Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students

1. Cardiac/cardiovascular
examination in children
-Case based approach
Dr Varsha Atul Shah
Singapore General Hospital

2. Case : Heart murmur
You are asked to see a baby girl in the Emergency
Department. She was born 12 weeks ago after an
uncomplicated pregnancy, had NICU admission for
TTNB for 6 hours after birth. She was discharged
after 3 days of life, with 6 weeks FU appointment.
She defaulted 6 weeks appointment, since she was
asymptomatic and was FU at polyclinic for routine
hep B vaccines at 1 months and 5 in 1 at 3 months.
At 12 weeks, Mum noticed, she has had increasing
difficulty completing bottle feeds, sometimes taking
up to 45 minutes per feed. On examination she
looks breathless. She has a heart murmur.
(a) What else would you look for on examination to
establish whether the murmur is the cause of her
symptoms?

3. •Examine for signs of heart
failure (tachypnoea,
tachycardia, hepatomegaly,
sweating). Respiratory
causes such as pneumonia
are excluded by the lack of
crackles, cough or wheeze
and the absence of fever.

4. • The murmur is loudest at the left sternal
edge and radiates to the apex.
• It has a harsh rasping quality and is
throughout systole.
• The heart sounds are normal.
• A chest radiograph shows cardiomegaly and
plethoric lung fields.
• What is cardiac diagnosis?

6. The nature of the
murmur and the
breathlessness suggest
a left-to-right shunt
through a ventricular
septal defect.

7. • You arrange for a cardiac
echocardiogram on this child.
• It confirms the diagnosis.
• The child is commenced on
diuretic medication.
• A corrective operation is
planned for when the child is
older.

8. What advice would you give the
child’s parents regarding dental
treatment?

9. Dental prophylaxis
The left-to-right shunt across the ventricular septal defect means that the child is
at risk of bacterial endocarditis.
antibiotic prophylaxis is no longer recommended
it is important that parents are advised to keep their child’s teeth and gums
healthy
visit a dentist regularly and to avoid body piercing when she is older.

10. S/S of CCF
in infant
and child:
1. poor feeding, tiredness, lethargy
2. poor weight gain
3. sweating over forehead, cold sweat
4. dyspnea/breathlessness
5. puffy eyelids
6. tachycardia
7. tachypnea
8. Poor perfusion/cyanosis
9. crackles, ronchi
10. hepatomegaly
11. gallop rhythm
12. cardiomegaly on CXR
13. increased pulmonary marking, pulmonary oedema on CXR

11. What are causes of acyanotic heart
disease that present with CCF:

12. What are the
causes of CCF in
neonates:
At birth:
1. Hypoplastic left heart syndrome
2. Severe tricuspid or pulmonary
regurgitation
3. Large systemic AV fistula
Week 1
1. Large PDA in preterm
2. TGA
3. TAPVR below diaphragm
Weeks 1-4
1. Critical AS or PS
2. Preductal COA

13. What are the
non cardiac
causes of
CCF in
neonates:
Non Cardiac causes:
1. Birth asphyxia
2. Metabolic hypoglycaemia, hypocalcaemia
3. Severe anaemia
4. Sepsis
5. Over hydration
Myocardia diseases
1. Myocarditis,
2. cardiomyopathy
Arrhythmias
1. SVT,
2. CHB,
3. AF

14. What are
causes of
acyanotic
heart disease
that present
with CCF
1. Anemia
2. Aortic atresia
3. Aortic stenosis (AS)
4. Arteriovenous malformation
5. Coarctation of the Aorta (COA)
6. Complete arteriovenous canal
7. Cor pulmonale caused by
bronchopulmonary dysplasia
8. Endocardial cushion defect (ECD)
9. Hypoplastic left heart (HLHS)
10. Interrupted aortic arch
11. Mitral valve atresia
12. Patent ductus arteriosus (PDA)
13. Truncus arteriosus (TA)
14. Ventricular septal defect (VSD

15. What are the causes of
cyanotic heart disease: the five
“terrible Ts”(one “S”)

16. Causes of
cyanotic heart
disease: the
five “terrible
Ts”(one “S”)
1. Transposition of the
great vessels (TGA)
2. Total anomalous
pulmonary venous return
(TAPVR)
3. Tetralogy of Fallot (TOF)
4. Truncus arteriosus (TA)
5. Tricuspid atresia (TrA)
6. Severe pulmonic
stenosis

17. Location of
murmurs
The site where the murmur originates from tends to
correspond to where it is loudest or most intense.
Timing and location tend to be the most important
identifying characteristics of a murmur.
Classical descriptions of valve auscultation areas:
• Mitral area: cardiac apex, 5th intercostal space (ICS)
in the midclavicular line
• Mitral valve prolapse, regurgitation, and stenosis;
Still’s murmur, aortic stenosis
• Tricuspid area: 4-5th ICS, left sternal edge
• Tricuspid regurgitation, ventricular septal defect
(VSD), Still’s murmur, hypertrophic cardiomyopathy.

18. Location of
murmurs
Pulmonary area: 2nd ICS, left sternal edge
• Pulmonary regurgitation and stenosis, ASD, TAPVR, PDA, and
pulmonary flow murmurs.
Aortic area: 2nd ICS, right sternal edge
• Aortic stenosis, benign aortic systolic murmur
Using the bell and diaphragm, you should first perform a sweep
at these locations for heart sounds and then a second sweep for
murmurs.
Other sites of auscultation:
• Infra and supraclavicular areas: auscultate for a venous hum:
• Common carotid areas: auscultate for supraclavicular or
brachiocephalic systolic murmurs. Differentiating these from a
radiating murmur of aortic stenosis is difficult.
• On the patients’ back: aortic stenosis

19. Radiation
Radiation of murmurs
• Murmur of aortic stenosis tends to radiate to
the common carotid arteries,
• Murmurs of mitral regurgitation classically
radiates to the left axilla.
• A VSD does not radiate to those areas.
• Auscultating the back and infraclavicular
areas for a peripheral pulmonary arterial
stenosis murmur and a venous hum,
respectively.

20. Cardiac
Examination
in Chidren
Introduction
 Introduce yourself to the parents and the child, including your name
and role.
Confirm the child’s name and date of birth.
 Briefly explain what the examination will involve using patient-friendly
language: “Today I’d like to perform an examination of your child’s
heart, which will involve first watching your child, then feeling their
pulse and listening to their chest with my stethoscope.”
 Gain consent from the parents/carers and/or child before proceeding:
“Are you happy for me to carry out the examination?”
 Wash your hands.

21. General
inspection
• Appearance and behaviour
Observe the child in their environment (e.g. waiting room, hospital bed) and take note of
their appearance and behaviour:
• Activity/alertness: note if the child appears alert and engaged, or quiet and listless.
• Cyanosis: bluish discoloration of the skin due to poor circulation (e.g. peripheral
vasoconstriction secondary to hypovolemia) or inadequate oxygenation of the blood
(e.g. right-to-left cardiac shunting).
• Shortness of breath: may indicate underlying cardiovascular (e.g. congenital heart
disease) or respiratory disease (e.g. asthma).
• Pallor: a pale color of the skin that can suggest underlying anaemia (e.g. blood
dyscrasia, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
• Edema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen
(i.e. ascites). There are many causes of oedema including cardiac failure and nephrotic
syndrome.
• Rashes: note the characteristics and distribution of any skin rashes (e.g. petechiae
suggesting clotting disorder).
• Weight: note if the child appears a healthy weight for their age and height.

22. Syndromic
features
• Pay attention to features that may indicate
the presence of an underlying genetic
condition:
• Stature (e.g. tall/short)
• Syndromic facial features

23. Common
CHD with
common
syndromes:
1. Down syndrome: ECD/CAVSD, VSD
2. Turner syndrome: COA, AS, ASD
3. Noonan syndrome: PS
4. Marfan syndrome: MVP, AR, MR
5. William syndrome; Supravalvular AS,
PA stenosis
6. Kartageners syndrome: Dextrocardia
7. Tuberous Sclerosis: Rhabdomyoma
8. VATER: VSD
9. Trisomy 18: VSD, PDA, PS
10.Trisomy 13: VSD, PDA, Dextrocardia
11.Holt Oram syndrome: ASD, VSD
12.Ellis-Van Crevald syndrome: Single
atrium

24. Equipment in
environment
•Observe for any equipment
in the child’s immediate
surroundings and consider
why this might be relevant to
the cardiovascular system:
•Oxygen: saturation probe,
mask, nasal prongs, oxygen
tank and other breathing
support.
•Mobility equipment:
wheelchair, crutches and
walking frame.

25. Inspect the
hands
General observations
Inspect the hands for clinical signs relevant to the
cardiovascular system:
• Colour: pallor suggests poor peripheral
perfusion (e.g. congestive heart failure) and
cyanosis may indicate underlying hypoxaemia.
• Xanthomata:
• Arachnodactyly (‘spider fingers’): fingers and
toes are abnormally long and slender, in
comparison to the palm of the hand and arch
of the foot. Arachnodactyly is a feature of
Marfan’s syndrome, which is associated with
mitral/aortic valve prolapse and aortic
dissection.
• Absent thumbs: associated with Holt-Oram
syndrome, an autosomal dominant genetic
condition which causes abnormalities in the
bones of the arms and hands as well as the
heart (atrial septal defect, heart block).
• Finger clubbing

26. Signs in the
hands
associated
with
endocarditis
• Splinter haemorrhages: a
longitudinal, red-brown haemorrhage
under a nail that looks like a wood
splinter. Causes include local trauma,
infective endocarditis, sepsis,
vasculitis and psoriatic nail disease.
• Janeway lesions: non-tender,
haemorrhagic lesions that occur on
the thenar and hypothenar
eminences of the palms (and soles).
Janeway lesions are typically
associated with infective
endocarditis.
• Osler’s nodes: red-purple, slightly
raised, tender lumps, often with a
pale centre, typically found on the
fingers or toes. They are typically
associated with infective
endocarditis.

27. Palpation
• Temperature
• Cool hands may suggest poor peripheral perfusion
(e.g. congestive cardiac failure, cardiac shunting).
Capillary refill time (CRT)
• Apply five seconds of pressure to the distal phalanx
of one of a child’s fingers and then release.
• In healthy individuals, the initial pallor of the area
you compressed should return to its normal colour
in less than two seconds.
• A CRT that is greater than two seconds suggests
poor peripheral perfusion (e.g. hypovolaemia,
congestive heart failure) and the need to assess
central capillary refill time.

28. Pulses
Radial pulse
• Palpate the child’s radial pulse, located at
the radial side of the wrist, with the tips of
your index and middle fingers aligned
longitudinally over the course of the artery.
• Once you have located the radial pulse,
assess the rate and rhythm.
• In babies, assess the femoral pulse instead.
• Heart rate
• Assessing heart rate
• Radio-radial delay

29. Jugular
venous
pressure
(JVP)
• JVP is only performed in children older than 8 years old
• Should be no greater than 4cm).
A raised JVP indicates the presence of venous
hypertension. Cardiac causes of a raised JVP include:
• Right-sided heart failure: commonly caused by left-
sided heart failure. Pulmonary hypertension is another
cause of right-sided heart failure.
• Tricuspid regurgitation: causes include infective
endocarditis and rheumatic heart disease.
• Constrictive pericarditis: often idiopathic, but
rheumatoid arthritis and tuberculosis are also possible
underlying causes.

30. Eyes
Inspect the eyes for signs relevant
to the cardiovascular system:
Conjunctival pallor:
Plethora in CCHD

31. Mouth
• Central cyanosis: bluish
discoloration of the lips and/or the
tongue associated with hypoxemia
(e.g. a right to left cardiac shunt).
• Angular stomatitis: a common
inflammatory condition affecting
the corners of the mouth. It has a
wide range of causes including iron
deficiency.
• High arched palate: a feature of
Marfan syndrome which is
associated with mitral/aortic valve
prolapse and aortic dissection.
• Dental hygiene: poor dental
hygiene is a risk factor for infective
endocarditis.

32. Inspection of
chest:
Scars, DO NOT MISS THE
SCARS,
•Precordial bulge, Apical
heave, apical impulse,
pulsation
•Respiration
•Type of breathing

33. Close
inspection of
the chest
•Scars suggestive of previous
thoracic surgery: see the thoracic
scars section below.
•Pectus excavatum: a caved-in or
sunken appearance of the chest
(e.g. Marfan syndrome).
•Pectus carinatum: protrusion of
the sternum and ribs (e.g. Noonan
syndrome).
•Visible ventricular impulse: normal
in thin children, can be associated
with left ventricular hypertrophy.

34. Thoracic
scars
Median sternotomy scar: Complete repair— any major bypass surgery, for example
valvular repair or one of the more, Complicated cardiac repairs. Waterson shunt (caval
shunt bet ascend Ao and rt PA), PA banding. Thymectomy for MG, cardiac valve
replacement and pulmonary artery banding.
Right thoracotomy scar: pulmonary artery banding and a Blalock–Taussig shunt.
Left thoracotomy scar: located between the lateral border of the sternum and the mid-
axillary line at the 4th or 5th intercostal space on the left. Horizontal:
1. PDA ligation
2. PA banding
3. Pulmonary valvotomy
4. Left BT shunt
5. COA repair, repair of interrupted aortic arch
6. Diaphragmatic hernia repair
7. Oesophageal atresia repair
8. Hiatus hernia repair
9. Lung Biopsy
Infraclavicular scar: located in the infraclavicular region (on either side). This surgical
approach is used for pacemaker insertion.
Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous
implantable cardioverter-defibrillator (ICD).

35. Thoracotomy scars
Left thoracotomy scar:
located between the lateral border of the sternum
and the mid-axillary line at the 4th or 5th intercostal
space on the left. Horizontal:
1. PDA ligation
2. PA banding
3. Pulmonary valvotomy
4. Left BT shunt
5. COA repair, repair of interrupted aortic arch
6. Diaphragmatic hernia repair
7. Esophageal atresia repair
8. Hiatus hernia repair
9. Lung Biopsy
Right thoracotomy scar:
1. pulmonary artery banding
2. Blalock–Taussig shunt.

36. Palpation of Chest-Apex beat
• Palpate the apex beat
• Palpate the apex beat with your fingers placed horizontally
across the chest, noting its position.
Normal position:
• <7 years old: 4th intercostal space to the left of the
midclavicular line.
• >7 years old: 5th intercostal space in the midclavicular line.
Abnormal position:
• To avoid missing the examiner's favorite - dextrocardia - a
two handed approach may be used.
• The apex beat can usually be felt in the 5th, left intercostal
space in the mid-clavicular line; the character of the beat
should be noted.
• Left displacement: causes include cardiomegaly, pectus
excavatum and scoliosis.
• Right displacement: causes include dextrocardia, left
diaphragmatic hernia, collapsed right lung, left pleural
effusion and left pneumothorax.

37. Assess for
heaves and
thrills
Heaves:
A parasternal heave is a precordial impulse that can
be palpated.
Place the heel of your hand parallel to the left
sternal edge (fingers vertical) to palpate for heaves.
Tip: Instead of the heel of your hand, use your
fingertips with babies and younger children.
If heaves are present you should feel the heel of
your hand being lifted with each systole.
Parasternal heaves are typically associated with right
ventricular hypertrophy.

38. Thrills:
A thrill is a palpable vibration caused by
turbulent blood flow through a heart valve (a
thrill is a palpable murmur).
You should assess for a thrill across each of
the heart valves in turn (see valve locations
below).
To do this place your hand horizontally across
the chest wall, with the flats of your fingers
and palm over the valve to be assessed.

39. Auscultate
the heart
Areas of the heart to auscultate
4 areas, suprasternal, carotids, axilla, back
Auscultate ‘upwards’ through the valve areas using the diaphragm
of the stethoscope:
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal
edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Repeat auscultation across the four valves with the bell of the
stethoscope.

40. AUSCULTATE THE LUNG FIELDS ON THE
ANTERIOR AND POSTERIOR ASPECT OF THE
CHEST:
COARSE BI-BASAL CRACKLES MAY BE A LATE
SIGN OF PULMONARY CONGESTION
SECONDARY TO CONGESTIVE HEART FAILURE.
ASSESS FOR EVIDENCE OF OEDEMA:

41. To complete the examination…
Explain to the child and parents that the examination is now finished.Explain
Ensure the child is re-dressed after the examination.Ensure
Thank the child and parents for their time.Thank
Explain your findings to the parents.Explain
Ask if the parents and child (if appropriate) have any questions.Ask
Wash your hands.Wash
Summarise your findings to the examinationSummarise

42. Further
assessments
and
investigations
Suggest further assessments and investigations to the
examiner:
• Abdominal examination: if hepatomegaly was noted.
• Respiratory examination: if abnormalities noted during
inspection and auscultation of the chest.
• Peripheral vascular examination: if poor peripheral
perfusion or oedema were identified.
• Vital signs
• ECG: if concerned about cardiac pathology.
• Measure and plot height and weight on a growth chart.
• Urinalysis: if oedema present.

43. Syndromes
and CHD
• Trisomy 21: Ventricular septal defect, Atrial septal
defect, atrioventricular septal defect
• DiGeorge syndrome 22q11.1:Ventricular septal
defect, Tetralogy of Fallot, Interrupted aortic arch
• Noonan: Pulmonary stenosis, Hypertrophic
cardiomyopathy
• Turner: Coarctation of the aorta, Aortic stenosis
• William: Supravalvular aortic stenosis, Pulmonary
stenosis
• Marfan: Aortic dilatation/régurgitation, Mitral
prolapse
• FAS: Ventricular septal defect, Atrial septal defect
• Alagille: Pulmonary stenosis, Tetralogy of Fallot
• Holt-Oram: ASD,VSD

44. Congenital
Heart
Disease:
Surgical
Corrective
Procedures
BLALOCK-TAUSSIG SHUNT
= end-to-side anastomosis of subclavian artery to pulmonary
artery, performed ipsilateral to innominate artery/opposite to
aortic arch: Tetralogy of Fallot, tricuspid atresia c pulmonic
stenosis
AORTICOPULMONARY WINDOW SHUNT
= side-to-side anastamosis between ascending aorta and left
pulmonary artery (reversible procedure) – used in Tetralogy of
Fallot
BLALOCK-HANLON PROCEDURE
= surgical creation of ASD: Complete transposition
FONTAN PROCEDURE
= (1) external conduit from R atrium to pulmonary trunk (=
venous return enters pulmonary artery directly) (2) closure of
ASD: floor constructed from flap of atrial wall and roof from
piece of prosthetic material: Tricuspid atresia

45. Congenital
Heart
Disease:
Surgical
Corrective
Procedures
GLENN SHUNT
= end-to-side shunts between distal end of right pulmonary artery and IVC; reserved
for patients with cardiac defects in which total correction is not anticipated: Tricuspid
atresia
POTT SHUNT
= side-to-side anastomosis between descending aorta + left pulmonary artery:
Tetralogy of Fallot
MUSTARD PROCEDURE: Removal of atrial septum (b) pericardial baffle placed into
common atrium such that systemic venous blood is rerouted into left ventricle and
pulmonary venous return into right ventricle and aorta: Complete Transposition
RASHKIND PROCEDURE
= balloon atrial septostomy: Complete transposition
RASTELLI PROCEDURE
= external conduit (Dacron) with porcine valve connecting RV to pulmonary trunk:
Transposition
WATERSON-COOLEY SHUNT
= side-to-side anastomosis between ascending aorta and right pulmonary artery (a)
extra pericardial (WATERSON) and (b) intrapericardial (COOLEY): Tetralogy of Fallot

46. Example of presentation of the cardiac examination:
ABC is _ years old C/I/M boy, is/not syndromic, is/not in any respiratory distress, seems not under
nourished, would like to chart gender specific progressive percentile charts for OFC, HT and wt,
is/not tachypnoeic, is/not centrally cyanosed. Not pale, is/not clubbed. Afebrile, Pulse: 90 per
minute, regular, good volume with good upstroke and down stroke, all peripheral pulses are well
felt. No water hammer pulse, There is no radio femoral or radio radial delay. I would like to take 4
limbs BP. No peripheral signs of SBE.
There is no conjunctival pallor/congestion/jaundice, tongue no cyanosis, teeth no caries. On
inspection of chest RR is no sign of RD, no surgical scars seen, no bulge, no asymmetry, not
hyperdynamic, No visible pulsation. Palpation, AB is on left side, heaving in character, in 6th LICS in
MCL. There are no thrills felt on precordium or carotid or left parasternal heave or palpable
pulmonary sound o felt. On auscultation grade 3/6, ESM, high low pitched, heard best over LUSE,
not radiated. No fixed split. No hepatomegaly, splenomegaly, lung no crepts.
In summary: This child has congenital acyanotic heart disease, with DD of PS/ASD, not in cardiac
failure or pulmonary HT

47. • QUIZ on cardiac examination

48. 1-Capillary refill
time is normally
A. 15 seconds.
B. 7 to 10 seconds.
C. 4 to 6 seconds.
D. 1 to 3 seconds.

49. Q2: 6-day old baby
Well at birth, though noted to have a
murmur, discharged for review at 1 week
of age poor feeding last 48 hours cyanosis,
sats 80% 3/6 ejection systolic murmur
upper left sternal edge
A.VSD
B.Aortic Stenosis
C.Pulmonary Stenosis
D.Tetralogy of Fallot
E.Truncus Arteriosus

50. Q 3:
10-day old baby,
3 days history of poor feeding,
Tachypnoea with recession. Mild
oxygen requirement. Admitted:
head box O2, NG feeds.
Diagnosed Bronchiolitis. After 2
days on ward, deteriorating:
absent femoral, BP differential
in limbs
A. Myocarditis
B. VSD
C. Aortic stenosis
D. Critical pulmonary stenosis
E. Coarctation of Aorta

51. Q4: 3 week old
baby
Well since birth
Reduced feeding
last few days Sats
99% ECG: HR
210/min
A. SVT
B. Tetralogy of Fallot
C. VSD
D. Hypoplastic Left Heart syndrome
E. TGA

52. 5-The most
common
form of
congenital
heart disease
is...
A. Atrial septal defect
B. Atrioventricular septal defect
C. Ventricular septal defect
D. Pulmonary stenosis

53. 6-Which of
the following
presents
with
cyanosis?
A. VSD
B. ASD
C. Tetralogy of fallot
D. Coarctation of the aorta

54. 7-Which of
the following
is associated
with coronary
artery
aneurysm?
A. Rheumatic fever
B. Type 1 diabetes mellitus
C. Kawasaki disease
D. Downs syndrome

55. 7-Which of
the following
are risk
factors for
congenital
heart
disease?
A. Maternal diabetes in pregnancy
B. Congenital rubella infection
C. Down’s syndrome
D. All of the above

56. 8-The Smith’s Family
is caring for their
youngest child,
Justin, who is
suffering from
tetralogy of Fallot.
Which of the
following are defects
associated with this
congenital heart
condition?
A. Aorta exits from the right ventricle,
pulmonary artery exits from the left
ventricle, and two noncommunicating
circulations
B. Ventricular septal defect, overriding aorta,
pulmonic stenosis (PS), and right
ventricular hypertrophy
C. Coarctation of aorta, aortic valve stenosis,
mitral valve stenosis, and patent ductus
arteriosus
D. Tricuspid valve atresia, atrial septal defect,
ventricular septal defect, and hypoplastic
right ventricle

57. Q 9: 6 years old short girl with incidental cardiac
murmur, likely differentials :
A.Bicuspid aortic valve
B.coarctation of aorta
C.VSD
D.PS

58. 10 :Choose
the complete
and accurate
grouping of
right to left
shunts
A. Atrial septal defect (ASD), Patent ductus
arteriosus (PDA), Ventricular septal defect
(VSD)
B. Truncus arteriosus, Transposition of great
vessels, Tricuspid atresia, Tetralogy of
Fallot, Total anomalous pulmonary venous
return (TAPVR)
C. CASD, TAPVR, VSD
D. PDA, Truncus arteriosus, tetralogy of Fallot