Heart Murmurs in the Neonate

The following recommendations represent the minimum requirements to ensure the safe management of neonates with heart murmurs and the timely identification of congenital heart disease.

• All infants with a heart murmur on neonatal examination should be reviewed by a senior paediatrician (middle grade or consultant).
• All infants with a heart murmur should remain in hospital until >24 hours old (unless definitive diagnosis is reached before this).
• All infant with a heart murmur should have a detailed cardiovascular clinical examination which must include measurement of pre and post ductal saturations.
• If a baby with a heart murmur is discharged before a definitive diagnosis is reached, the parents should be given a written

information leaflet describing warning signs and advising them of what to do in the event that their baby became unwell.

Examination

• Dysmorphic features
• Pulses – compare brachial and femoral
• Presence or absence of heave (best felt just below xiphisternum)
• Heart sounds
• Murmur – intensity, character, location and radiation

Investigations

• Pre and post ductal saturations (ESSENTIAL) 
• >3% difference between pre and post and/or a reading <96% needs further investigation ¹
• ECG (WHERE PRACTICAL)
• Useful but not sensitive or specific for abnormalities other than AVSD
• A normal neonatal ECG shows right axis deviation because of the right ventricular dominance of the newborn heart. Left axis deviation in a newborn is a significant abnormal finding and should prompt further investigation.

• Whilst an abnormal ECG should prompt further investigation, a normal ECG should not be considered reassuring if there are abnormal clinical findings

There is no evidence to support the use of CXR or 4 limb blood pressure measurements in the assessment of neonates with heart murmurs ^3,4,5,6.

This is the gold standard investigation for differentiating between innocent and pathological murmurs.

1.   Likely significant congenital heart disease –urgent echocardiogram and review (same day)

Infants with a heart murmur and any of the following warning signs:

• lower limb saturations < 96%;
• >3% pre / post ductal difference; absent/weak femoral pulses;
• signs of heart failure or shock.

These infants require admission SCBU for further assessment, consideration of prostaglandin and urgent discussion +/- transfer to a cardiac centre.

Discuss with Cardiology Consultant on call via

Royal Hospital for Children, Glasgow Switchboard   0141 201 0000

If Dr Irving is available to perform echocardiogram while retrieval is awaited then this can be linked by telemedicine link or used to update surgical centre. This should not be allowed to delay transfer

2.  Asymptomatic but clinically pathological murmur – soon echocardiogram (pre-discharge or as soon as possible within 1 week)

Infants without any of the above warning signs but with any of the following abnormal clinical findings:

• dysmorphism;
• heave;
• abnormal heart sounds;
• loud murmur (>2/6);
• pansystolic, diastolic, continuous murmur;
• murmur location other than left sternal edge /radiation;
• abnormal ECG .

Discuss with Dr Irving re timing of echo, prior to discharge where practicable.

If Dr Irving unavailable for the next week then other options for discussion

In working hours: RHCYP Edinburgh via Paediatric Cardiology Service Coordinator 0131 312 0433

Out of hours: on call Cardiology Registrar or Consultant RHC Glasgow via switchboard 0141 201 0000

3.  Low risk of congenital heart disease –

Well infants with no signs of heart failure, normal pulses, lower limb saturations >96%, soft (1-2/6) systolic murmur at the left sternal edge with no radiation.

Book into next available urgent slot in Dr Irving’s cardiology clinic (monthly clinic)

Use Referral Proforma for Cardiology clinic. Email to paediatric.secretaries@borders.scot.nhs.uk to ensure follow up appointment is made.

Give parents the information sheet including phone number of where to phone if concerned

Details (sticker if available)

Name

Address   

CHI

Contact Phone number

Examination findings

Loudness

Location

Site

Heave   Y   N

ECG    Y     N         MUST BE ATTACHED IF PERFORMED

Pre ductal saturations                         Post ductal saturations

(>3% difference must be investigated urgently)

Senior REVIEW     Y        N     By whom

Family History

Parent information sheet given  Y        N

Signature

Designation

Date

Return to paediatric.secretaries@borders.scot.nhs.uk

Secretaries – please book into next available urgent slot in CI Cardiology clinic and scan this referral into Trak

Heart murmurs in the newborn Information for parents | Right Decisions