenital heart lesion announces itself in one of two ways: cyanosis that does not correct with oxygen in the first days of life, or shock and acidosis as the duct closes. Both demand prostaglandin E1 before the anatomy is known, and both are missed most often because the murmur is quiet or absent at the worst moment. The cardiovascular examination is therefore an exercise in safe triage: recognise the benign fingerprint, recognise the red flags, and escalate. [2] [1]
Overview & Definition
The paediatric cardiovascular examination is a structured bedside assessment of a child's heart and circulation, performed to detect structural and functional heart disease and to characterise a murmur found incidentally. It has three inseparable parts: the general inspection of colour, breathing, growth and syndromic features, the focused palpation of the precordium and the peripheral and central pulses, and the systematic auscultation of the heart sounds and any added sounds in the five classical areas. The examination is incomplete without a four-limb blood pressure and a pulse oximetry reading taken in the right hand and a foot, because these two measurements alone detect the duct-dependent and shunt lesions that a stethoscope can miss. [1] [3]
A heart murmur is the sound of turbulent blood flow. Laminar flow is silent; when blood accelerates through a narrowing, crosses a shunt, or flows over a roughened surface, vortices form and the surrounding tissue vibrates, producing an audible murmur. The character of the murmur — its timing in the cardiac cycle, its location, its radiation, its intensity, and its quality — encodes the lesion that generated it. A fellow who reads the murmur by its character can predict the anatomy at the bedside, long before the echocardiogram confirms it. [6] [4]
The clinical importance of the examination sits in its prevalence. Murmurs are heard in up to half of all children at some point in childhood, and the overwhelming majority are innocent. The task of the clinician is therefore not to investigate every murmur but to separate, with the history and the bedside examination alone, the large benign majority from the small pathological minority that needs echocardiography and cardiology referral. Roughly one in a hundred and ten to one in a hundred and thirty infants is born with congenital heart disease, and a quarter of these have a critical lesion that presents in the neonatal period or early infancy — population examination and the pulse-oximetry screen exist to catch. [1] [2]
References12ShowHide
- [1]Ford B, Lara S, Park J. Heart Murmurs in Children: Evaluation and Management. Am Fam Physician, 2022.PMID 35289571
- [2]Singh Y, Lakshminrusimha S. Perinatal Cardiovascular Physiology and Recognition of Critical Congenital Heart Defects. Clin Perinatol, 2021.PMID 34353581
- [3]Fillipps DJ, Bucciarelli RL. Cardiac evaluation of the newborn. Pediatr Clin North Am, 2015.PMID 25836709
- [4]Hueckel RM, Leyland C. Pediatric Murmurs. Nurs Clin North Am, 2023.PMID 37536793
- [5]Naik RJ, Shah NC. Teenage heart murmurs. Pediatr Clin North Am, 2014.PMID 24267454
- [6]Poddar B, Basu S. Approach to a child with a heart murmur. Indian J Pediatr, 2004.PMID 14979389
- [7]Dalal NN, Dzelebdzic S, Frank LH, et al. Recurrent Cardiology Evaluation for Innocent Heart Murmur: Echocardiogram Utilization and Costs. Clin Pediatr (Phila), 2018.PMID 29993270
- [8]Law MA, Collier SA, Sharma S, Tivakaran VS. Coarctation of the Aorta. StatPearls, 2026.PMID 28613663
- [9]Bailliard F, Anderson RH. Tetralogy of Fallot. Orphanet J Rare Dis, 2009.PMID 19144126
- [10]Hipona FA, Sanyal SK. Differential cyanosis in congenital heart disease. J Pediatr, 1968.PMID 5638144
- [11]Johnson BA, Shepherd J, Bhombal S, et al. Special considerations for the stabilization and resuscitation of patients with cardiac disease in the Neonatal Intensive Care Unit. Semin Perinatol, 2024.PMID 39477714
- [12]van Roekens CN, Zuckerberg AL. Emergency management of hypercyanotic crises in tetralogy of Fallot. Ann Emerg Med, 1995.PMID 7832359