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Is My Child's Heart Murmur Dangerous? · Pediatrics in Practice: A CME Podcast

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  Dr. Bob Underwood (Host):
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  Welcome to Pediatrics in Practice, a CME podcast.
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  I'm your host, Dr.
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  Bob Underwood.
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  And with us today are Dr.
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  Pezad Doctor, a board-certified pediatric cardiologist and advanced
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  cardiac imaging specialist from Children's Mercy, along with Dr.
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  Mahmoud Jaara, pediatric cardiology fellow.
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  And today, we are talking about heart murmurs.
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  We're going to have a panel discussion and talk about what's innocent,
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  what's not, and how primary care providers can confidently evaluate
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  murmurs and counsel families on them.
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  So, Doctors, welcome to Pediatrics in Practice.
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  Dr. Mahmoud Jaara:
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  Thank you.
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  Host: It's really great to have you on.
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  I mean, we all learn about murmurs when we're in our training.
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  And unless you listen to them and are very familiar with them, it's hard
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  to distinguish sometimes what are the important murmurs and which ones are
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  clinically relevant and which ones aren't.
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  So, Dr.
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  Jaara, let's start with you and talk about what features help
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  distinguish an innocent murmur from one that might need more evaluation?
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  Dr. Mahmoud Jaara:
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  Sure.
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  Thank you so much again for hosting us.
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  Hopefully, we'll be able to provide some helpful information.
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  When it comes to innocent murmurs, they're usually soft, systolic
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  and short duration and position dependent murmurs, and they're often
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  louder when the patient is in supine position and softer when standing.
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  Some of the concerning features that could be suggestive of not innocent murmur is
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  if the murmur itself is diastolic and it's harsh or loud murmur, and if it's a
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  holosystolic murmur in duration or with abnormal S2 and any other additional
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  sounds like a click or a thrill or radiation to the back or the neck.
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  So, the child's overall clinical picture is really important,
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  not only the murmur itself.
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  So, I would look into many other pieces on the physical exam.
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  Host: Yeah.
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  So, there's definitely a clinical context component.
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  I'm seeing this in the patient and there is a murmur, and those things come
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  together to really drive what does this evaluation need to be in a next step?
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  So Dr.
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  Pezad, what red flags really start to prompt referral to pediatric cardiology?
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  Dr. Pezad Doctor:
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  Yeah.
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  So, as Dr.
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  Jaara said, definitely the physical examination is key.
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  But also, in addition to that, I feel understanding the patient
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  overall, how the patient is doing clinically in terms of the symptoms.
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  And it depends on how old the child is at presentation.
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  So, let's say if it's a baby and the pediatrician heard a heart murmur,
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  then the things that I would be looking for is how the kid is feeding, how
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  the kid is gaining weight, is there any like sweating while the child
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  is feeding or is breathing faster.
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  So, any clinical concerns that the child is working hard while
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  doing the regular activities.
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  And as you get older, in older kids, the incidence of congenital
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  heart disease undiagnosed gets less and less as they grow older.
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  So, other symptoms like not able to keep up with their friends while
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  playing or having severe chest pain or other clinical symptoms would
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  warrant further investigation.
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  Host: And I think that's really important for us to be able to keep
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  that in context when we see these kids.
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  So, we talked about context, infancy, adolescence, prenatal findings.
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  What about family history?
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  Have you any kind of lower or higher thresholds for further
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  evaluation of the murmur based on those contextual things, Dr.
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  Jaara?
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  Dr. Mahmoud Jaara:
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  Yeah.
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  Sure thing.
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  I think to echo what Dr.
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  Pezad just said, you know, that we have always lower threshold in a newborns and
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  young infants, because we didn't want to miss significant congenital heart
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  disease that may have a subtle findings.
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  And also, the presence of risk factors about the family history
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  or prenatal cardiac abnormalities.
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  If mom had a scan and we are already aware of certain cardiac diagnosis,
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  then this is an automatic scan and automatic referrals to the cardiology.
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  A presence of any genetic syndromes or on the testing, on the physical exam,
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  if there's any abnormal pulse oximetry screening, this is very important.
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  Some of the important aspects of the family history, we really need to
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  clarify always with the family is cardiomyopathy or history of arrhythmia
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  or sudden unexplained death of, different generations in the family.
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  This is definitely a lower threshold for scan and referring the patient
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  to the pediatric cardiology clinic.
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  In otherwise healthy older children or adolescent, if it's a classic innocent
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  murmurs with the correct resting that we have discussed, I would have much
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  higher threshold to refer to cardiology.
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  It's completely reasonable to watch it and maybe examine the patient on two different
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  days and see how the patient is doing.
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  Host: Again, looking at context as being really, really important for those
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  patients and how they're presenting.
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  So, Dr.
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  Pezad, what misconceptions about heart murmurs do you see most often?
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  And we all have our predetermined concepts of what we think about them.
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  What are a couple of misconceptions that are out there?
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  Dr. Pezad Doctor:
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  So, when parents come to me in the clinic and they have been referred by
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  their pediatrician or other physician who heard a heart murmur, they're quite
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  nervous and anxious as you could imagine.
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  You know, anything with the heart can sound scary initially.
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  But most of the times that I've heard is parents tell me, "Is
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  my child going to be normal?
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  Will he be able to play?
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  Will he be able to do grow and do other things normally?"
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  I feel that's one of the most common concerns that parents have.
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  And then, I have to reassure them multiple times that this heart
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  murmur is an innocent heart murmur.
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  Sometimes it's as funny as I make this sound of what I hear on the
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  stethoscope when I listen to the kid and kind of reassure them that
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  your child is going to do well and if it's an innocent heart murmur.
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  And of course, if there are other findings associated with, we'll
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  definitely investigate further.
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  Host: Sure.
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  Absolutely.
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  And so, Dr.
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  Jaara, so say a patient has been appropriately referred to cardiology,
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  how do you approach that workup after that referral has been done?
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  And when is echocardiography or other advanced imaging needed?
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  Dr. Mahmoud Jaara:
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  Yeah.
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  I think, once we get the patient to clinic, we really circle back to the
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  most important tools in murmur patients is the history and the physical exam.
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  And we focus if the patient has any symptoms, if the patient has
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  normal growth or not, and then any family history, like I mentioned.
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  And then, some of the vital signs that we look at always, the oxygen
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  saturation, pulses, and blood pressures, and detailed auscultation.
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  If the heart murmur sound is innocent, that's it really.
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  It's not every patient would need an ECG and an echocardiogram.
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  ECG could be helpful in certain selected cases.
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  But the echo specifically, we do it if we see certain finding on the
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  EKG of left ventricle hypertrophy or right ventricle hypertrophy or
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  any other finding that could be suggestive of structural heart disease.
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  So, echo specifically, if we really suspect heart disease and symptoms
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  and risk factors are present already, and the diagnosis remains
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  uncertain after all that evaluation.
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  So, these are the most important things on the workup.
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  Advanced imaging or advanced more tools in cardiology is less likely to be done
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  for the murmur itself, except if we see a certain finding on the echocardiogram
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  Host: Yeah, I think those things are really, really important to keep in mind.
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  Again, we're coming back a lot to the clinical context in terms of
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  what's going to be important to be able to look at more thoroughly.
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  So, thank you for that great explanation.
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  And Dr.
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  Pezad, you already kind of mentioned this in terms of
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  talking to families about murmurs.
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  So, how should a pediatrician counsel a family when a murmur is first detected?
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  Dr. Pezad Doctor:
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  I would like to emphasize that a heart murmur is, again, an exam finding
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  rather than a diagnosis itself.
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  And I feel it's important that the pediatrician explain that, most of
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  the times, a heart murmur can be an innocent finding in a healthy
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  child and then, of course, can give a broader explanation of what to
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  expect when you see a cardiologist.
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  As Dr.
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  Jaara said, we will examine the child, again, take a detailed history,
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  and then depending on what we find, can do further imaging or EKG and
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  diagnostic testing in the clinic.
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  Host: I think that that's incredibly important.
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  I think that family members often will jump to the worst-case scenario, and
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  sometimes it's just really important to say, "Hey, a murmur's kind of
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  normal in a lot of circumstances and doesn't necessarily mean that there's
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  something bad that's going on."
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  So as we conclude, this is really to both of you, is there anything else
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  that you'd like to add, especially for pediatricians who are evaluating, managing
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  children that might have heart murmurs?
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  Dr. Mahmoud Jaara:
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  I would emphasize on really three things when it comes to the murmurs.
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  The first one is look at the child and not just the murmur.
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  As I said, like it's an exam finding, it's a sound, it's not a diagnosis.
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  Check femoral pulses and oxygen saturations.
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  And the most important one is trust your clinical judgment.
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  If you have something on the history and the physical exam that does not fit an
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  innocent murmur, that's completely fine to refer and ask for more resources and more
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  help from the pediatric cardiology teams.
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  But if you don't see anything that's really concerning and does not concern
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  you about the patient himself or herself, I would trust the clinical judgment and
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  just assume this is an innocent murmur.
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  Dr. Pezad Doctor:
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  Similarly, I would like to echo saying that usually a murmur is
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  something where parents are anxious, pediatricians are anxious, rightfully,
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  you know, as it's a scary thing.
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  But again, overall looking at the child and acknowledging that we are there
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  if needed, that a cardiologist input would be necessary if there are other
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  things associated with the heart murmur.
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  Host: Yes, absolutely.
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  And thank you.
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  And thank you for being there to help some of us who aren't ultra-specialists
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  like you to kind of be able to determine, what may be a normal transitional
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  physiology versus what might be something that might be more serious.
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  So, thank you for being with us and helping explain these things to us today.
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  Really, really great stuff.
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  Dr. Pezad Doctor:
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  Thank you so much for your time.
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  Host: Yeah, absolutely.
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  And as a reminder to our audience, claim your CME credits after listening
• 10:42
  to this informative episode today.
• 10:45
  You can do so by visiting cmkc.link/cmepodcast
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• 10:55
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  I'm your host, Dr.
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  Bob Underwood, and this has been Pediatrics in Practice, a CME podcast.