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Papunen I, Poutanen T, Ylänen K. Major congenital heart defects are rarely diagnosed after newborns' hospital discharge with modern screening. Acta Paediatr 2024; 113:143-149. [PMID: 37522553 DOI: 10.1111/apa.16928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/16/2023] [Accepted: 07/28/2023] [Indexed: 08/01/2023]
Abstract
AIM Our aim was to assess undiagnosed congenital heart defects (CHD) after newborns' hospital discharge in patients with a murmur or CHD suspicion, to find out the signs that predict CHDs and to estimate the costs of the examinations. METHODS We reviewed retrospective medical records of patients (n = 490) referred for the evaluation of CHD suspicion during 2017-2018. RESULTS The median age of the patients was 2.5 (IQR 0.5-7.4) years. Sixty-three (13%) patients had an abnormal echocardiography. Neither ductal-dependent nor cyanotic CHDs were found. Cardiac interventions were performed for 14 out of 63 (22%) patients. Clinical signs indicating CHDs were murmur grade ≥3 (10/11 [91%] vs. 53/479 [11%], p < 0.001) and harsh murmur (15/44 [34%] vs. 48/446 [11%], p < 0.001). Abnormal electrocardiography did not indicate CHD (8/40 [20%] vs. 55/447 [12%], p = 0.165). The total cost of the examinations was 259 700€. The share of the cost of studies assessed as benign was 59%. CONCLUSION Only a few CHDs were found after newborn hospital discharge among patients who received foetal and newborn screening and were examined due to CHD suspicion. The high number of benign murmurs in children leads to many referrals, resulting in unnecessary healthcare costs.
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Affiliation(s)
- I Papunen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - T Poutanen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - K Ylänen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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Akrivopoulou G, Fouzas S, Gkentzi D, Galanopoulou K, Dimitriou G, Karatza AA. Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography. J Reprod Infant Psychol 2022; 40:412-419. [PMID: 34369214 DOI: 10.1080/02646838.2021.1959023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Previous studies in children with innocent murmurs have shown that parental concern is common. METHODS We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation. RESULTS The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient β = - 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (β = 0.312; P < 0.001). CONCLUSION In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.
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Affiliation(s)
- Georgia Akrivopoulou
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
| | - Sotirios Fouzas
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
| | - Despoina Gkentzi
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
| | - Katerina Galanopoulou
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
| | - Ageliki A Karatza
- Depatrment of Paediatrics, Neonatal Intensive Care Unit, University of Patras Medical School, Patras, Greece
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Precordial ECG Amplitudes in the Days After Birth: Electrocardiographic Changes During Transition from Fetal to Neonatal Circulation. Pediatr Cardiol 2021; 42:832-839. [PMID: 33507333 DOI: 10.1007/s00246-021-02547-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
During the first month of life, the relation between right and left ventricular function is markedly altered. We aimed at describing the electrocardiographic transition from fetal to neonatal circulation by investigating changes in R- and S-wave amplitudes in V1 and V6 during the first 4 weeks of life. This study is part of the prospective, population-based Copenhagen Baby Heart Study offering cardiac evaluation to newborns within 28 days from birth. ECGs were obtained and analyzed using a computerized algorithm. A total of 14,577 newborns (52% boys), median age of 11.0 days, were included. All had normal echocardiograms. Within 28 days from birth, the amplitudes in V1 decreased: R-V1 (1262 µV day0; 947 µV day28, p < 0.001) and S-V1 (1240 µV day0; 473 µV day28, p < 0.001). An increase was observed for R-V6 (825 µV day0; 1196 µV day28, p = 0.002), while S-V6 decreased (830 µV day0; 634 µV day28, p = 0.003). For all amplitudes, interindividual variation was large (up to 20 times). The amplitudes were not affected by sex (p > 0.05), but R-V1, R-V6, and S-V6 positively correlated with newborn weight (p < 0.01). R-V1 and S-V6 showed positive correlation with gestational age (p < 0.05). In conclusion, systematic analyses of ECGs from healthy newborns showed significant decreases in R-V1, S-V1, and S-V6 amplitudes, while R-V6 increased. Interindividual variation was large, making ECGs unlikely as a sensitive tool for diagnosing congenital heart diseases. Our data may serve as updated, digitalized reference values in newborns.
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Yoon SA, Hong WH, Cho HJ. Congenital heart disease diagnosed with echocardiogram in newborns with asymptomatic cardiac murmurs: a systematic review. BMC Pediatr 2020; 20:322. [PMID: 32605548 PMCID: PMC7325562 DOI: 10.1186/s12887-020-02212-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 06/16/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND More than 50% of newborns with congenital heart disease (CHD) are unrecognized at birth; however, the use of echocardiogram (Echo) for diagnosing CHD in newborns with asymptomatic, non-syndromic cardiac murmurs (ANCM), has not been systematically reviewed yet. We aimed to identify the incidence of CHD diagnosed with Echo and systematically review whether Echo should be recommended in this patient group. METHODS The methodology utilized in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Using the MEDLINE, EMBASE, Web of Science, and Cochrane Library databases, we performed a systematic review of publications reporting CHD diagnosed with Echo in newborns with cardiac murmurs. The quality of the included studies was evaluated using the Study Quality Assessment Tools developed by the National Institutes of Health. RESULTS Of the 630 studies screened, six cohort studies, four cross-sectional studies, and two case reports were included in this review. The incidence of cardiac murmurs ranged from 0.6-8.6%. Among the 1928 newborns with ANCM, 719 (37.3%) were diagnosed with Echo as having CHD, and ventricular septal defect was the most common congenital malformation. More than 50% of the newborns showed moderate CHD necessitating outpatient cardiology follow-up, and 2.5% had severe CHD requiring immediate interventions, such as cardiac catheterization and heart surgery. CONCLUSIONS In this systematic review, a high incidence of CHD in newborns with ANCM was detected using Echo. This indicates that the use of Echo for diagnosing CHD in healthy newborns with cardiac murmurs could be helpful in earlier detection of CHD, thereby improving clinical outcomes for newborns with severe CHD.
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Affiliation(s)
- Shin Ae Yoon
- Department of Pediatrics, Chungbuk National University Hospital, (28644) 1 Chungdae-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do South Korea
| | - Woi Hyun Hong
- College of Medicine, Medical Research Information Center, Chungbuk National University, (28644) 1 Chungdae-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do South Korea
| | - Hwa Jin Cho
- Department of Pathology, Inje University Busan Paik Hospital, (47392) 75 Bokji-ro, Busanjin-gu, Busan, South Korea
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Accuracy of cardiac auscultation in detection of neonatal congenital heart disease by general paediatricians. Cardiol Young 2019; 29:679-683. [PMID: 31012400 DOI: 10.1017/s1047951119000799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Challenges remain in the judgement of pathological murmurs in newborns at maternity hospitals, and there are still many simple major CHD patients in developing countries who are not diagnosed in a timely fashion. This study aimed to evaluate the accuracy of cardiac auscultation on neonatal CHD by general paediatricians. METHODS We conducted a prospective study at three hospitals. All asymptomatic newborns underwent auscultation, pulse oximetry monitoring, and echocardiography. Major CHD was classified and confirmed through follow-up. We evaluated the accuracy of various degrees of murmurs for detecting major CHD to determine the most appropriate standards and time of auscultation. RESULTS A total of 6750 newborns were included. The median age of auscultation was 43 hours. Cardiac murmurs were identified in 6.6% of newborns. For all CHD, 44.4% had varying degrees of murmurs. A murmur of grade ≥2 used as a reference standard for major CHD had a sensitivity of 89.58%. The false positive rate of murmurs of grade ≥2 for detecting major CHD was significantly negatively related to auscultation time, with 84.4% of false positives requiring follow-up for non-major CHD cardiac issues. Auscultation after 27 hours of life could reduce the false positive rate of major CHD from 2.7 to 0.9%. CONCLUSIONS With appropriate training, maternity hospital's paediatricians can detect major CHD with high detection rates with an acceptable false positive rate.
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Ip HL, Menahem S. Does Echocardiography Have a Role in the Cardiologist's Diagnosis of Innocent Murmurs in Childhood? Heart Lung Circ 2019; 29:242-245. [PMID: 30876810 DOI: 10.1016/j.hlc.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/20/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Innocent murmurs are common in childhood. Echocardiography may diagnose almost all congenital cardiac abnormalities. Earlier studies have suggested that it may be unnecessary when a clinical diagnosis of an innocent murmur is made by an experienced cardiologist. Yet, echocardiography is commonly performed despite such a diagnosis. Is that justifiable? METHODS Patients referred to a paediatric cardiologist for evaluation of a murmur were assessed. If an innocent murmur was clinically diagnosed, an echocardiogram and an electrocardiogram were ordered when requested. The cardiologist completed a questionnaire documenting the reasons for the investigations and his degree of confidence in the clinical diagnosis. The parents and patients were informed of the diagnosis and the results of the investigations. RESULTS In almost all 62 cases whose murmurs were clinically considered to be innocent, the referring doctor expected an echocardiogram to be performed. Following echocardiography, one patient was found to have a small muscular ventricular septal defect. On review, the murmur was consistent with that diagnosis. Three (3) others had abnormal echocardiograms namely congenitally corrected transposition of great arteries, partial anomalous right upper lobe pulmonary vein, and left ventricular non-compaction. All on review were still considered clinically to have innocent murmurs. CONCLUSIONS Despite the competency of the cardiologist, echocardiography diagnosed important but relatively uncommon cardiac abnormalities with prognostic implications that would have been missed if only the clinical examination was performed. Over and above the referring doctor's expectations for an echocardiogram to be performed is the need for the cardiologist to provide a complete and definitive diagnosis.
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Affiliation(s)
- Hiu L Ip
- Melbourne Clinical of School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia
| | - Samuel Menahem
- School of Clinical Sciences, Monash Health, Monash University, Melbourne, Vic, Australia.
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Kostopoulou E, Dimitriou G, Karatza A. Cardiac Murmurs in Children: A Challenge For The Primary Care Physician. Curr Pediatr Rev 2019; 15:131-138. [PMID: 30907325 DOI: 10.2174/1573396315666190321105536] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/22/2018] [Accepted: 03/14/2019] [Indexed: 02/08/2023]
Abstract
Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
| | - Ageliki Karatza
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
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Fenster ME, Hokanson JS. Heart murmurs and echocardiography findings in the normal newborn nursery. CONGENIT HEART DIS 2018; 13:771-775. [PMID: 30039518 DOI: 10.1111/chd.12651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the clinical findings and management implications of echocardiograms performed on infants with murmurs in the nursery. DESIGN Retrospective cohort study conducted from January 2008 through December 2015. Patients in the study were followed by chart review for up to 5 years. In addition, a survey of nursery providers was conducted in February 2016. SETTING A single community hospital associated with a university. PATIENTS All 26 573 infants who received care in the normal newborn nursery were eligible for inclusion in the study. Infants with echocardiograms were analyzed. The survey was sent by e-mail to all 135 physicians who work in the nursery. OUTCOME MEASURES The primary outcomes include the specific findings on echocardiogram and whether the findings required an acute change in management, outpatient follow up, or were incidental findings. The primary survey question was how physicians would manage an otherwise asymptomatic newborn with a heart murmur. RESULTS Four hundred ninety-nine infants had echocardiograms, and over the study period the utilization of echocardiography increased from 1.02% to 2.56% (P < .001) of all infants. Three hundred fifty-four babies had echocardiography performed because of a heart murmur. One hundred sixty-three (46.0%) of these echocardiograms were normal and 160 (45.2%) had findings that did not require additional care. Twenty-three neonates (6.5%) had echocardiographic findings that necessitated outpatient follow-up and 8 neonates (2.3%) required neonatal intensive care due to the findings on their echocardiogram. In total, 14 infants (4%) would go on to require heart surgery or interventional cardiac catheterization. 63/135 (47%) physicians completed the survey, with wide variations in the management of newborns with heart murmurs. CONCLUSIONS The use of echocardiography in the normal newborn nursery has increased with time despite improved prenatal detection of heart disease and the use of pulse oximetry screening, and identifies significant heart disease in a small but important number of infants.
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Affiliation(s)
- Michael E Fenster
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - John S Hokanson
- Division of Pediatric Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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Abstract
An asymptomatic child with a murmur can be challenging practice management conundrum. Some providers refer all patients with a "new" murmur to a cardiologist, likely resulting in excessive resource utilization and parental anxiety. This study examines whether the prevalence of significant cardiac pathology differs in asymptomatic patients aged 2 to 18 years who were referred for a murmur that was "new" versus those referred for a murmur that was known to exist and followed conservatively during the previous 2 years. Of 473 patients meeting inclusion criteria, 33/473 (7.0%) were diagnosed with cardiac pathology, with 21/357 (5.9%) occurring among "new" murmur referrals and 12/116 (10.3%) occurring among "known" murmur referrals. Notably, 34/357 (9.5%) patients referred for a "new" murmur had no murmur present when assessed by the cardiologist. This study suggests that asymptomatic children with a "new" murmur may be conservatively managed. This may lessen health care resource utilization rates and overall parental anxiety.
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Affiliation(s)
- Lisa J Gupta
- 1 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Joseph W May
- 1 Walter Reed National Military Medical Center, Bethesda, MD, USA
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10
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Lai LS, Redington AN, Reinisch AJ, Unterberger MJ, Schriefl AJ. Computerized Automatic Diagnosis of Innocent and Pathologic Murmurs in Pediatrics: A Pilot Study. CONGENIT HEART DIS 2016; 11:386-395. [DOI: 10.1111/chd.12328] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Lillian S.W. Lai
- Children's Hospital of Eastern Ontario, University of Ottawa; Ottawa Ontario Canada
| | - Andrew N. Redington
- The Heart Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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Abstract
OBJECTIVES We sought to benchmark the utilisation of echocardiography in the outpatient evaluation of heart murmurs by evaluating two large paediatric cardiology centres. BACKGROUND Although criteria exist for appropriate use of echocardiography, there are no benchmarking data demonstrating its utilisation. METHODS We performed a retrospective cohort study of outpatients aged between 0 and 18 years at the Sibley Heart Center Cardiology and the Children's Hospital of Philadelphia Division of Cardiology, given a sole diagnosis of "innocent murmur" from 1 July, 2007 to 31 October, 2010. Using internal claims data, we compared the utilisation of echocardiography according to centre, patient age, and physician years of service. RESULTS Of 23,114 eligible patients (Sibley Heart Center Cardiology: 12,815, Children's Hospital of Philadelphia Division of Cardiology: 10,299), 43.1% (Sibley Heart Center Cardiology: 45.2%, Children's Hospital of Philadelphia Division of Cardiology: 40.4%; p1-5 years had the lowest utilisation (32.7%). CONCLUSIONS In two large paediatric cardiology practices, the overall utilisation of echocardiography by physicians with a sole diagnosis of innocent murmur was similar. There was significant and similar variability in utilisation by provider at both centres. Although these data serve as initial benchmarking, the variability in utilisation highlights the importance of appropriate use criteria.
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Khalilian M, Malekian A, Aramesh M, Dehdashtian M, Maryam T. Innocent versus pathologic murmurs: A challenge of neonatal examination. J Clin Neonatol 2016. [DOI: 10.4103/2249-4847.191254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
This article presents an approach for identification of infants with congenital heart disorders. These disorders are difficult to diagnose because of the complexity and variety of cardiac malformations; additionally presentation can be complicated by age-dependent physiology. By compiling data from the history and the physical examination, the emergency physician can identify lesion category and initiate stabilization procedures. Critical congenital cardiac lesions can be classified as left-sided obstructive ductal dependent, right-sided obstructive ductal dependent, and shunting or mixing. The simplified approach categorizes infants with these lesions respectively as "pink," "blue," or "gray." The emergency provider can provide life-saving stabilization until specialized care can be obtained.
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Szatmári V, van Leeuwen MW, Teske E. Innocent Cardiac Murmur in Puppies: Prevalence, Correlation with Hematocrit, and Auscultation Characteristics. J Vet Intern Med 2015; 29:1524-8. [PMID: 26415555 PMCID: PMC4895663 DOI: 10.1111/jvim.13632] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 08/14/2015] [Accepted: 09/01/2015] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The aims of this study were to establish the prevalence of innocent cardiac murmurs in clinically healthy puppies, to investigate a possible correlation between the presence of an innocent murmur and hematocrit, and to describe the auscultation characteristics of innocent murmurs. HYPOTHESIS Lower hematocrit contributes to the genesis of innocent murmurs. ANIMALS Five hundred and eighty-four client-owned clinically healthy puppies, between 20 and 108 days old. METHODS Two cross-sectional surveys with a 1-year (n = 389 pups) pilot and a half-year (n = 195 pups) principal study periods. Cardiac auscultation was performed by a single, board-certified cardiologist. Hematocrit was measured with an automatized hematology analyzer. Echocardiography was performed only on puppies with a cardiac murmur in the principal study. RESULTS In the pilot study, 15% of the dogs had a murmur. Innocent murmur was diagnosed in 28% of the 195 dogs in the principal study. Innocent murmurs were systolic, mostly with a musical character and with a maximal intensity of 2 of 6, and mostly with the point of maximal intensity in the left cardiac base. The hematocrit was significantly lower in the group with a murmur compared to the group without (P = .023). CONCLUSIONS AND CLINICAL IMPORTANCE Innocent murmur was a common finding in puppies at the age when the first veterinary controls usually take place. Physiologic anemia contributes to the genesis of innocent murmurs in puppies. Rising hematocrit in growing puppies can explain the spontaneous disappearance of innocent murmurs with aging. Hematocrit did not differentiate innocent murmurs from abnormal murmurs.
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Affiliation(s)
- V Szatmári
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - M W van Leeuwen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - E Teske
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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Abstract
The first-time appearance of a murmur in an adolescent can create a substantial amount of anxiety in the parents and the teenager. The appropriate evaluation and diagnosis is very important in decision-making regarding sports participation in this population. Accurate identification of the innocent murmurs can obviate the need for echocardiography. Identification of a pathologic murmur may reduce morbidity and, possibly, mortality in critical lesions such as hypertrophic cardiomyopathy. This article discusses the physiology and characteristics of different murmurs, and outlines an approach to cardiac murmurs in adolescents.
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Affiliation(s)
- Ronak J Naik
- Division of Cardiology, Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 50 North Dunlap Avenue, Level 3, Memphis, TN 38103, USA
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16
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Abstract
Cardiac murmurs can be a source of anxiety for both physicians and parents until serious cardiac disorders are excluded. The innocent cardiac murmur is still the most common finding in healthy children and can usually be diagnosed through obtaining a complete history and performing a complete physical examination. However, a cardiac murmur may be the first sign of a structural cardiac disease and should not be ignored. Referral to a pediatric cardiologist for further evaluation is required when murmur assessment is not clear and diagnostic uncertainty is present. Educating and reassuring parents remains an important aspect of this evaluation. This article discusses features of innocent and pathological murmurs and provides an approach to cardiac murmurs in children.
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Affiliation(s)
- Yousef Etoom
- 1The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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17
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O’Reilly KM, Hall FM, Richens T, Cunningham C, Simpson JH. An audit of the management of heart murmurs on the postnatal wards. Scott Med J 2013; 58:e11-4. [DOI: 10.1177/0036933012474603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Investigation and management of neonatal heart murmurs varies widely and is dependent on local resources. In order to standardise the management of heart murmurs in our hospital a guideline (based on clinical examination with selective cardiology review) was introduced. Aims To establish adherence to and safety of the guideline; to review workload implications and to define the causes of neonatal heart murmurs in our population. Methods Patients were prospectively identified over a 2-year period (August 2006 to July 2008). Case notes were reviewed and examination findings, investigations, follow up and diagnosis recorded. Results 89 babies were identified. The guideline was generally well adhered to. In total 51 (57%) of babies were referred for cardiology assessment. In 40 babies this assessment included an echocardiogram. 30 babies (34%) had an underlying cardiac malformation: 25 were identified before discharge home. 15/30 (50%) of the babies with a cardiac malformation remain under cardiology follow up at the age of 1 year. No baby discharged from follow up without cardiology review subsequently presented with a cardiac problem. Conclusion A significant minority of babies with a heart murmur have an underlying cardiac malformation. Our guideline appears to ensure the timely identification of these babies and rationalises our use of specialist services.
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Affiliation(s)
- KM O’Reilly
- Consultant Neonatologist, Neonatal Unit, Southern General Hospital, UK
| | - FM Hall
- Consultant Neonatologist, Royal Hospital for Sick Children, UK
| | - T Richens
- Consultant Paediatric Cardiologist, University Hospital Southampton Foundation Trust, UK
| | - C Cunningham
- Paediatric Specialty Trainee, Royal Hospital for Sick Children
| | - JH Simpson
- Consultant Neonatologist, Royal Hospital for Sick Children, UK
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Abstract
AIM To review the findings and outcomes of predischarge echocardiography service for postnatal heart murmurs provided by neonatologists. METHODS We retrospectively reviewed all predischarge echocardiograms performed on babies from the postnatal wards (PNW) over the last 3 years. We evaluated the indications, median age, findings and outcome. RESULTS A total of 408 echocardiograms were performed on 350 babies on the PNW. The most common indication was presence of a murmur (58%). In babies with a heart murmur, 26% had a normal echocardiogram, 2% had major structural heart defects, 38% had minor structural heart defects and 34% had transient circulatory changes. 32% were discharged with no follow-up, 28% were followed up in the local cardiac clinic and 40% were referred to the cardiologist. CONCLUSION Predischarge echocardiography service for postnatal heart murmurs provided by neonatologists has the benefit of providing an early diagnosis, counselling of the parents and arranging appropriate follow-up. It helps to triage the referrals to the cardiologist. We felt that we were able to alleviate parental anxieties by providing a definitive diagnosis and written information prior to discharge from hospital. We strongly believe that this service should only be provided by those appropriately trained and skilled in echocardiography.
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Affiliation(s)
- Anju Singh
- Neonatal Intensive Care Unit, Birmingham Women's Hospital, Edgbaston, Birmingham, UK.
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Karatza AA, Fouzas S, Tzifas S, Mermiga A, Dimitriou G, Mantagos S. Accuracy of cardiac auscultation in asymptomatic neonates with heart murmurs: comparison between pediatric trainees and neonatologists. Pediatr Cardiol 2011; 32:473-7. [PMID: 21327893 DOI: 10.1007/s00246-011-9905-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 01/31/2011] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess whether cardiac auscultation performed by pediatric trainees and neonatologists can reliably distinguish innocent from pathologic heart murmurs in asymptomatic neonates. From January 2008 to April 2009 the pediatric trainees of our institution were requested to refer all asymptomatic neonates with a murmur and classify the murmurs as "innocent," "pathologic," or "possibly pathologic." Prior to echocardiography, each neonate was evaluated by two experienced neonatologists. The echocardiographic studies of 169 neonates were analyzed. Abnormal cardiac anatomy was found in 55 neonates (32.6%). The overall ability of pediatric trainees in identifying congenital heart disease (CHD) was moderate [area under the curve (AUC) = 0.855] and significantly lower compared to neonatologists (AUC = 0.919, p = 0.007). However, at "lower" levels of clinical confidence (i.e., clinical diagnosis of possibly pathologic murmurs), pediatric trainees had good ability in excluding CHD (sensitivity 94.6%; negative likelihood ratio = 0.09). The ability of cardiac auscultation for diagnosing CHD in asymptomatic neonates is limited and dependent on the physician's experience and level of clinical confidence. Echocardiography should remain an option for all neonates with a possibly pathologic murmur.
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Affiliation(s)
- Ageliki A Karatza
- Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Patras, Patras, Greece
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Abstract
PURPOSE OF REVIEW Nearing the end of the first decade of this new century, the challenges and changes in the field of outpatient pediatric cardiology continue to accelerate. RECENT FINDINGS To help the general pediatrician and family practice physician become aware of several new care guidelines and practice trends as well as the controversies surrounding them this article reviews recent publications and places them in a larger context. Current guidelines and policy statements for cardiovascular monitoring for children with attention deficit disorder, subacute bacterial endocarditis prophylaxis and follow-up of adults with congenital heart disease are discussed. Trends regarding use of echocardiograms, changing drug therapy for Marfan syndrome, follow-up of infant with complex coronary heart disease, and treatment of obesity are reviewed. SUMMARY It is important for the practicing pediatrician to be aware of these developments, so they can be incorporated into current patient care and increase the physician's ability to answer patient and family questions about these guidelines.
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Teixeira OHP. Distinguishing innocent from pathologic murmurs in neonates. J Pediatr 2009; 155:300; author reply 300-1. [PMID: 19619760 DOI: 10.1016/j.jpeds.2009.03.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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