Title: Pediatric Cardiology / Innocent Murmurs
Tags: innocent-murmur innocent-murmurs peds-cardio high-yield stills physical-exam venous-hum arterial-bruit counseling diagnosis differential newborn pps prognosis pulmonary-flow red-flags referral s2 workup

Q: What are the 6 S's of innocent murmurs?
A: Soft, Short, Systolic, Single S2, Symptom-free, no abnormal Sounds (no clicks, no gallops)

Q: What is the most common innocent murmur in children aged 3-7 years?
A: Still's murmur - low-pitched, vibratory/musical, grade 1-2/6, best at LLSB, louder supine

Q: What is the typical location and quality of a Still's murmur?
A: LLSB to apex, vibratory/musical ("twanging string"), low-frequency, grade 1-2/6

Q: What innocent murmur is heard at the upper sternal borders in children?
A: Pulmonary flow murmur - soft, ejection quality at LUSB, no click, normal S2 split

Q: What causes a venous hum and where is it heard?
A: Turbulent flow in jugular veins; heard at right (or left) supraclavicular area; continuous but disappears with head turning or supine position

Q: How do you distinguish a venous hum from a PDA murmur?
A: Venous hum: disappears with head turning, lying supine, or gentle jugular compression. PDA murmur: continuous machinery murmur at left infraclavicular area, doesn't change with position

Q: What maneuver increases the intensity of most innocent murmurs?
A: Supine position, fever, anemia, anxiety, exercise (anything that increases cardiac output)

Q: What murmur characteristics suggest pathology rather than innocence?
A: Diastolic murmur, holosystolic murmur, harsh quality, grade 3+, abnormal S2, associated click, radiation to back/neck, thrill, symptoms

Q: Do innocent murmurs require echocardiography?
A: NO - if classic innocent murmur features are present and no concerning findings, echo is not needed

Q: What is a peripheral pulmonary stenosis (PPS) murmur and when is it heard?
A: Soft systolic murmur radiating to axillae and back; common in newborns due to acute angle of branch PAs; resolves by 6 months

Q: What innocent murmur may be heard in a thin, athletic adolescent?
A: Supraclavicular arterial bruit - harsh, brief, heard above clavicles, decreased by shoulder hyperextension

Q: At what age does Still's murmur typically resolve?
A: Often disappears by adolescence

Q: What is the significance of a normal S2 in evaluating a murmur?
A: Normal S2 split (widens with inspiration) essentially rules out significant structural heart disease; fixed split suggests ASD

Q: When should you refer a child with a murmur to cardiology?
A: Diastolic murmur, holosystolic murmur, symptoms (cyanosis, failure to thrive, exercise intolerance), abnormal S2, associated abnormalities, grade ≥3/6 murmur

Q: What do you tell parents about innocent murmurs?
A: "Your child's heart is completely normal. The murmur is just the sound of normal blood flowing through a healthy heart. No restrictions, no follow-up needed, and it will likely go away as they grow."