Dear Dr. Lanny: At our last well-child visit, the pediatrician said he heard a heart murmur. The doctor said we didn’t need to worry about it, but now I wonder if I should get my 6-year-old daughter checked out by a specialist. What exactly is a heart murmur? Is it worth paying for a cardiologist to do more testing and examine her?
A: Congratulations on your new baby. She’s just beautiful, but she has a heart murmur. Or perhaps your first-grader comes home from school with a yellow card from the school nurse that says, “A heart murmur was noted on a recent exam.”
Pretty scary? I’d say so. But the question is “Does it need to be?” The answer is “It depends.”
Heart murmurs are quite common in children. As many as 50 percent of children will have a heart murmur at some point in their childhood, and that murmur may disappear as mysteriously as it first appeared.
Heart murmurs come in two basic types: good and bad. Fortunately the good, also called “innocent,” “benign” or “functional” murmurs, far outnumber the bad. Often, the “bad” murmurs are not really very bad, and will get better by themselves.
Although it would take a few years more than this column to make me or you a pediatric cardiologist, a very short review of the heart may be helpful.
The heart is a muscular organ comprised of four chambers. Two of these chambers, each called an atrium, receive blood from the lungs and the rest of the body and deliver that blood to the two other chambers, the ventricles. The ventricles then pump that blood to the lungs and the rest of the body. There are valves that regulate blood flow into and out of these four chambers. Each cycle of opening and closing of the four heart valves causes the well known “lub-dub” sound and can be thought of as one heartbeat.
Heart rates while at rest vary considerably depending on age and physical condition, but 80 beats per minute can be thought of as average. Eighty beats per minute, 60 minutes per hour, 24 hours per day, 365 days per year, year after year, never stopping. The numbers are staggering. It is truly a wondrous organ.
A heart murmur, regardless of its cause, represents some degree of turbulence as blood flows through the valves or the blood vessels, or through abnormalities in the heart’s anatomy. The most common example of an abnormality in the heart causing a murmur is a ventricular septal defect, or VSD.
The ventricular septum is the wall between the two ventricles, and a defect simply means a hole in that wall. As blood rushes through the VSD it makes a rough-sounding and fairly loud noise—an abnormal rather than an innocent murmur. In the case of innocent murmurs, there are no abnormalities in the heart’s anatomy. It is just a vibratory noise and not to be thought of as heart disease or the forerunner of heart disease.
The VSD may not be serious, but it usually will require referral to a pediatric cardiologist for further evaluation and possible treatment. The innocent murmur requires nothing further and in no way affects your child’s future.
So, back to your question. Should you go to the specialist? In many cases the pediatric cardiologist will not be necessary. Your primary care provider can be trusted to either make a specific diagnosis or to be comfortable following your child’s progress, and referring if it seems appropriate.
If your first-grader has generally been growing consistently, can run around like the other 6-year-olds of similar body type, has healthy color, normal blood pressure, no chest pain or unusual number of significant infections, and the murmur sounds innocent to your doctor, then referral is not needed. Sometimes your doctor may order a chest X-ray or an EKG, but she may not even feel that is necessary. Congenital heart murmurs (meaning those present at birth) lasting beyond the first few days of life are more likely to need the skills and sophisticated equipment of the pediatric cardiologist.
If your concern is not relieved by discussing the murmur with your doctor, this is probably a case where requesting a specialist’s opinion is not unreasonable.
Fortunately, we have a practice of several pediatric cardiologists in Syracuse, and their help would be readily available to you and your doctor.
Dr. Alan Freshman, father of two grown sons, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.
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