📊 Epidemiology
• 50-90% of children have an audible murmur at some point
• Most are innocent murmurs
• H&P is standard for diagnosis (not routine echo)
• Refer to cardiology if diagnosis unclear
🩺 Innocent Murmurs
• Still murmur: vibratory, musical, LLSB, age 3-7, diminishes with standing
• Pulmonary flow murmur: soft, systolic, LUSB, normal S2 split
• Venous hum: continuous, infraclavicular/neck, disappears supine or with jugular pressure
• Peripheral pulmonary stenosis (PPS): soft systolic, LUSB/axillae/back, resolves by 6 months
⚠️ Pathologic Murmur Features
• Diastolic murmur (except venous hum)
• Holosystolic murmur
• Grade ≥3 (thrill palpable)
• Abnormal S2 (fixed split, single, loud P2)
• Associated symptoms: poor feeding, failure to thrive, cyanosis, exercise intolerance
❤️ Common Congenital Lesions
• VSD: most common, holosystolic, LLSB, ± thrill
• ASD: fixed widely split S2, systolic murmur LUSB
• PDA: continuous machinery murmur, bounding pulses
• Coarctation: diminished femoral pulses, HTN, systolic murmur back
• PS: ejection click, systolic murmur, right ventricular heave
📌 Decision strategy: Innocent murmurs diagnosed by characteristic features + normal H&P. Any concerning feature (diastolic, grade ≥3, abnormal S2, symptoms) → cardiology referral or echo.