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"Child`s Health" 2 (61) 2015

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Cardiac murmurs in children.

Authors: O.P. Volosovets, S.P. Kryvopustov, O.L. Kovalchuk, T.I. Shevtsova, A.V. Kupkina
O. O. Bogomolets National Medical University, Kyiv, Ukraine

Categories: Pediatrics/Neonatology

Sections: Clinical researches

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Auscultation of the heart  can be performed  in children with using pediatric stethoscope in the position of a child standing, lying down, including lying  on the left side, with normal breathing, holding the breath you exhale, after physical activity (in children of appropriate age).
After listening to the main points of auscultation it should be listening the whole area of the heart. Tones of the heart must be  taken into account primarily, and then additional  auscultative phenomenas  might be estimated, including murmurs. Murmurs are additional sounds which might occur in process of auscultation and they can be listened between the tones of the heart during systole and diastole. Heart murmurs are usually characterize on such indicators as: the phase of their occurrence, epicenter, intensity, timbre, irradiation, dependence on the phase of respiration, dependence on the position of the child, from physical exertion and others.
Systolic murmur has 6 degrees of intensity. Intensity of the systolic murmur might be represented as a fraction: the numerator of the fraction is the intensity and the denominator is the number VI - maximum intensity. I / VI - very weak, cardiac thrill is absent; II / VI - auscultation a lot of easier, medium-intensity, without cardiac thrill; III / VI - strong intensity, but  cardiac thrill yet no; IV / VI - loud murmur, the presence of cardiac thrill; V / VI - very loud murmur with cardiac thrill, phonendoscope touches the chest part; VI / VI - very loud murmur with cardiac thrill, phonendoscope do not touches the chest (remote). Diastolic murmur has 4 degrees of intensity: I / IV - barely audible; II / IV - audible but quiet; III / IV - well heard; IV / IV - loud.
Extracardiac murmurs appear because of causes that are outside of the heart, for example: pericardial friction murmur, the murmur of the pulmonary artery in the area of bifurcation, cardio-pulmonary murmurs, murmurs on anemia, pleuropericardial murmurs. The appearance of organic intracardial murmurs associated with the presence of congenital or acquired anatomical changes. They appear in particular by incomplete closing valves, narrowing holes in congenital heart defects, when blood is flowing in the wrong direction (defect of interventricular septum, patent ductus arteriosus, etc.). There are numerous examples of organic murmurs. 
Intracardiac functional murmurs may occur in children who have not structural pathology of the cardiovascular system. Functional murmurs are usually systolic, but pansystolic murmur should be recognized as organic murmur. Diastolic murmurs are usually always organic murmurs. It should be remembered about intracardiac murmurs which are caused by "small" abnormalities of the heart and blood vessels.The most common variant of functional murmurs is Still’s vibratory murmur.
Primary care physicians often face in their work with the cardiac murmurs in children, therefore the main problem is the differentiation organic and inorganic murmurs.
For example, such features of murmurs as: intensity volume III/VI and more, presence of diastolic or pansystolic murmur, irradiation  are  evidence of pathology and necessity further examination of the child. In this case information received by instrumental methods, primarily electrocardiography, echocardiography, chest radiography is very important.
Consultation of children's cardiologist is recommended in cases where murmur can't  be differentiated clearly by pediatrician or family doctor. For example, some congenital heart defect of the child can be hidden by functional murmur (small patent ductus arteriosus, small precardiac junction, hypoplasia of the aortic isthmus, etc.). So, the primary care doctor, family doctor, pediatrician must timely detect cardiac murmurs, differentiate organic and inorganic murmurs and, if it necessary, timely send a child to additional examination and consultation to children's cardiologist.

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