[Referral practice and clinical assessment of heart murmurs in children]

Heart murmurs in infants and children are common, and in most cases these are physiological murmurs. In a few cases they represent congenital heart disease; it is important to detect those few children by referral to paediatric cardiologists.

220 consecutive children with heart murmur were investigated prospectively as outpatients in the Children's clinic, Haukeland University Hospital from January through December 2001. Referrals were from general practitioners (n = 157), paediatricians or residents at the Children's clinic (n = 51), and from one community-based paediatrician (n = 12). The purpose was to assess the referrals for completeness and judgment before cardiological assessment. Our second goal was to see if the paediatric cardiologist could differentiate between innocent and pathological murmurs by history and clinical assessment only.

22 (10%) of the referred patients had congenital heart defects. They had been through a complete clinical assessment by 38.9% of the general practitioners and 83.3% by the community-based paediatrician (p = 0.0001). A conclusion regarding diagnosis before hospital evaluation was reached in only 17.8% of the patients by the general practitioners and in 50% by the paediatricians (p < 0.0001). The diagnostic accuracy of the clinical evaluation by the paediatric cardiologists had a sensitivity of 81.5%, specificity of 98.5%, positive and negative predictive values of 88 and 97.5%, respectively. Two patients with significant atrial septum defect would have been missed by clinical assessment only.

Skills in clinical assessment of heart murmurs in infants and children can be improved among general practitioners and paediatricians in training. Paediatric cardiologists can differentiate between physiological and pathologic murmurs by clinical evaluation only.