Paeds · cardiology
Innocent murmurs and normal paediatric cardiovascular variants
Also known as Innocent cardiac murmur · Functional murmur · Physiological murmur · Still's murmur · Normal cardiovascular variants in children
Fellowship guide to recognising innocent murmurs and normal paediatric cardiovascular variants, distinguishing them from pathology, and avoiding unnecessary referral and investigation.
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Target exams
Red flags
- Diastolic, holosystolic or continuous murmur (other than venous hum)
- Harsh, loud (grade >=3/6) or thrill-associated murmur
- Fixed wide split S2, single or loud P2, or abnormal heart sounds
- Murmur radiating to the back or neck
- Symptoms: failure to thrive, exertional symptoms, syncope, dyspnoea, cyanosis
- Abnormal pulses (weak femorals, bounding pulses, radio-femoral delay)
- Neonatal murmur: refer rather than label innocent
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Clinical Applications
- Short Cases
- Long Cases
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Clinical
- Cardiovascular examination
- General Pediatrics Content Outline — Cardiology
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 2: Diagnostic reasoning
- Medical Expert
- Pediatrics: Performing and presenting a cardiovascular examination
Innocent vs pathologic
Innocent (functional)
Pathologic
Quote the source before you argue a cut-off, and never call a murmur innocent until you have excluded the red flags. [1] [2]
Still's vibratory (left sternal edge, 2–7 yr) · Pulmonary flow (left upper sternal edge) · Aortic flow / supraclavicular bruit · Venous hum (infraclavicular, disappears on lying or jugular compression) · carotid Bruit · hepatic/periNatal (newborn ductal closure) · mammary Souffle (pregnancy, adolescent). [3] [5]
Overview & Definition
An innocent murmur is an audible sound generated by normal turbulent blood flow in a structurally normal heart, with no haemodynamic abnormality and no cardiac symptoms. It is the single most common reason a child is referred for a "heart check", and the skill of confidently recognising it saves families from anxiety, unnecessary investigations and sport restriction. [1] [2]
The same label should never be used loosely. Before you call a murmur innocent you must confirm a normal history (growth, feeding, exertion, colour, syncopal symptoms), normal heart sounds, normal pulses and a normal oxygen saturation, and you must be dealing with one of the recognised innocent patterns. [3] [6]
References12ShowHide
- [1]Ford B Heart Murmurs in Children: Evaluation and Management. American family physician, 2022.PMID 35289571
- [2]Huq A Cardiac murmurs in children. Australian journal of general practice, 2024.PMID 38957059
- [3]Menashe V Heart murmurs. Pediatrics in review, 2007.PMID 17400822
- [4]Naik RJ Teenage heart murmurs. Pediatric clinics of North America, 2014.PMID 24267454
- [5]Pelech AN The physiology of cardiac auscultation. Pediatric clinics of North America, 2004.PMID 15561171
- [6]Pelech AN The cardiac murmur. When to refer? Pediatric clinics of North America, 1998.PMID 9491089
- [7]Dursun H Blood pressure and heart rate monitoring in children and adolescent with Still's vibratory murmur. Blood pressure monitoring, 2022.PMID 34992203
- [8]Advani N The diagnosis of innocent murmurs in childhood. Cardiology in the young, 2000.PMID 10950330
- [9]Shekhar R Automated identification of innocent Still's murmur using a convolutional neural network. Frontiers in pediatrics, 2022.PMID 36210944
- [10]Begic Z Evaluation of Diagnostic Methods in the Differentiation of Heart Murmurs in Children. Acta informatica medica, 2016.PMID 27147798
- [11]Hueckel RM Pediatric Murmurs. The Nursing clinics of North America, 2023.PMID 37536793
- [12]Watrous RL The impact of computer-assisted auscultation on physician referrals of asymptomatic patients with heart murmurs. Clinical cardiology, 2008.PMID 18257026