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Pediatric Cardiology Management and Referral Guidelines

Pediatric Cardiology Management and Referral Guidelines

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Pediatric Cardiology Management and Referral Guidelines

Cardiac Murmur (R01.1)

Diagnosis: ICD-10

Murmur: R01.1

Target Population • Infants • Children • Young adults

Clinical Findings

• A murmur is made by the sound of turbulent blood flow within the heart and/or blood vessels and is transmitted through the chest wall to the skin.

• Murmurs can be innocent or pathologic. Innocent murmurs are common (>50% of children), can be heard at any age, and often are intermittent in nature.

Evaluation Recommendations

• A detailed clinical history and physical examination is typically the most useful way to distinguish innocent from pathologic murmurs.

o Asymptomatic children: In patients with a low intensity/low frequency murmur, typically systolic, that is localized and no other concerning findings, prudent observation can be considered.

o Symptomatic children: Patients with clinical symptoms, poor growth, or abnormal exam findings should be referred to a pediatric cardiologist.

Red Flags

Signs mandating urgent cardiology referral:

• Cyanosis • Diminished/absent pulses • Hepatomegaly • Respiratory distress • Clubbing • Poor perfusion.

The likelihood of pathologic murmur increases with diastolic murmur, >III/VI murmur, abnormal S2, a click, or increased intensity when patient stands. Neonates are more likely to have a pathologic murmur than older asymptomatic children.

Treatment Recommendations

• Patients with a routine innocent murmur do not require referral. • Patients with abnormal physical exam findings, history of

personal conditions that increase likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified should

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Pediatric Cardiology Management and Referral Guidelines

These recommendations s are designed to be used by primary care physicians wishing to refer children with a murmur for additional evaluation and care. They are recommendations and are based on best evidence and expert consensus.

be referred to a pediatric cardiologist. Consult with the specialist is recommended over outpatient echocardiogram so potentially unneeded testing can be avoided and counseling can be provided in the case of positive findings.

Ancillary Documentation

Needed

• Referral request

Additional Information

1. Rosenthal, A. How to distinguish between innocent and pathologic murmurs in childhood. Pediatric Clin North Am. 1984 Dec; 31(6): 1229–1240.

2. Behrman, Richard E., Robert M. Kliegman, and Hal B. Jenson. "Evaluation of the Cardiovascular System." Nelson's Textbook of Pediatrics. 18th ed. Philadelphia: W. B. Saunders, 2007. Print.

3. Park, Myung K. Park's Pediatric Cardiology for Practitioners. Philadelphia: Elsevier, 2014. Print.

If at any time patient develops signs/symptoms that make more urgent evaluation important, please alert Pediatric Cardiology (512-454-1110) to this change in status or go to the Emergency Room.