The innocent heart murmur in children

ORIGINAL ARTICLE

The Innocent Heart Mwrnur in Children

a

Karen

R

M.

Smith,

MSN,

RN,

CPNP

eports throughout literature indicate that approximately

50% to 90% of all children are given the diagnosis of a cardiac murmur. Although most of these murmurs are innocent, some require follow-up

with a pediatric cardiologist.

Not only is

referral costly, it is sometimes unnecessary. Accurate diagnosis can easily be made by the pediatric nurse practitioner provided proper assessment techniques are used. Nurses who perform primary health assessments must be aware of the difference between innocent and pathologic murmurs to refer only those patients requiring further evaluation. Furthermore communication

with the parents is essential to alleviate unnec-

essary fears. This article reviews the identification ’ ~:innokent murmurs are asymptomatic, they require minimal follow-up care, and the expected outcome for a child with the diagnosis of such a murmur is excellent. J Pediatr Health Care. (1997). 1 I, 207-2 14.

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1997

tiation of the innocent murmur

Reprint requests: Karen M. Smith, MSN, RN, CPNP, The Cleveland Ave., Cleveland, OH 44195. 0 1997 by the National Association

0891.5245/97/$5.00

+0

and differen-

for the nurse practitioner. The

Karen M. Smith is a Pediatric Clinical Nurse Specialist at The Cleveland Cleveland Clinic Foundation in Cleveland, Ohio.

Copyright

thorough

Clinic Children’s

Clinic Children’s

of Pediatric Nurse Associates

Hospital at The

Hospital,

9500 Euclid

& Practitioners.

25/l/77283

207

ORIGINAL ARTICLE

Smith

Pulmoni Area t

FIGURE 1. Areas of auscultation.

techniques and tools for assessment are reviewed followed by the management and expected outcome for children with the diagnosis of an innocent murmur.

ASSESSMENT A thorough understanding of normal heart sounds is necessary for proper evaluation of the pediatric patient presenting for a cardiac examination. The choice of how and where to auscultate for these heart sounds has a significant impact on the complete examination. The successful assessment begins with a good stethoscope. McNamara (1990) defines this as a stethoscope with short tubing and having both a bell and a diaphragm. Adult stethoscopes are preferred, because the pediatric stethoscope is less effective in transmitting low-intensity or low-frequency sounds. Both the diaphragm and the bell of the stethoscope are used in each area to

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assess heart sounds. The diaphragm is best for the high-frequency sounds of Sl, S2, clicks, murmurs, or rubs that have high frequency. The bell is best for lowpitched sounds and murmurs of the atrioventricular (AV) valves. It is important to note that a bell held too tightly against the skin acts as a diaphragm. The examination begins with a brief visual assessment, because one should not rely on auscultation alone for diagnosis. Auscultation is only part of the complete cardiac examination. The practitioner must assess the respiratory system for rate and effort. This is followed by observation of the lips, nailbeds, and skin for proper color. Precordial palpation of the apical impulse and assessment for lifts or heaves is done next. Assessment of the peripheral pulses is then completed, and the upper extremity pulses are compared with those of the

lower extremities, Other components of the cardiac examination include assessment of peripheral circulation and examination of the neck veins and arteries. When auscultating for heart sounds, a quiet environment is needed. This ideally includes the examination room, the child, and the parent. Heart sounds can be difficult to assess especially on a cooing, kicking, small infant, or an active child. No matter how skilled the examiner, any extra noise will interfere with the auscultation. Ideally, the child is placed in the supine position on the examination table or in the parent’s arms, whichever provides the child the most comfort and cooperation. The traditional areas of auscultation were first developed in the nineteenth century (Lehrer, 1992). Each area of auscultation corresponds with the exact area of the heart in the thorax. Figure 1 illustrates the areas of auscultation. The aortic area is located at the second intercostal space right of the sternal border. The pulmonic area is found at the second intercostal space left of the sternal border. The tricuspid area is found at the fourth and fifth intercostal space left of the sternal border. The mitral valve is best auscultated at the cardiac apex or the fifth intercostal space, mid-clavicular line. The mitral area in infants and toddlers is located at the fourth intercostal space. The left ventricular area is centered on the apex and extends to the anterior axillary line. The right ventricular area is located at the level of the third to fourth intercostal spaces on either side of the sternum. The left atria1 area is best heard at the apex, whereas the right atrium encompasses the fourth and fifth intercostal spaces right of the sternal border. When assessing for heart sounds, each sound should be auscultated in a systemic fashion at each site. Auscultation begins with the dia-

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ORIGINAL

II4

TABLE

ARTICLE

1 Characteristics

Sound

-

Smith

of heart sounds

Cause

Significance

Sl

Closure

of AV valves

s2

Closure

of semilunar

s3

Opening

of AV valves

Vibration

of walls

Beginning valves

Frequency

of systole

Location

High

frequency

Late systole

High

frequency

Upper

left sternal

Early

Low

frequency

Apex

or left lower

sternal

border

Low

frequency

Apex

or left lower

sternal

border

diastole

Apex border

(ventricular

gallop) S4 (atrial

gallop)

because

of atrial

and valves kick

Pathologic decreased

because

of

ventricular

compliance

Datafrom Emmanouilides,Allen, Riemenschneider,& Cutgesell(19951. -

phragm, which is inched over the second to fourth intercostal space, followed by the sternal borders, and the apex. No matter how experienced the examiner is, a systematic auscultation beginning with ea’ch heart sound individually is necessary. The practitioner must listen for three to six full cardiac cycles, concentrating on Sl, S2, systole, and diastole separately. The practitioner should pay careful attention to the rate, rhythm, and intensity of each sound and to abnormal sounds. Finally, if not already incorporated into the nurse practitioner’s routine examination, and the child’s cooperation allows, auscultation of all areas in the supine, left lateral, sitting, standing, squatting, and standing after squatting positions is performed.

HEART SOUNDS Heart sounds are the result of two phenomena. The opening and closing of the heart valves along with the vibration of the blood against the heart and vessel walls produce these sounds (Avery & First, 1994). Table 1 summarizes the characteristics of heart sounds. Sl, the first heart sound, is produced by the closure of the AV valves (Lehrer, 1992). The low-frequency vibration of Sl is best heard at the apex of the heart. Sl signifies the beginning of systole. S2, the

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second heart sound, corresponds with the vibration of the closure of the semilunar valves (Lehrer, 1992). S2, best heard at the left upper sternal border, is higher pitched and shorter than Sl. S2 occurs during late systole and is normally a physiologically split sound. This splitting is due to the fact that the aortic valve (A2) closes slightly before the pulmonic valve (P2) (Emmanouilides, Allen, Riemenschneider, & Gutgesell, 1995). A normal split is approximately 0.03 to 0.05 seconds in length. Splitting is best heard with the diaphragm at the second to fourth intercostal space along the left sternal border. Respiration has a dramatic effect on the splitting of S2 (Avery & First, 1994). With inspiration there is increased blood flow into the right heart, which slows the contraction of the right ventricle. As a result the aortic valve closes before the pulmonic valve, widening the splitting of S2. No split or narrowing of S2 is heard with expiration. A persistent split throughout the respiratory cycle or no split at all is considered abnormal. S3, the third heart sound, results as blood flows into the ventricle. It is a low-frequency sound commonly heard in children. S3 is always considered to be normal in children during times of increased cardiac output such as fever, exercise, or

excitement. 53 correlates with the early rapid ventricular filling of diastole. S4, if auscultated, is heard immediately before Sl. The pathologic S4 is caused by excessive flow across the AV valve into a ventricle with decreased compliance. It is an abnormal heart sound in children and most often indicates cardiomyopathy (Emmanouilides et al., 1995). It is best heard at the apex or the left lower sternal border.

CHARACTERISTICS OF MURMURS A murmur is defined as a vibration inside a heart chamber or one of the major arteries (Emmanouilides et al., 1995). Murmurs are relatively long noises compared with the heart sounds. There are many types of murmurs; some are pathologic, but most murmurs heard in children are innocent. There are many causes for murmurs. Abnormal connections between the chambers of the heart or the valves cause most pathologic murmurs (Lehrer, 1992). A murmur can also exist in a healthy heart. A murmur can occur when there is increased flow across a normal valve. Flow across an abnormal valve with or without an obstruction will also produce the sound of a murmur. Blood flowing into a dilated structure or from an area of

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Ipzr !

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Smith

higher pressure creates a murmur. Finally, regurgitant blood flow across an incompetent valve will cause a murmur to be audible. Murmurs are classified into categories based on the effect of the murmur (Sapire, 1991). Innocent murmurs have no anatomic or physiologic abnormalities. Functional murmurs have no anatomic abnormality but do have a physiologic cause such as fever, anemia, or dehydration. Organic murmurs result from a defect in the heart with or without a physiologic component. Murmurs are evaluated for the relative intensity, location, pitch, quality, and timing. The intensity of murmurs is graded from I through VI (Table 2). The location of maximal intensity of the murmur is of diagnostic significance (Avery & First, 1994). It is important to note whether the murmur radiates from its original position. The pitch of a murmur relates to the velocity of blood flow through the restricted or alternate path. Quality is a term used to describe the sound. Musical, blowing, or harsh are terms frequently used to describe the quality of a murmur. The timing of a murmur relates to when in the cardiac cycle the murmur is audible. A systolic murmur occurs during systole. Diastolic murmurs are audible in early diastole, mid-diastole, or presystole. Continuous murmurs, as the name implies, are audible throughout systole into diastole. Overall, the timing of the murmur relates to the severity of the defect causing the murmur. Most murmurs occur during systole or between ‘31 and S2 (Avery & First, 1994). Systolic murmurs include ejection murmurs and regurgitant murmurs. Most are due to the passage of blood through a narrow pathway. The intensity of the murmur directly reflects the pressure change across the pathway or

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TABLE

Grade

2 Grading

I

Barely Not

Grade

II

of murmurs

audible heard

in all positions

Soft but easily

audible

in

all positions No thrill Grade

111

Moderately

audible,

no thrill Grade

IV

Louder

palpable*

with

palpable

thrill Grade

V

Audible

with

slightly Grade

VI

stethoscope

off the chest

Palpable

thrill

Audible

with

stethoscope

off chest Palpable

*Suprastemal fication.

thrill

thrills are not considered

Data from Emmanouilides, & Gutgesell (1995).

in the classi-

Allen, Biemenschneider,

the amount of blood flow involved (Avery & First, 1994). A systolic ejection murmur is described as diamond-shaped as it occurs after the semilunar valves have opened. The maximum intensity occurs in mid-systole. Examples include the murmurs of aortic or pulmanic stenosis or flow into a dilated vessel. The innocent systolic ejection murmur will be discussed separately. The systolic regurgitant murmur is also referred to as a pan/ holosystolic murmur. This murmur starts with Sl and plateaus during systole while maintaining the same intensity throughout. Often, Sl is not heard because it is buried in the murmur. It has a harsh, blowing quality. It is caused by the flow of blood from a high-pressure area into a low-pressure area. Examples include the murmur heard with a ventricular septal defect or mitral regurgitation (Rosenthal, 1984). Diastolic murmurs are audible between S2 and Sl They are always of hemodynamic or structural significance (Rosenthal, 1984). These mur-

murs, audible early in diastole, signify semilunar regurgitation (Avery & First, 1994). The high-frequency, blowing murmur of aortic regurgitation is audible along the left sternal border with the patient sitting, during expiration, or leaning forward. The murmur of pulmonic regurgitation is of low frequency and is heard in the pulmonic area. Mid-diastolic murmurs, indicative of left to right shunts or marked AV valve regurgitation, have the lowest frequency (Sapire, 1991). The frequency may be so low that the murmur is palpable rather than audible. For best auscultation the bell of the stethoscope should be held slightly against the child’s chest. A continuous murmur extends throughout systole into diastole. It is diamond-shaped and peaks at S2 into diastole. It has a medium to high pitch and is indicative of aortic or pulmonic shunts. The intensity of this murmur can change throughout the cardiac cycle depending on the pressure differences between the two structures creating the shunt and the amount of blood shunted through (Avery & First, 1994). Additional heart sounds are sometimes audible. Ejection clicks, difficult to auscultate in children, are often missed. These snappy, short, high-frequency sounds are audible just after Sl. The two types of ejection clicks are the aortic click and the pulmonic click. Both are significant findings in stenosis of these valves. The aortic ejection click is best heard at the left lower sternal border and the apex. The pulmonic click is best heard at the left upper sternal border. The aortic click is not affected by respiration, whereas the pulmonic click disappears with inspiration (Sapire, 1991). A mid-systolic click is indicative of mitral leaflet prolapse. It occurs during mid-systole and is best

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heard at the apex of the heart. Despite the significance of the sound, many clinicians report it is difficult to truly hear (Lehrer, 1992). An opening snap is an abnormal sound of diastole. This sharp, highpitched sound is audible after S2. The snap, heard at the left lower sternal border, is associated with the mitral stenosis of rheumatic heart disease (Lehrer, 1992). Murmurs considered pathologic include all diastolic murmurs, all pan-systolic murmurs, late systolic murmurs, very loud murmurs (greater than grade III/IV), continuous murmurs, and all murmurs associated with cardiac anomalies (Rosenthal, 1984). Children with cardiac anomalies will tend to exhibit other noncardiac signs such as frequent respiratory infections or failure to thrive as well.

INNOCENT

MURMURS

Innocent murmurs are those murmurs not associated with any structural or hemodynamic abnormality. Innocent murmurs are referred to as functional, insignificant, dynamic, or benign. The innocent murmur is diamond-shaped with a musical sound (Rosenthal, 1984). It is characterized as a short systolic murmur with no transmission to other areas of the heart. It has an intensity of grade I-III/VI. The murmur is affected by the child’s position. It is most audible in the supine position. It will often disappear with a change in the child’s position or vary with respiration. The innocent murmur is benign in nature, has no associated signs or symptoms, and disappears by adolescence (Emmanouilides et al., 1995).

The exact cause of the innocent murmur is not clear. The murmur is more audible in children because of the relatively thinner chest wall. It is brought on by high output states such as fever, anxiety, exercise, or anemia, As mentioned, an

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TABLE 3

Common

Murmur

innocent

murmurs liming

Age

Stills

3-5 yrs

Quality

Midsystolic

Low

Location

frequency,

vibratory

LMSB

or between

the LLSB and the apex

Pulmonary

8-l 4 yrs

Early

to

Blowing,

midsystolic Pulmonary murmur

flow

O-6 mos

of

Early

short

to

High

frequency

midsystolic

venous

LUSB, transmits

the newborn Cervical

LUSB

harsh to

the back 3-6

yrs

Continuous

Intensity

hum

with

changes rotation

Supraclavicular area

of head LMSB, Left middle sternal border; LLSL?, left lower sternal border; LUSB, left upper sternal border. Data from Emmanouilides, Allen, Biemenschneider, & Gutgesell (19%). -

innocent murmur is louder in the supine position. This is due to the increased stroke volume and ejection velocity when supine. The cardiac examination is benign including a normal electrocardiogram and chest x-ray. Rosenthal (1984) theorizes that innocent murmurs are due to turbulence from the larger ventricles into the narrower great vessels. Others suggest it is caused by the vibration of intracardiac structures (Emmanouilides et al., 1995). Gardiner and Joffe (1991) designed a study to evaluate the causes of innocent murmurs. This study compared 40 children with innocent murmurs with 40 children without murmurs. Echocardiograms were performed on all five children. The results of the study theorize the innocent murmur is a vibratory phenomenon in the left ventricle, but the exact mechanism is unknown. Children with innocent murmurs tended to have higher aortic flow volume and velocity when compared with the control group. The Still’s murmur is a common innocent murmur (Rosenthal, 1984). It is most common in the preschool years. Best heard in the

left lower sternal border, it disappears if the stethoscope is pressed too hard against the skin. This murmur is audible in early to mid-systole and has a crescendo-decrescendo form. It has a low-frequency, vibratory, musical sound. The murmur is best heard in the supine position and is exaggerated in high output states. The pulmonary flow murmur of children is the second type of innocent murmur (Lehrer, 1992). It is most common in late school age or early adolescence. As the name implies, this benign murmur is audible in the second left intercostal space in the supine position. It is a short, harsh, crescendodecrescendo murmur heard in early to mid-systole with the diaphragm. The murmur is thought to result from turbulent flow in the right ventricular outflow tract. The pulmonary flow murmur of the newborn is a low-intensity systolic ejection murmur audible at the base of the heart and transmits to the axillae and the back. It is the result of hypoplasia of the pulmonary arteries during fetal life. It often persists until 3 to 6 months after birth. The radiation of this murmur to the back is important in

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differentiating it from other murmurs. The cervical venous hum is a continuous murmur that is innocent in nature. It is the most common continuous murmur in children. Heard throughout the cardiac cycle, it is loudest during diastole. This murmur is most prevalent in the preschool and early school-age years, This humming sound is audible in the supraclavicular space over the right internal jugular vein in the sitting position and may transmit to the anterior chest wall. The hum disappears in the supine position, with the Valsalva maneuver, or when slight pressure is applied to the internal jugular vein. The hum becomes louder when the head of the child is turned away. Table 3 summarizes the innocent murmurs. Fortunately most murmurs in children are innocent. That is, the heart is structurally and functionally normal. A pathologic murmur is usually associated with clinical signs and symptoms reflective of the abnormal hemodynamics.

INTERPRETATION The astute practitioner will be able to differentiate the innocent murmur from the pathologic murmur based on clinical assessment (Castellotti, Makssoudian, Mendes, & Fisberg, 1992). A good history and thorough physical examination will confirm the diagnosis of the innocent murmur. However, assessment of heart sounds is not an easy task, especially in children. Assessment of heart sounds is a learned skill that requires practice and continued use to maintain the skill. The environment and the activity level of the child can make the examination more difficult. A full cardiac examination of a child at each well-child care visit may be impractical for a routine visit, but if carefully structured, the examination can be quick and effective.

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If a murmur is suspected, the child should be asked to exercise in the office. Most heart sounds and murmurs will be exaggerated by this increase in cardiac output. Hopping, skipping, or jumping types of exercise for 30 to 60 seconds are sufficient to increase the intensity of the heart sounds. The necessity to refer all children with a murmur to a pediatric cardiologist is an issue that is often debated. An overwhelming majority of children referred to a pediatric cardiologist have innocent murmurs (Steiner, 1991). Clinical diagnosis by a pediatric cardiologist is highly accurate and specific (Danford, Nasir, & Gumbiner, 1993). The cost of these referrals becomes an issue, especially in today’s society. One must assess the necessity and cost-effectiveness of referring these children to a pediatric cardiologist. The assessment of heart sounds, as mentioned earlier, is an acquired skill that requires repetition for mastery. However, it is realistic for the well-trained primary care practitioner to correctly identify an innocent murmur (Danford et al., 1993). Steiner (1991) demonstrated that 96% to 98% of innocent murmurs are diagnosed correctly by the primary practitioner. A study by Castellotti et al. (1992) looked at the incidence of innocent murmurs referred to their institution. A complete history and physical were performed on each of these children by the pediatric cardiologist. Results showed that the original diagnosis of innocent murmur was correctly made by the primary practitioner. They concluded that any practitioner should be able to distinguish between an innocent murmur and a pathologic murmur based on the history and physical examination. Provided the murmur meets the criteria mentioned earlier of systolic, low intensity and no associated signs of heart disease, the practitioner can rest

assured that the diagnosis of an innocent murmur is accurate. Diagnosis of an innocent murmur does not require advanced technology. The stethoscope is the most cost-effective tool to diagnose an innocent murmur. It is relatively inexpensive and does not require the nurse practitioner to have years of training in higher technologic methods such as echocardiography or invasive testing procedures. Further testing for the innocent murmur has not been proved to be of any benefit. The diagnosis of an innocent murmur is unlikely to change, and further testing is costly, An electrocardiogram is the least expensive means for further evaluation if the need arises. If anything, it will alleviate parental fears and rule out other physiologic abnormalities such as Wolf-ParkinsonWhite Syndrome.

practitioner.

An echocardiogram and chest x-ray evaluation are often used to confirm the presence of congenital heart disease, to assess the function and structure of the heart, or to show the heart is normal. A study by Temmerman, Mooyaart, and Taverne (1991) found the chest xray evaluation to be of little value when the diagnosis of an innocent murmur has been made by the primary practitioner. In this study a large number of children were identified as having no heart dis-

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ease after a thorough physical and history was performed by their primary practitioner. A chest x-ray film was obtained on all these children. The results found the x-ray film was useful in diagnosing a congenital heart defect in only 2.8% of the children, making the routine use of the chest x-ray evaluation impractical in this setting. Making a clear distinction between an innocent murmur and a pathologic one can be a challenge for the practitioner. Electrocardiograms, chest x-ray evaluations, echocardiography, or a referral to the pediatric cardiologist are all possible options. A study by Xu and McHaffie (1993) has shown that an echocardiogram by the primary care physician is at times beneficial in patients with nonspecific systolic murmurs, especially when used to confirm the suspicion that the murmur is innocent. The purpose of the study was to evaluate whether an echocardiogram was cost-effective in differentiating the innocent murmur from the pathologic murmur. In this study it was found to be cost-effective for the primary practitioner to obtain and review an echocardiogram, then send the results and the echocardiogram to the pediatric cardiologist for review rather than a complete referral to the pediatric cardiologist. If both the primary care practitioner and the pediatric cardiologist agreed, the noninvasive test alone was sufficient for diagnosis, and no further referral was deemed necessary, However, the echocardiogram rarely revealed significant abnormalities in the assessment of patients suspected of having an innocent murmur (Xu & McHaffie, 1993). An echocardiogram is beneficial if the parents are overly anxious about the murmur. The chest x-ray evaluation and echocardiogram are beneficial if the patient is in a high-risk category or if the physical examination was less than

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optimal. Neither is necessary to diagnose an innocent murmur in a healthy child with no symptoms if a thorough history and physical examination by the primary care practitioner is benign.

difficuit task. Danford et al. (1993), on the other hand, looked at whether the child should be sent directly to the pediatric cardiologist, or if the primary care practitioner should first obtain and review an echocardiogram. Results identified the referral &rate,7 as being the more cost-effective one. The clinical diagnosis by a pediatric cardiologist is highly sensitive and specific. The pediatric cardiologist would then identify whether an echocardiogram is beneficial. The authors believed it was unlikely for every primary practitioner to have access to highly skilled, properly trained pediatric echocardiography technicians (Toews, 1993). The cost/ benefit ratio is highly dependent on the skill of the interpreting physician as well. The primary care practitioner may not have the echocardiogram expertise of the cardiologist. Therefore the ideal approach in this setting is a referral to a pediatric cardiologist. An echocardiogram is beneficial in the newborn when a murmur is heard. Murmurs are commonly found in the newborn because of the incomplete functional closure of the fetal shunts and the relative hypoplasia of the pulmonary system in utero. Auscultation of a

murmur in the newborn period therefore is of little diagnostic value until all the cardiopulmonary hemodynamic changes have occurred. Echocardiography is most beneficial in infants younger than 1 year of age, especially when cardiac symptoms coexist with the audible murmur (Xu & McHaffie, 1993). The management of an innocent murmur is simple: if the practitioner is comfortable with the diagnosis of an innocent murmur in the absence of symptoms, no follow-up care is necessary. If the practitioner is somewhat suspicious and the child otherwise has no symptoms, the child can be monitored over time by the primary practitioner at the routine visits. When suspicion is low, follow-up has been found to be less expensive than referrals or testing (Rosenthal, 1984). As a general rule the younger the child when the murmur is first heard, the more important an early diagnosis becomes. Reassuring the parents that the child with an innocent murmur is healthy can be the most difficult task. The diagnosis of a murmur is distressing to the parent. The anxiety this creates often leads the parent of a child with an innocent murmur to consider their child vulnerable (Young, 1993). Parents often overreact and restrict the child’s activities even when reassured by the primary care practitioner that the child is healthy and the murmur is benign (Young, 1993). No matter how well explained, parents continue to believe the child’s heart is abnormal. Young compared the level of parental understanding of their child’s diagnosis after referral with the observed level of restriction in the child’s activity His results illustrated a significant relationship between level of parental understanding and comfort level with the diagnosis of an innocent murmur to the restriction of the child’s activities. The parents with

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P IORIGINAL ARTICLE Q high anxiety and discomfort with the diagnosis of an innocent murmur were more likely to label the child as vulnerable. The study identified communication, or lack of, as the key issue. Young suggests that all children with an innocent murmur referred to a pediatric cardiologist should have a follow-up visit with the primary practitioner to clear up any misconceptions. With clear communication most parents will then allow the child to live a happy, healthy, and active life. The expected outcome for an innocent murmur is excellent. Because there is no hemodynamic or structural cardiac abnormality, no follow-up care is necessary. An innocent murmur does not require subacute bacterial endocarditis prophylaxis or long-term follow-up (Rosenthal, 1984). One does not need to list it as a preexisting condition on insurance forms. When the primary care practitioner is confident in the diagnosis and communicates this clearly to the parents, the outcome for a child with no symptoms and an innocent murmur is indeed favorable.

Special thanks to Douglas S. Moodie, MD, MS, Chairman, Division of Pediatrics, The Cleveland Clinic Foundation, and Ceorges Z. Markarian, MD, for their assistance with this paper.

REFERENCES Avery, M. E., & First, L. R. (1994).Pediatric (2nd ed.). Baltimore: Williams

medicine

&Wilkins. Castellotti, D. S., Makssoudian, A., Mendes, M. C., & Fisberg, M. (1992). Heart murmur in pediatrics: Innocent or pathologic? Rmista Paulista de Medicina, 110, 29-33. Danford, D. A., Nasir, A., & Gumbiner, C. (1993). Cost assessment of the evaluation of heart murmurs in children. Pediatrics,

91,365-368.

Emmanouilides, G. C., Allen, H. D., Riemenschneider, T. A., & Gutgesell, H. l? (1995). Moss and Adams Heart disease in infants, children, and adolescentsincluding the fetus and young adult (5th ed). Baltimore: Williams and Wilkins. Gardiner, H. M., & Joffe, H. S. (1991). Genesis of Still’s murmur: A controlled doppler study. British Heart Journal, 66, 217-220. Lehrer, S. (1992). Understunding pediatric heart sounds. Philadelphia: W.B. Saunders.

McNamara, D. G. (1990). Value and limitatiions of auscultation in the management of congenital heart disease. Pediatric Clinics of North America, 37,93-113. Rosenthal, A. (1984). How to distinguish between innocent and pathologic murmurs in children. Pediatric Clinics of North

America,

31,1229-1240.

Sapire, D. (1991). Understanding

and diagnos-

Norwalk: Appleton and Lange. Steiner, M. L. (1991). Evaluation of heart murmurs (Letter to the Editor). Pediing

pediatric

heart

disease.

atrics, 87,952-953.

Temmerman, A. M., Mooyaart, E. L., & Taverne, I? I? (1991). The value of the chest roentgenogram in the cardiological evaluation of infants and children. European Journal ofPediatrics, 150,623-626. Toews, W. H. (1993). Heart murmurs. If you allow for mistakes costs are even higher! (Letter to the Editor). Pediatrics, 92,304305. Xu, M., & McHaffie, D. J. (1993). Nonspecific systolic murmurs: An audit of the clinical value of echocardiography. New Zealand

Medical

Journal,

106,54-56.

Young, P.C. (1993). The morbidity of cardiac nondisease revisited: Is their lingering concern associated with an innocent murmur? American Journal of Diseasesof Children, 147,975-977.

NAPNAP’s 19TH ANNUAL NURSING CONFERENCE ON PEDIATRIC PRIMARY CARE: CHALLENGES AND CHANGES IN CHILDREN’S HEALTH March l&22,1998 Sheraton Hotel Chicago, Illinois

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