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Pediatric Cardiac History & Physical Exam

Scope

This topic focuses on how to take a pediatric cardiac history and perform the non-auscultatory cardiac exam, recognize red flags, and decide urgency/next step (emergent evaluation vs cardiology referral vs routine follow-up).

Auscultation interpretation is intentionally deferred to:

Learning Objectives

Core Knowledge & Clinical Reasoning

  • [ ] Obtain a focused cardiac history including key red flag symptoms and high-yield family history
  • [ ] Perform a systematic pediatric cardiac physical exam (inspection, palpation, pulses, perfusion, vitals, oxygenation)
  • [ ] Recognize non-auscultatory exam findings suggestive of cardiac disease (cyanosis, poor perfusion, hepatomegaly, abnormal pulses, BP gradients, precordial heave/thrill)
  • [ ] Identify which findings require urgent evaluation, cardiology referral, or routine follow-up

Systems-Based Practice

  • [ ] Choose appropriate initial next steps based on risk (repeat vitals with correct technique, 4-extremity BP, ECG, urgent ED referral, or cardiology referral)

Cardiac History

Chief Complaint Red Flags

Symptom Cardiac Concerns
Syncope Arrhythmia, obstruction (AS, HCM, AAOCA)
Exertional symptoms Structural disease, arrhythmia
Chest pain Pericarditis, ischemia (rare), arrhythmia
Palpitations SVT, ectopy, WPW
Cyanosis Cyanotic CHD, R→L shunt
Diaphoresis with feeds Heart failure (infants)
Poor weight gain Heart failure
Exercise intolerance CHD, cardiomyopathy, arrhythmia

Key History Questions

Symptoms

  • Exercise tolerance compared to peers?
  • Syncope or near-syncope? (triggers, prodrome, exertional?)
  • Chest pain? (exertional, positional, reproducible?)
  • Palpitations? (sudden onset/offset, duration, frequency?)
  • Cyanosis or blue spells?
  • Shortness of breath? Orthopnea?
  • Diaphoresis with feeds? (infants)

Birth/Neonatal History

  • Prenatal diagnosis of CHD?
  • Gestational age?
  • CCHD screening result?
  • NICU stay? Why?

Past Medical History

  • Known heart disease or murmur?
  • Kawasaki disease?
  • Rheumatic fever?
  • Genetic syndrome?
  • Prior cardiac surgery or catheterization?

Family History (CRITICAL)

Ask About Concern
Sudden cardiac death <50 years HCM, channelopathy, ARVC
Cardiomyopathy Inherited cardiomyopathy
Pacemaker or defibrillator Channelopathy, heart block
Drowning or unexplained accident LQTS, CPVT
Early coronary disease <55y Familial hyperlipidemia
Congenital heart disease Increased recurrence risk
Marfan or connective tissue disorder Aortopathy

Medications

  • QT-prolonging drugs?
  • Stimulants (ADHD medications)?
  • Current cardiac medications?

Vital Signs by Age

Heart Rate

Heart rate depends on state (awake/asleep, fever, pain, anxiety). If the rate is persistently outside expected ranges at rest, reassess and consider secondary causes. (PALS 2025)

Age Awake (bpm) Sleeping (bpm)
Neonate 100–205 90–160
Infant 100–180 90–160
Toddler 98–140 80–120
Preschooler 80–120 65–100
School-age child 75–118 58–90
Adolescent 60–100 50–90

Blood Pressure

Technique first: correct cuff size, calm child, repeat manually if elevated.

Always measure in the right arm; if abnormal, obtain 4-extremity BP.

  • Hypertension classification (percentiles <13y; adult-style thresholds ≥13y) is covered in Pediatric Hypertension
  • Hypotension (red flag) quick rule (PALS):
  • Term neonate (0–28d): SBP <60
  • Infant (1–12mo): SBP <70
  • Child 1–10y: SBP <70 + (2 × age in years)
  • Children >10y: SBP <90 mm Hg

Respiratory Rate

Interpret with clinical context (work of breathing, retractions, feeding tolerance). (PALS 2025)

Age Normal (breaths/min)
Infant 30–53
Toddler 22–37
Preschooler 20–28
School-age child 18–25
Adolescent 12–20

Oxygen Saturation

  • Normal (room air): typically ≥95%
  • For newborn CCHD screening protocol details, see CCHD Screening

Physical Examination

General Inspection

Finding Significance
Cyanosis R→L shunt, cyanotic CHD
Clubbing Chronic hypoxemia/cyanotic physiology
Pallor Anemia, poor perfusion
Diaphoresis Heart failure, increased work
Respiratory distress Heart failure, pulmonary edema
Peripheral edema Heart failure (more common in older children/teens), nephrotic syndrome
Failure to thrive Chronic heart failure
Dysmorphic features Syndrome-associated CHD
Marfanoid habitus Aortopathy risk

Syndromic Features

Syndrome Cardiac Associations
Down syndrome AVSD, VSD (40-50% have CHD)
Turner syndrome Coarctation, bicuspid aortic valve
Williams syndrome Supravalvar AS, peripheral/branch PA stenosis
Noonan syndrome Pulmonary stenosis, HCM
DiGeorge (22q11) Truncus, IAA, TOF
Marfan syndrome Aortic root dilation, MVP

Precordial Inspection & Palpation

Inspection

  • Prominent/hyperdynamic precordium (especially infants)
  • Visible apex beat
  • Surgical scars

Palpation

  • PMI location: Normally 4th-5th ICS, MCL
  • Displaced = cardiomegaly
  • Heaves/Lifts:
  • Sustained parasternal heave (LLSB) → RV hypertrophy/pressure load (RV outflow obstruction, pulmonary hypertension)
  • Displaced/hyperdynamic apical impulse → LV dilation/volume load; sustained "heaving" apex suggests LV pressure load
  • Thrill: Palpable vibration suggesting hemodynamically significant turbulent flow → pathologic; escalate evaluation (see Heart Sounds & Murmurs for characterization)

Pulse Assessment

Rate and Rhythm

  • Regular vs irregular
  • Respiratory variation (sinus arrhythmia - normal)

Quality and Volume

Finding Significance
Bounding pulses PDA, AI, high-output state
Weak/thready pulses Poor cardiac output, shock
Pulsus paradoxus (>10 mmHg drop with inspiration) Tamponade, severe asthma
Pulsus alternans Severe LV dysfunction

Femoral Pulses (CRITICAL)

  • Always palpate in infants and hypertensive children
  • Weak/delayed = Coarctation until proven otherwise
  • Compare radial-femoral simultaneously

Board Pearls

Pearl: Always check femoral pulses

Weak/delayed radial-femoral = coarctation until proven otherwise. Essential in infants and any hypertensive child.

Pearl: 4-extremity BP for suspected coarctation

A meaningful upper-to-lower gradient supports coarctation. Note: neonates with ductal physiology can have blunted gradients—use pulses and perfusion too.

Pearl: Family history of SCD, drowning, or unexplained accident = screen the child

Even if asymptomatic, obtain ECG at minimum. Consider cardiology referral for further evaluation.

Pearl: Diaphoresis with feeds = heart failure in infants

Classic symptom of large left-to-right shunts (VSD, AVSD) as PVR drops at 4-8 weeks.

Self-Assessment

Q1: A 3-month-old is noted to have weak femoral pulses and a BP of 90/60 in the right arm. Lower extremity BP is 60/40. What is the most likely diagnosis?

Answer **Answer**: Coarctation of the aorta **Rationale**: Upper-to-lower extremity BP gradient >20 mmHg with weak femoral pulses is classic for coarctation.

Q2: According to AHA screening recommendations, what family history findings should prompt cardiac evaluation even in an asymptomatic child?

Answer **Answer**: - Sudden cardiac death in a relative <50 years - Known cardiomyopathy in a first-degree relative - Drowning or unexplained sudden death (possible channelopathy) - Early coronary disease <55 years (familial hyperlipidemia) - Marfan or connective tissue disorder **Rationale**: These suggest heritable conditions (HCM, channelopathies, familial hyperlipidemia) that may be present in the child.

Q3: A 6-week-old presents with poor feeding, diaphoresis during feeds, and failure to thrive. What cardiac condition should you suspect?

Answer **Answer**: Heart failure (likely from large left-to-right shunt such as VSD) **Rationale**: As PVR drops at 4-8 weeks, large shunts cause pulmonary overcirculation and heart failure symptoms.

Key Guidelines

AAP 2017 Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents Pediatrics. 2017;140(3):e20171904 PMID: 28827377

CDC/AAP CCHD Pulse Oximetry Screening Algorithm Pass/fail criteria for newborn screening CDC CCHD Screening

AHA 14-Element Cardiovascular Screening Checklist History and physical exam red flags for pre-participation screening

References

  • Flynn JT, et al. Pediatrics. 2017;140(3):e20171904 (AAP HTN Guideline)
  • PALS 2025 Guidelines - AHA Pediatric Advanced Life Support (vital signs by age)
  • CDC. Critical Congenital Heart Defects Screening. Last updated Dec 15, 2025
  • AHA Policy Guidance: Cardiovascular Preparticipation Screening of Student-Athletes. Updated March 2025. AHA.org
  • Park MK. Pediatric Cardiology for Practitioners, 7th ed.