Pediatric Murmur Evaluation Algorithm¶

flowchart TD
    A[Murmur Detected] --> B{Symptoms Present?}

    B -->|Yes - Cyanosis, CHF,<br/>Poor feeding, FTT| C[Urgent Echo<br/>Cardiology Referral]
    B -->|No - Asymptomatic| D[Characterize Murmur]

    D --> E{Murmur Characteristics}

    E --> F[Systolic]
    E --> G[Diastolic<br/>Always Pathologic]
    E --> H[Continuous]

    G --> C
    H --> I{Location?}
    I -->|Infraclavicular| J[Consider PDA]
    I -->|Other| C
    J --> C

    F --> K{Grade and Quality}

    K -->|Grade 1-2, Vibratory,<br/>LLSB| L[Likely Innocent<br/>Still's Murmur]
    K -->|Grade 1-2, Soft,<br/>LUSB| M[Likely Innocent<br/>Pulmonary Flow]
    K -->|Grade 3+, Harsh,<br/>or Holosystolic| C

    L --> N{Changes with Position?}
    M --> N

    N -->|Decreases standing/Valsalva| O[Supports Innocent]
    N -->|Increases standing/Valsalva| P[Concerning for HCM<br/>Echo indicated]

    O --> Q{Any Red Flags?}

    Q -->|Yes| C
    Q -->|No| R[Reassurance<br/>No Echo Needed]

    P --> C

    style C fill:#ff6b6b
    style R fill:#90EE90

📋 Text Version (if diagram doesn't render)

**Murmur Evaluation Algorithm** 1. **Symptoms Present?** (cyanosis, CHF, poor feeding, FTT) - **YES** → Urgent Echo + Cardiology referral - **NO** → Characterize murmur 2. **Murmur Characteristics:** - Diastolic → Always pathologic → Echo - Continuous → Consider PDA → Echo - Systolic → Check grade and quality 3. **Systolic Murmur:** - Grade 3+, harsh, or holosystolic → Echo - Grade 1-2, vibratory at LLSB → Likely Still's (innocent) - Grade 1-2, soft at LUSB → Likely pulmonary flow (innocent) 4. **Innocent Features Confirmed?** - Decreases with standing/Valsalva → Supports innocent - Increases with standing/Valsalva → Concerning for HCM → Echo 5. **No red flags + innocent features** → Reassurance, no echo needed

Red Flags Requiring Echo¶

Symptoms (cyanosis, CHF, poor feeding, exercise intolerance)
Diastolic murmur
Continuous murmur
Grade ≥3/6 systolic murmur
Holosystolic murmur
Harsh quality
Abnormal S2 (single, loud, fixed split)
Murmur increases with Valsalva/standing
Associated click
Abnormal pulses
Family history of CHD or cardiomyopathy
Syndromic features

Innocent Murmur Features¶

Still's Murmur (Most Common)¶

Musical/vibratory quality
Grade 1-2/6
LLSB location
Decreases with standing
Ages 2-6 years typically

Pulmonary Flow Murmur¶

Soft, blowing
Grade 1-2/6
LUSB
Common in thin children, pregnancy

Venous Hum¶

Continuous but varies with position
Supraclavicular
Disappears lying down
Obliterated by compression

Peripheral Pulmonary Stenosis¶

Infants <6 months
Radiates to axillae/back
Usually resolves by 1 year

When to Refer¶

Urgent Referral¶

Symptomatic infant
Cyanosis
Signs of heart failure

Routine Referral¶

Pathologic murmur features
Family/patient anxiety
Unable to characterize