Murmurs

General information 

  • Most children will have an audible heart murmur at some point during childhood and some persist to adolescence.
  • The majority of pathological heart murmurs are picked up in early infancy.
  • The vast majority are ‘innocent’ murmurs which require no further investigation.
  • The key characteristics of an innocent murmur are that they:
    • Always – intensity less than 4/6, no radiation, normal peripheral examination, not diastolic
    • Usually – intensity less than 3/6, short in duration, single, change with position, musical or vibratory.
    • If a murmur is pansystolic, diastolic, associated with a thrill or cardiac symptoms then it is probably NOT an innocent murmur.
  • Nonetheless a heart murmur can be an indication of an underlying congenital cardiac abnormality and even in a well child cause significant anxiety to families.

Initial management

  • History
    • Growth – any concerns about weight gain infants or growth in older children
    • Any colour changes or central cyanosis (peripheral cyanosis and acrocyanosis in infants is normal)
    • Shortness of breath chest pain or syncope (on rest or on exertion)
    • Has the murmur been heard before?
    • Family history of congenital heart disease?
  • Examination
    • Plot Growth on growth chart
    • Central cyanosis? Check oxygen saturations (if possible)
    • Check that femoral pulses are easily felt
    • Presence or absence of heaves/thrills, description/of murmur.
  • If murmur is heard in the context of an acute illness in an otherwise well, and thriving child, arrange to listen again when the child is well.
  • Provide patient information leaflet 
  • If referring, please avoid creating expectation that echocardiography will definitely be performed - often it is not required and diagnosis can be made clinically. 

Useful resources

Your child has been found to have a heart murmur (NHS Tayside leaflet)
Your child has an innocent heart murmur (MHS Tayside leaflet)

NHS Tayside Paediatric Heart Murmur Pathway
(more information about diagnosis and paediatric management)

Who to refer

  • Any child aged < 3 months
  • Persistent murmur (any age) when you are not confident the murmur is innocent.

Urgent referral if
  • faltering growth

Same day telephone discussion with on-call team if;
  • Central cyanosis and/or saturations <95% in air
  • Absent or weak femoral pulses
  • Signs of heart failure (respiratory distress, tachycardia, hepatomegaly etc)

How to refer 

  • Same day referrals via on-call paediatric registrar Ninewells hospital. 
  • Outpatient referrals - SCI Gateway/Paediatrics